Complex Care Program

• A primary care medical home for patients with complex medical conditions and their siblings
  • As patients of the Complex Care Program, children will receive:
    • Primary care services (annual well child exams, vaccines, etc.)
    • Frequent care coordination visits
    • Same day sick visits
    • Access to telehealth services
    • Patient portal access for communication with providers and care team members
    • Extended appointment times
    • Transitional Care Management (to aid in the transition from the hospital to home/subacute/rehabilitation facility)
    • Care from an interdisciplinary team (nurses, case managers, parent navigators, social work, psychology)
• Support in identifying comprehensive medical, social and developmental needs
• Communication among specialists, home care agencies, nursing agencies, equipment companies, community resources, educational institutions and primary caregivers
• Connections with both internal Children’s National specialists and community-based resources such as home care companies, schools, state agencies and insurance companies to maximize quality of life
• Continuum of care to the inpatient setting:
  • HELP Team: a Hospitalist Consult Service for patients with complex medical conditions
  • Complex Care Unit: Dedicated 5-10 bed unit staffed by experienced physicians
  • Pre-Operative Care Clinic
  • Palliative Medicine

• Children with multi-system, complex medical conditions, often with technology dependence (such as g-tubes or tracheostomies)
• Children followed by multiple specialists often within Children's National
• Children who are frequently admitted to the emergency department or the hospital 
• A sibling of a child with complex medical conditions 

The Complex Care Program accepts patients via a referral process. Referrals may be submitted by primary care providers, subspecialists, insurance case managers, early intervention programs, parents and patient caregivers.

Before the intake process, we will obtain a detailed medical history to help our team understand the needs of your child and family.

Your first appointment will last approximately one hour. Please arrive to the hospital 30 minutes early as the hospital campus is large and it takes time to park, check-in at security and locate our clinic. Please note: All adults need to bring a picture ID to the Welcome Desk for registration.

Please bring a list or pictures of your child’s current and past medications, including the dose of the medication and frequency. Also, please bring along any supplies, like a trach go-bag, with you to clinic. Please bring your child’s own medical supplies (trach go-bag) from home.

Please feel free to write down specific goals you have for your child and family, as well as any specific problems or concerns.

As your child’s primary care medical home, you will receive care from our team members for:

• Well child exams. These exams are frequent in infants and toddlers and occur on an annual basis for ages 3+.
• Care coordination visits. During these visits, members of our team will meet with you and your child to better understand your goals. During these visits our team can also aid you in any care challenges you are experiencing. At a minimum, these visits occur annually, usually within six months of your child’s annual well child exam. However, if needed, these visits can occur quarterly and often via our telehealth platform. 
• Acute illness. Same day sick visits for ear infections, fevers, vomiting, etc. These visits may be conducted via our telehealth platform.
• Discharges from the hospital and/or emergency department to support you and your child in the transition home. These visits may be conducted via our telehealth platform.