Complex Care Service Program

The Division of General Pediatrics strives to provide high quality of care across the continuum to over 4,000 children in the Complex Care Service Program. These children have with lifelong, life-limiting complex chronic conditions that affect the function of multiple organ systems.  CCS often relies on multiple medications and medical equipment and supplies to optimize their health. Many 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 these children.

Patient-and-family centered care provided to these children 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 children in the Division include:

Rainbow Program: A patient-centered medical home, providing comprehensive primary care services to children, including well-child visits, immunizations, care coordination, and urgent care.

Complex Care Service: A consultative health home for children who have an existing, community-based primary care provider.

Multi-Disciplinary Clinics: General and developmental pediatricians in the Division staff multi-disciplinary clinics alongside medical and surgical specialists for children with cerebral palsy, myelodysplasia, and aerodigestive health problems.

Inpatient Hospitalist Service: A dedicated, inpatient service to serve the acute inpatient needs of children.

Home Care: Post-discharge home visits provided by a children 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 orthopedic surgeons to prepare children for elective spine surgeries and to assist with shared decision making on whether to undergo surgery.

Telehealth: Virtual visits for established children patients.