Complex Care Program
The Complex Care team at Monroe Carell specializes in helping children with severe chronic disease affecting multiple organ systems. Many of the children we follow depend on medical technology. Our team members are experts in working with gastrostomy tubes, tracheostomies and other devices. We coordinate your child's inpatient care and follow up with your local pediatrician. In the hospital, we work with with subspecialists as they visit your child to ensure continuity of care. We also see your child in quarterly outpatient visits to continue supporting your family through the year.
Following are requirements for enrollment in the complex care program. We make exceptions depending on your child's situation:
- Involvement with a primary care physician with whom we can partner (we do not replace the primary care physician)
- A lifelong chronic illness that is not expected to go away and that will require ongoing care.
- One hospital admission of 10 days or more, or one ICU admission, or two hospital admissions in the past year.
- Involvement with at least four subspecialty groups
- Not under care of team dedicated to the child's illness, such as cystic fibrosis, cancer, sickle cell disease, diabetes, autoimmune diseases such as lupus, and juvenile rheumatoid arthritis.
- Age under 15 years at enrollment (we follow enrolled patients for years after that, but generally do not take patients who will soon transition to adult care)
Conditions We Treat
- Bladder dysfunction
- Chronic lung disease
- Chronic renal disease
- Congenital brain malformation
Meet Your Care Team
Why Choose the Complex Care Program at Monroe Carell
- Family-centered care
You know your child best. That's why we believe in shared decision making and empowering your family by including you as part of the healthcare team. We provide education and discussion about your child's problems, as well as advocacy with insurers, government agencies, schools and workplaces. In some cases, we can prevent admissions, emergency department visits, and time in the hospital. Finally, we help your family decide on goals of care for your child.
- Continuity of care
Our team seeks to improve continuity of care by following children over time, including during hospital admission and after discharge. Most families find it reassuring that a person who knows them and their child's special problems will remain involved in their care in the hospital and out.
- Streamlined care
We streamline care, with the goal of improving quality of life for the children and families we serve. Children in our program often require many specialist visits and hospital admissions. It's much easier for us to communicate with all the specialists involved than for doctors who may be off site.
- Collaborative care
Our team meets frequently to discuss the healthcare needs of children we follow. We work with home health and durable medical equipment companies. We also coordinate referrals, medical appointments, and tests to minimize your child's hospital and office visits.
- Supplementary care
Our program is not intended or resourced to replace your child's primary care provider. Instead we seek to supplement his or her care.
