Client Profile

Who is the Integrated Plan of Care process for?

The Ottawa Service Collaborative recognizes that some children and youth with complex needs and their families access services from multiple providers. The Integrated Plan of Care process is about creating continuity of care for these clients between and across services and/or sectors. The Integrated Plan of Care process is intended to facilitate the effective intervention of multiple organizations, setting out a process for service providers for essential communication, coordination and collaboration to develop an Integrated Plan of Care.

What are the criteria for becoming involved with the Integrated Plan of Care Process?

1)  To identify a need for the Integrated Plan of Care, the Referring Service Provider will consider the following:

  • Is the client between 6 and 18 years of age?
  • Is the client currently accessing two or more services from across sectors or has the client in the past received services from multiple service providers?
  • Is the client experiencing minimal success with current services and the rationale for lack of progress or improvement is unclear and worrisome?
  • Is the client presenting behaviours that, if left unattended, place them, their family and/or community at considerable risk?

2)  If yes can be answered to all of these questions, consider the inclusion criteria for the Integrated Plan of Care process. Review the following inclusion criteria:

  • The client is at serious risk of harm to self and/or others, exhibiting behaviors such as cutting, suicidal ideation, serious physical assault of another, etc.
  • The client is experiencing multiple intersecting complex needs that are severe and broad that lead to major challenges for the client to participate meaningfully in society.

What is meant by complex needs?

Complex Needs are understood to mean:

Multiple intersecting needs that span health, mental health and social issues, leading to major challenges participating in society. Categories of complex needs and contributing social factors include concurrent disorders, complex trauma, suicide and self-harm, inter-generational trauma, residential school trauma, homelessness. There is no generic complex needs case. Each individual with complex needs has a unique interaction between their health and social care needs and requires a personalised response from services.

  • Rather than use the term ‘complex needs’ to describe an individual’s characteristics, it is defined in terms of an active framework for response.
  • Complex needs fits within the tiered framework (see Brian Rush’s article “Tiered frameworks for planning substance use service delivery systems: Origins and key principles”)
  • Essence of complex needs implies both
    • Breadth of need – multiple needs (more than one) that are interrelated or interconnected across multiple domains of health, mental health and social circumstances.
    • Depth of need – reflects the overall severity of the person’s situation and ability to manage

In considering the criteria for inclusion in the Integrated Plan of Care process, it is important to note the distinction between complexity and severity. A client could be severely impacted and even at high risk but if they can be effectively served by one agency, they may not have complex needs, for example a youth with schizophrenia who is actively psychotic and suicidal would have severe needs but not necessarily complex needs if they are being effectively served by one agency. On the other hand, a youth who is dealing with depression, has experienced trauma, and has a very difficult family environment, may have less severe needs but more complex needs in relation to care planning.