Program In action
Established in 2014, the Pediatric Complex Care Program at American Family Children's Hospital provides enhanced, coordinated care for children with complex medical problems that often involve multiple medical and surgical specialties.
Leads: Mary Ehlenbach, MD; Ryan Coller, MD, MPH
- Objective: To provide care coordination and medical management in order to optimize health and coordination of care for children with medical complexities who are high utilizers of tertiary care services at American Family Children’s Hospital.
- Target Population: Patients under the age of 18 who meet the following criteria:
- Have problems with three or more organ systems
- See three or more medical or surgical specialists
- Have had a hospital stay lasting at least five days or had at least ten medical or surgical subspecialty visits in the past year
- Design: Health care teams including physician, nurse practitioner, registered nurse, and social worker, work with patients and families to coordinate care and communication between all medical providers. Interventions are patient and family-centered and include inpatient consults, regular outpatient enrollment visits, routine follow-up visits, acute care visits and attendance to speciality visits when desired and/or appropriate.
- Feedback: Families report high satisfaction with program services, particularly in the areas of care coordination, scheduling of appointments, family education, and assistance with durable medical equipment arrangements.
- Funding: The Pediatric Complex Care Program is funded by a $9 million grant from the Center for Medicare and Medicaid Innovation awarded to the Wisconsin Department of Health Services (DHS). Approximately $3 million of the award is earmarked for American Family Children’s Hospital. Grant funding supports the salaries of the staff over the three-year grant period. A key objective of the grant is to develop a sustainable funding model with DHS.
- Enrollment Goal: By end of the grant period, aim to triple its enrollees and work with the Wisconsin Department of Health Services to develop a rate of payment for care coordination/medical co-management services that can be implemented nationally to sustain such complex care programs.
View the program page on uwhealth.org/kids