Pediatric Complex Care Program
What is the Pediatric Complex Care
We are a team at American Family
Children’s Hospital (AFCH) who manage
and coordinate care for children with
complex medical needs. Our team includes
doctors, nurse practitioners, nurses, care
coordination assistants, and a social worker.
We take part in our patients’ care in the
hospital, clinic, or at home.
Who can be in the Program?
ξ Have problems in three or more body
ξ Get care from three or more
ξ Have a hospital stay lasting at least 5
days or have at least 10 specialty
clinic visits in the past year, and have
unmet care coordination needs.
Many of our patients…
ξ Use a feeding tube.
ξ Have seizures or other neurologic
ξ Have breathing issues.
ξ Take many medicines.
How can my child become a part of the
First, we need a referral. A parent, guardian,
or health care provider who knows your
child can ask for a referral. After we receive
the referral, we review your child’s chart to
make sure your child qualifies for the
program. If your child qualifies, we call you
to explain the program and set up a clinic
visit. The program starts at the time of the
first clinic visit.
What are barriers to being in the
Our mission is to serve patients and families
whose needs we have the expertise and
resources to meet and cannot be met by
ξ Sometimes for certain health
problems there are other doctors or
teams that can best manage and
coordinate care. Some examples
include cystic fibrosis, pediatric
cancer, and transplants.
ξ Sometimes for certain health
conditions we do not have the
expertise and resources. Examples
include mental health disorders and
ξ Sometimes there are insurance issues
that prevent us from being part of a
If your child doesn’t qualify for the Pediatric
Complex Care Program, a letter is sent to
your child’s primary care doctor and the
person who requested the referral to let
What happens when my child is enrolled
in the Program?
At the first visit:
ξ We talk about your child’s history
and current problems. This visit
takes up to two hours. We try to have
at least 3 members of our team at this
ξ Using the information from the visit
and your child’s health record, we
create care and crisis plans for your
child. These plans are sent to you.
After your child is enrolled, we provide
ξ Clinic visits at least every 6 months.
There is an option to schedule these
visits on days when your child has
other appointments at AFCH. We
try our best to do this for you if you
would find it helpful.
ξ Join you at your child’s clinic
visits with other specialists. This is
an option that we try our best to do
for you if you would find it helpful.
ξ Phone advice and/or clinic visits
when your child is ill. We may give
advice on how to manage issues at
home, see your child for an urgent
care visit, or contact the emergency
department to give some background
on your child.
ξ Consults when your child is in the
hospital. We talk with the team
caring for your child in the hospital.
We try to be a part of daily rounds
with the team. We help with
transition back to home.
ξ Monthly phone or electronic
contact. We check in to see if there
are any questions or issues we can
ξ Ongoing program support.
Between visits call us if you have
questions and don’t know who to
ξ A resource to schedule
appointments, talk to insurance
providers, arrange home health and
medical equipment, and locate
The Pediatric Complex Care Program is a
voluntary program. We hope you are willing
to partner with our team.
How long can my child be part of the
Your child will graduate from the program:
ξ When care transitions from pediatric
to adult providers. This is around age
18. We help your child with this
ξ When your child’s medical issues
become less complex.
ξ If you find our services are no longer
needed or helpful.
Sometimes we find it is no longer
ξ If your child misses 3 or more
scheduled Pediatric Complex Care
ξ If we cannot reach you by phone or
electronic contact after multiple
How can my child be successful in the
We believe you are the expert on your child.
Please talk to us:
ξ If you do not understand your child’s
illness or treatment plan.
ξ If you feel like the plan is not
Your health care team may have given you this information as part of your care. If so, please use it and call if you
have any questions. If this information was not given to you as part of your care, please check with your doctor. This
is not medical advice. This is not to be used for diagnosis or treatment of any medical condition. Because each
person’s health needs are different, you should talk with your doctor or others on your health care team when using
this information. If you have an emergency, please call 911. Copyright © 3/2017 University of Wisconsin Hospitals
and Clinics Authority. All rights reserved. Produced by the Department of Nursing HF#7966.