Care for Children with Medical Complexity

The Division of General Pediatrics strives to provide high quality of care across the continuum to over 4,000 children with medical complexity (CMC). CMC have with lifelong, life-limiting complex chronic conditions that affect the function of multiple organ systems. CMC often rely on multiple medications and medical equipment and supplies to optimize their health. Many CMC require large health care teams to meet their health care needs.

Our general pediatricians, developmental/behavioral specialists, registered nurses, advanced practice nurses, social workers, case managers, schedulers, and other healthcare professionals have extensive experience caring for CMC.

Patient-and-family centered care provided to CMC includes:

  • chronic disease management
  • treatment of acute illnesses
  • proactive care planning and shared decision making
  • management of polypharmacy and durable medical equipment and supplies
  • care coordination with specialists and other healthcare professionals

Health services provided to CMC in the division include:

Rainbow Program: a patient-centered medical home, providing comprehensive primary care services to CMC, including well-child visits, immunizations, care coordination, and urgent care [617-355-7701 (phone), 617-730-0505 (fax)]

Complex Care Service: a consultative health home for CMC who have an existing, community-based primary care provider [617-355-6162 (phone), 617-730-0621 (fax)]

Multi-Disciplinary Clinics and Centers: general and developmental pediatricians in the division staff multi-disciplinary clinics alongside medical and surgical specialists for children with cerebral palsy, spina bifida, craniofacial, and aerodigestive health problems

Inpatient Hospitalist Service: a dedicated, inpatient service to serve the acute inpatient needs of CMC

Home Care: post-discharge home visits provided by a complex care nurse to ensure a safe and successful transition from hospital to home

Baclofen Pump Program: a comprehensive program with neurosurgery providers to install and maintain intrathecal baclofen pumps in children with musculoskeletal spasticity

Complex Spine Team: an integrated program with anesthesiologists and orthopaedic surgeons to prepare CMC for elective spine surgeries and to assist with shared decision making on whether to undergo surgery

Telehealth: virtual visits for new and established CMC patients