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Complex Care Program

Contact number | 202-476-4664
Complex Care Patient in Wheelchair with Family

Specializing in Children with Complex Needs

The Complex Care team can coordinate every aspect of care for children with multiple chronic conditions.

Meet us

The Complex Care Program (CCP) at Children's National Hospital 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.


  • 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:

  • CCP Physician sees the patient and family every 4-6 months
  • Care team provides continual care coordination between CCP visits

For those without a PCP, we will provide primary care including:

  • Well Child Care
  • Urgent Care
  • All CCP care coordination services


  • 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

Xiomara's Story


xiomara teaser 2

When Xiomara's mother Elena was 20 weeks pregnant, her ultrasound uncovered something that didn’t look right. Elena was referred to Children’s National Health System to meet with Mary Donofrio, M.D., in the Fetal Heart Program who flagged a few potential heart issues and continued to monitor Xiomara throughout the remainder of the pregnancy.

Xiomara's Story

Complex Care Program Team