Pediatric Complex Care Coordination
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Helping families navigate complex medical care
Children with complicated health conditions often need special medical equipment, visits with multiple specialists and in-home care.
Our team helps families access the health services their child needs at UCSF Benioff Children's Hospital San Francisco. Our team works to:
Prevent interruptions in treatment
Improve communication among care teams
Solve problems and assist you as you navigate the health care system
Ease the transition from hospital to home
Our services
We offer families:
Appointment coordination. We streamline your child's care by scheduling several appointments on the same day and urgent appointments as soon as possible. We can arrange medical transportation when necessary for appointments at UCSF Benioff Children's Hospital San Francisco.
Guidance for nonemergency medical concerns. We can triage minor medical issues and connect you with the right specialists to meet your child's health needs.
Medical device assistance. If your child's medical devices are not meeting their needs, we work with medical equipment providers to address concerns.
Community support advocacy. We help you access necessary support from regional centers, schools, nursing agencies, in-home services and California Children's Services.
Ongoing care after a hospital stay
After a hospital stay, families receive supportive services:
Discharge planning. We work with your child's doctors and care teams to support a smooth transition from hospital to home.
Follow-up care assistance. We organize follow-up care, including in-person and virtual care appointments. (Virtual care is available to California residents.)
Care coordination plan. We create a plan identifying your child's medical needs and challenges and their care team members.
Access plan. You'll receive contact information for all your child's providers, so it's easier to reach them when needed.
Program eligibility
A doctor referral is required to receive program services. Your child must also meet these three criteria:
1. Medical complexity
Your child must see at least four specialists at UCSF Benioff Children's Hospital San Francisco.
2. Medical technology use
Your child must use at least one medical device, such as:
Respiratory support. Includes a nasal cannula, noninvasive ventilation device (CPAP, BiPAP), tracheostomy or home-based ventilator
Feeding tube. Includes gastrostomy (G-tube) or a nasogastric (NG) tube
Central line providing intravenous (IV) access. Includes central venous catheter, port-a-cath or peripherally inserted central catheter (PICC) line
3. Need for care coordination
There must be an unmet care coordination need, demonstrated by both of the following:
Several appointments necessary. Your child needs a range of care appointments in our hospital and clinics.
Lack of wraparound services. No other program is providing this coordination support for your family.
Helping families navigate complex medical care
Children with complicated health conditions often need special medical equipment, visits with multiple specialists and in-home care.
Our team helps families access the health services their child needs at UCSF Benioff Children's Hospital San Francisco. Our team works to:
Prevent interruptions in treatment
Improve communication among care teams
Solve problems and assist you as you navigate the health care system
Ease the transition from hospital to home
Our services
We offer families:
Appointment coordination. We streamline your child's care by scheduling several appointments on the same day and urgent appointments as soon as possible. We can arrange medical transportation when necessary for appointments at UCSF Benioff Children's Hospital San Francisco.
Guidance for nonemergency medical concerns. We can triage minor medical issues and connect you with the right specialists to meet your child's health needs.
Medical device assistance. If your child's medical devices are not meeting their needs, we work with medical equipment providers to address concerns.
Community support advocacy. We help you access necessary support from regional centers, schools, nursing agencies, in-home services and California Children's Services.
Ongoing care after a hospital stay
After a hospital stay, families receive supportive services:
Discharge planning. We work with your child's doctors and care teams to support a smooth transition from hospital to home.
Follow-up care assistance. We organize follow-up care, including in-person and virtual care appointments. (Virtual care is available to California residents.)
Care coordination plan. We create a plan identifying your child's medical needs and challenges and their care team members.
Access plan. You'll receive contact information for all your child's providers, so it's easier to reach them when needed.
Program eligibility
A doctor referral is required to receive program services. Your child must also meet these three criteria:
1. Medical complexity
Your child must see at least four specialists at UCSF Benioff Children's Hospital San Francisco.
2. Medical technology use
Your child must use at least one medical device, such as:
Respiratory support. Includes a nasal cannula, noninvasive ventilation device (CPAP, BiPAP), tracheostomy or home-based ventilator
Feeding tube. Includes gastrostomy (G-tube) or a nasogastric (NG) tube
Central line providing intravenous (IV) access. Includes central venous catheter, port-a-cath or peripherally inserted central catheter (PICC) line
3. Need for care coordination
There must be an unmet care coordination need, demonstrated by both of the following:
Several appointments necessary. Your child needs a range of care appointments in our hospital and clinics.
Lack of wraparound services. No other program is providing this coordination support for your family.
Providers
Jennifer Albon, MD
Pediatrics • Pediatric Hospital Medicine
Vivien Wentworth Bazarko, MD
Pediatrics • Pediatric Hospital Medicine
Kimberly Burfiend, MD
Pediatrics • Pediatric Hospital Medicine
Camila Cribb Fabersunne, MD, MPH
Pediatric Hospital Medicine
Related conditions & treatments
Treatments
- Feeding Tube Management
- Tracheostomy Management