Who Is Eligible
In order to qualify for care within our Complex Care Clinic, the patient must meet one of the below descriptions:
- A chronically medically fragile child with at least two medical specialists that are not psychiatric
- A child with chronic multisystem disease and social determinants of health that limit them from having multiple specialists or that make them medically fragile
Services Provided
Within this clinic, a patient might see one or all of these team members: a medical doctor, a nurse practitioner, a dietician, an integrated behavior health therapist and a case manager.
Services provided within the Pediatric Complex Care Clinic include:
- Neurology/neurodevelopmental/neuropalliative care, if applicable
- Complex symptom management (pain, fussiness or agitation, feeding and nutrition, airway clearance)
- Care coordination (care plan development, coordinate with school, community services, other providers)
- Case management (service delivery, social determinants of health)
- Goal-directed decision making (advanced directives, service triage, discharge planning)
- Provider-level home visits for triage or when unable to get to PCP
