Complex Care and Education

Frieda takes eight pills a day to manage her multiple chronic conditions. At 68, she has diabetes and high blood pressure. Two years ago she had a heart attack followed by bypass surgery. Frieda is a complex case, but her situation is not unusual.

Studies show that four out of five Ontarians over age 45 have a chronic condition and of those, 70 per cent have two or more chronic conditions. Every year 60 per cent of all deaths in Ontario are linked to chronic conditions. In fact, chronic conditions account for 55 per cent of Ontario’s direct and indirect health costs.

Women’s College Hospital’s Complex Care Clinic (CCC) was established specifically to help these patients improve their quality of life and help keep them out of hospital. It’s an internal medicine clinic that treats the top users of the health-care system. The clinic is staffed by attending doctors, medical residents, nurses and pharmacists with access to Community Care Access Centre resources, and also works with occupational therapy, respiratory therapy, physiotherapy, nutrition, social work and psychiatry. Because of its unique role in the health-care system, the CCC is able to provide outpatients with more efficient access to specialists.

As a teaching hospital specializing in ambulatory, or outpatient, care, Women’s College is uniquely positioned to generate evidence-based knowledge and models of teaching, as well as to provide relevant training opportunities through programs such as the CCC. The clinic supports primary care doctors in treating their most complex patients. This not only helps keep these patients out of emergency rooms, and out of hospital, but also provides excellent teaching opportunities. That’s why CCC is part of Women’s College’s Centre for Ambulatory Care Education (CACE), whose main priority is educating the health-care professionals of the future.

“We teach residents, medical nursing and health discipline students and allied health profession students how to manage complex patients and hopefully keep them out of hospital,” says medical director Dr. Tina Borschel. “Medical residents get a lot of in-patient experience, but not much opportunity to work in ambulatory care.”

Thanks to innovation and advances in treatment, most health care now takes place in an ambulatory setting. People with complex chronic conditions are treated primarily in the community. However, most teaching still takes place in in-patient hospitals. To meet the challenges facing health care, we need to provide health-care professionals with training opportunities that are more relevant. That’s the mission of the CACE and its CCC.

“The care model has shifted,” says CACE director Dr. Heather Carnahan. “What we need to do is rethink how we educate our health professionals to be ready to work in ambulatory care settings and be trained within ambulatory programs.”

A collaboration between Women’s College Hospital and the University of Toronto, CACE is an extra-departmental unit that serves the entire Toronto Academic Health Science Network (TAHSN). CACE is dedicated to building capacity and developing a research base in ambulatory care education. That means initiating teaching programs, faculty development opportunities and mentorship programs at Women’s College and beyond.

In eight months of operation, CACE’s research arm has had 15 papers accepted for publication and attracted a team of nine University of Toronto researchers working to build evidence-based teaching models.

Together, CACE and the Complex Care Clinic are not only filling a health system gap by providing a unique model of care, but are also educating the physicians and health-care professionals of the future.

Dr. Tina Borschel
Medical Director, CCC
Women’s College Hospital
Dr. Heather Carnahan
CACE Director
Women’s College Hospital


Ontario’s Action Plan for Health Care, Ministry of Health and Long-Term Care

“If we are to meet the needs of a growing population with multiple, complex and chronic conditions, our health-care system must be even better co-ordinated, with seamless levels of care.”