• About the Complex Care Center

    Our staff of highly skilled physicians, nurses, nurse practitioners, social workers, nutritionists and support staff use an approach emphasizing care coordination, advocacy and education to improve the quality of life for children and youth with special healthcare needs (CYSHCN), including complex medical, developmental and behavioral disorders. We work with the patient, family, hospital and community to provide a medical home. We assist families in finding and accessing healthcare, financial resources and community services and supports. Our goal is to reduce hospitalizations, length of stay and emergency department visits.

    Our clinic has evolved into a complex care program. Complex care is a subset of children and youth with special health care needs (CYSHCN). A child or young adult with multiple (3-7 is the range currently referred to) and chronic medical, developmental, behavioral, and/or psychosocial conditions, have the highest needs and are the highest users of inpatient and/or outpatient medical services including the number of services, frequency of use, and cost.

    The goal of the physician in complex care is to improve quality of life of patients and their families, while reducing the need for emergency room visits, hospital admissions, length of stay, and clinic visits.

    This definition is different from the definition of CYSHCN which refers to any patient with or is at risk for even a single chronic medical, behavioral, or developmental condition. Complex care patients are also more likely to have daily issues with at least one of their chronic conditions. While, as a group, CYSHCN are higher users of medical services than the rest of the population, and all chronic care expenditures amount to approximately 80% of every health care dollar, most individual patients would not fit the complex care definition. CYSHCN include those with complex care and both groups benefit from a medical home, especially the concepts of care coordination and advocacy. Complex care patients constitute the sickest 2 to 5% of CYSHCN and their cost of care is 7 to 50 times greater than their numbers. 

    The Complex Care Center provides:

    • 24/7 inpatient and outpatient management of children and young adults with chronic, complex medical, developmental and mental health conditions
    • Education and empowerment of patients and caregivers to obtain and provide the best care possible
    • Interpretation of subspecialty recommendations and coordination of care when multiple physicians and / or therapists are involved
    • Guidance and referral for family counseling
    • Advocacy with insurers, government programs, schools and / or workplace
    • Coordination of referrals, medical appointments, procedures and tests to reduce strain on the patient and family
    • Discharge planning
    • Information on diagnosis, treatment and support services
    • Information on general medical data, community resources, website resources and support groups and maintaining this information on the largest and most comprehensive online resource directory in the country
    • Guidance with guardianship and adult transition issues
    • Assistance with palliative care and hospice issues
    • Active participation in the development and operation of community programs and projects that will benefit the chronically ill population:
    • Special Needs Resource Directory
    • Annual resource information fairs including the "Remarkable Families Symposium: Building Resiliency in Families Raising Children with Special Needs." Co-hosted with Xavier University, this annual conference brings together parents of children with special needs to help them find information and resources and network with others facing similar challenges. The symposium includes speakers, vendors and community service agencies.
    • Child Care
    • Online parent community
    • Recycling equipment and unused supplies
  • Children and youth with special healthcare needs are those who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition. They also require health and related services of a type or amount beyond that needed generally by children.

    Advocacy means providing one’s expertise, experience and voice in support of an issue or need on behalf of yourself or others.

    Care coordination is a holistic approach that looks at the medical and psychosocial needs in all areas affected by the patient’s condition. It creates a system of care for the patient and family that promotes the provision of seamless care by reducing duplication and fragmentation of services. Care coordination begins with intake and continues across outpatient, inpatient and community settings and concludes with the transition to adult care. It is not the same as case management, which focuses on the supervision of benefits within the narrow range of a given insurance plan or community / state program. Case management usually does not involve addressing patient needs that would be outside the benefit package such as those affecting school, work, other programs and / or family.

    A medical home provides accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective care for the individual infant, child or adolescent. A key feature is that the pediatrician has a relationship of mutual responsibility and trust established with the child, family and community. The pediatrician is charged with identifying the needs of the child and family in the context of the child’s ongoing health care requirements and then providing a plan for achieving those goals.