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Complex Care Program


The Complex Care Program (CCP) at Children’s National Medical Center has been providing a “medical home” for children and youth with special health care needs since 2002. A “medical home” is defined as family-centered, coordinated, compassionate, comprehensive, and continuous care for children with special health care needs.

Located in the Children's Health Center, our integrated model allows us to provide primary care and consultative services to children with complex conditions.

Services:
  • Provide services to children who meet the eligibility criteria:
    • Child is medically complex and has two or more chronic conditions
    • Followed by multiple specialists often within Children's system
    • May be technology dependent (G-Tube, ventilator, and tracheostomy)
  • Provide ongoing care coordination between visits including communication with family, primary care providers, and specialists
  • Help families negotiate the healthcare system and provide a link to community resources
  • Create written care plans with the family to share with the primary care provider
  • Provide comprehensive care coordination through a team approach that includes nurse case management, parent navigators, and social work

CCP serves as a point of contact for families and primary care providers of children with special needs. The CCP staff works to:
  • optimize the care of medically complex patients
  • coordinate inpatient and outpatient care,
  • link families to hospital and community resources
  • improve communication among providers
  • collaborate with community partners such as home nursing agencies or Early Intervention programs
Services are provided in two (2) distinct formats:
For those with an established PCP For those without a PCP, we will provide primary care including:
CCP Physician sees the patient and family every 4-6 months Well Child Care
Care team provides continual care coordination between CCP visits Urgent Care
  All CCP care coordination services



Referrals:
  • May be made by primary care physicians, subspecialists, insurance case managers, early intervention programs, and self-referrals
  • Evaluation of referral will be made to determine if child is eligible for the program
  • Must receive recent medical information that may be useful to the family and the physician
  • Family/patient must be aware of the nature of the referral
- Departments & Programs - Children's National Medical Center