Complex Primary Care

At Mary Bridge Children’s, we understand how challenging this can be for families. We have a specialized pediatric primary care team that manages and coordinates care for children who have complex medical needs. Our team includes pediatricians, a nurse care manager, a care coordinator, a clinic nurse as well as other clinical and social support.

We are the primary “medical home” for children in our program and work closely with your child’s specialists, community, home health and school teams.

Who is eligible for Complex Primary Care?

Children who:

• Have three or more major organ systems involved in their medical condition(s)
• Get care from three or more medical and/or surgical specialists (not including behavioral health)
• Have an unplanned hospital stay lasting at least five days or have had at least 10 specialty clinic visits in the past year (we count therapies as one specialty visit)

Many of the children and adolescents we care for:

• Use a feeding tube
• Have seizures or other neurologic problems
• Have breathing issues or use a mechanical ventilator
• Take many medications

How can my child receive Complex Primary Care?

Please call 253-403-7380 to inquire about a child’s eligibility for Complex Primary Care. We will let you know if our providers have openings, as sometimes they are closed to new patients. If we are not accepting new patients and you remain interested, please call back every three months to check on availability.

If we are accepting new patients, our clinical team will review your child’s medical information to determine eligibility. If they are eligible, our team will call you to schedule an appointment. We ask that your child remain with their current primary care provider until seen by us.

If your child does not meet eligibility for Complex Primary Care, a letter will be sent to the person who requested the review. You may resubmit a request for review of eligibility if your child’s condition changes.

Are there barriers to receiving care from the Complex Primary Care team?

Our mission is to serve children and families whose needs cannot be met by other services or programs. Sometimes, however, our providers are not accepting new patients, and we ask that you call back every few months to check on provider status.

Another reason a child may not be eligible to receive Complex Primary Care is if they have certain health problems that are best managed by specialists with the expertise and resources for these conditions. Examples include cystic fibrosis, pediatric cancer, transplants, cleft lip or cleft palate, mental health disorders and chronic pain.

What happens at the first Complex Primary Care appointment?

At the first visit we will:

• Talk about your child’s history and current needs.
• Listen to your concerns and future needs.
• Allow 90 minutes for routine visits and 60 minutes for sick visits. The extra time allows a more comprehensive and coordinated service to provide the best care for your child.

What happens after my child’s visit?

We will see your child at least every four to six months. If your child is due for a physical, we will schedule that as soon as possible and provide catch up vaccines, if needed.

Our nurse care manager or care coordinator will reach out to you and schedule a Shared Plan of Care (SPoC) consultation when you and your child’s provider determine best timing for this. SPoCs are created together with you, your child’s pediatrician, our nurse care manager and care coordinator. Consultations last approximately one to two hours.

We provide 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 acute visit or contact the emergency department to give some background on your child.

Our providers will support you and talk with the inpatient care team for your child, if/when your child is in the hospital.

Between visits, please call us if you have questions and don’t know who to ask. We may call you to provide test results, schedule appointments and ask questions about your child’s medical needs. Please let us know if your phone number or address changes.

We can help you schedule appointments, talk to insurance providers, arrange medical equipment or other supplies, and assist with forms, home health plans and community resources.

How long can my child receive Complex Primary Care?

Your child will graduate from our care:

• When care transitions from pediatric to adult providers, usually around age 18. We help your child with this process.
• If you find our services are no longer needed/helpful, or your child’s medical issues become less complex and can be managed by general pediatric primary care. This will be a shared decision.

Sometimes we find Complex Primary Care may no longer be working if:

• Your child misses three scheduled visits without notice given
• We cannot reach you by phone or email after multiple attempts over a three-month period

What if I have questions about my child’s care?

We believe you know your child best. Our goal is to partner with you in caring for your child’s unique needs. Please feel free to speak with us if you don’t understand your child’s illness or treatment plan, or if you feel the plan is not working.