Pediatric Coordinated Care Clinic

Overview

For families of children with medically complex healthcare needs, our Coordinated Care Clinic provides help with important aspects of each child’s care.

• Arrangements of visits with pediatric specialists
• Facilitation of communication and collaboration with specialists
• Collaboration with school systems to coordinate medical and education needs and with community resources such as early intervention.
• Clinical care provided by physicians, a nurse practitioner, a nurse care manager, and a registered dietician nutritionist as well as consultations with social workers, physical therapists, and other allied health professionals.

At the Coordinated Care Clinic, your child becomes the center of a team effort. We work hard to ensure that all providers can collaborate effectively, facilitating communication among primary care physicians, specialists, therapists, schools, and families, to provide the continuity of care children with complex medical conditions need.

Continuity of Care and Ongoing Support

The Coordinated Care Clinic also provides continuity of care over time. For families of children with chronic conditions, we are here today, tomorrow, and next year—we're available to your family for as long as you need us.

We provide transitional outpatient care for children discharged from the neonatal and pediatric intensive care units and the inpatient wards, and assistance to families dealing with a new diagnosis, new medical equipment, or new medications.

We help children transition back home and into the community, assisting with school and education plans, transportation, and community services.

We aim to maximize quality of life for patients and families facing a life-threatening illness by working closely with the Pediatric Supportive and Palliative Care Service.

The Coordinated Care team consists of healthcare professionals with broad experience caring for medically complex children. The team includes pediatricians and a nurse practitioner who direct medical work-up, a nurse care manager, a registered dietician nutritionist, a scheduler, and a program manager. We can arrange consultations with pediatric subspecialist, financial assistance counselors and a broad array of other hospital resources.

The overall goal of the CCC team is to truly understand the experiences of families living with a medically complex child and help optimize their ability to have the best life possible within their home and community. This requires assisting families to navigate an increasingly complex health care system.

Making an Appointment with the Coordinated Care Clinic

Please review this letter for parents and caregivers from the Coordinated Care Clinic team.