Care Coordination Program

Care Coordination for Children with Medical Complexity

Coordinating the care of a child with medical complexity is a big job: making countless appointments, ensuring that information is shared, working with the school system, dealing with supplies and equipment, talking with insurers, and finding helpful community resources.That takes knowledge, skill and a lot of time. Parents want the best for their kids, and coordinating care can be difficult and stressful.

The Care Coordination Program is a new service in which a team from The Children’s Institute works with families to ensure that their children with complex medical conditions receive the services they need when they need them. The team includes nurse care coordinators, health coaches and social workers, and is overseen by a physician. 

Depending on each family’s needs, care coordination can include:

• Making appointments for families with physicians, hospitals, therapists, in-home nursing, early intervention, testing centers, dentists, aides, medical equipment companies and others
• Ensuring that appointments happen in the right order and in a timely way, and that providers share all necessary records and other information
• Identifying school and community resources– such as transportation–that can support each child and family
• Working with insurers on coverage

How the Care Coordination Program works:

It’s easy, convenient–and tailored to each family’s needs.
1. Parents or guardians can refer their own child, or ask a physician or nurse to do it.
2. A care coordinator visits the family. Child and family needs are discussed, and goals are set.
3. The care coordinator creates the child’s care plan–and the team goes to work for the child and family.
4. Under a physician’s direction, care coordinators partner with the child’s physicians and other healthcare providers to ensure a smooth flow of care and communication.
5. Each family has its own health coach, who works directly with the family and answers any questions.

6. Social workers coordinate family needs with community resources.
7. The child’s health is monitored, and parents meet periodically with the care coordination team to re-assess the care plan and discuss any needed changes.

Expected Outcomes of Care Coordination:

Better health
Better healthcare
Lower healthcare costs

Eligibility for the Care Coordination Program:

Western Pennsylvania children and young people with medical complexity are eligible—for example, acquired brain injury, amplified pain disorders, spinal cord injury or multiple major diagnoses. 

Medical complexity takes many forms, so please call us at 412-420-2599 for more information or to determine whether your child or patient can be enrolled. Download our referral form here. 

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