Facts about the Program for Children with Medically Complex Needs

  • The team includes two physicians, a nurse practitioner, two nurses, a program coordinator, and a shared social worker, nutritionist and pharmacist.
  • If the child needs to see another subspecialist, in many cases, program coordinators are able to schedule it on the same day to reduce the number of hospital visits for families.
  • Patients enrolled in the program have markedly reduced admissions and readmissions after discharge and fewer emergency department visits and days in the hospital compared to before enrollment.
  • The program offers care between visits. Patients are called after the child returns home from a hospital stay, and problems are handled over the phone when possible. The team works with home nursing and other agencies to maximize care at home.
  • Complex Care team members participated in shared decision making with families. Parents are considered the expert on their child, and the providers provide the medical knowledge and experience of working with many other children with medically complex problems. Together, they seek to determine treatment options and goals of care.

 

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