Pediatric Complex Care Program (PCCP)

Referring Providers

At the Pediatric Complex Care Program (PCCP) at Tufts Children's Hospital, we are dedicated to supporting our community partners by offering comprehensive and coordinated care for your pediatric patients with complex medical conditions and special health care needs.

Whenever your patients need us, our team of experts will be ready to provide excellent care and supportive services in a compassionate, family-centered environment. We provide coordination of subspecialty medical care and home care, acute care and transition management, and psycho-social support. To be considered for enrollment in the Pediatric Complex Care Program, a referral from a primary care provider or specialist is required.

To refer a patient to the Pediatric Complex Care Program, please see information on eligibility here and fill out the referral packet here.

Frequently asked questions

1. What is the difference between the complex care and the ACO care team?

At Tufts Children's Hospital at Tufts Medical Center, if patients are enrolled within the Wellforce Care Plan ACO, they may benefit from any or all members of the ACO care team. The team is composed of an ACO nurse care manager, community health worker, and a social worker. The patients served by the ACO team all have Fallon.

The Pediatric Complex Care Program (PCCP) supports patients regardless of who their insurance provider is. If a patient or family meet the program criteria or have been recognized as a patient who would benefit from our services, then someone from the complex care team will assist. The PCCP team is composed of medical directors, nurse practitioner, nurse care manager, and social worker.

There are some patients who may fall within the ACO and the Pediatric Complex Care Program. If there is a designated ACO care team working with a child and family, the complex care team will work collaboratively with the team to best meet patient and family needs.

2. What do I tell my patient when I tell them about the program?

The program is an extension of their primary care provider and team. Our team will partner with patients’ primary care providers, specialists, home care agencies, and community support programs. The PCCP offers services such as: social work needs, care management support for home services or DME equipment, creation of care management plans in collaboration with specialists, resources related to a child’s diagnosis, and support for coordination of visits.

3. Who should I refer?

If you have a patient who sees more than two specialists at the Tufts Children's Hospital, your patient may meet our programs’ criteria. If you have a patient that is dependent on medical technology, or lives with one chronic condition AND has social or behavioral ongoing needs, you could consider referral to the program.

4. If I refer a patient, should I assume that patient is enrolled?

Our team will review each referral made to the program. There may be cases when a multidisciplinary team is already engaged with a family, or a family has an established home care team, where adding another team may not be the best fit. Our team will review every referral and ensure that you as the referring provider are aware of the review and the decision made, whether in enrollment or as a conduit to connect specialists with a patient’s home care team.

5. What will happen if I refer?

The PCCP team will review your referral form and assess the patient needs based on reported information and medical chart review. After confirmation of eligibility, our team will reach out to the family to discuss the program and confirm their interest. If the family agrees with participation, the PCCP team will inform the referring provider of enrollment. If the family does not agree to participate in the PCCP you will be notified that the family has declined to participate.

6. Will you be managing all durable medical equipment (DME) or prior authorizations (PAs) for patients that are referred to the Pediatric Complex Care Program?

The PCCP team is well aware that most practice settings have established processes in place to manage DME or PAs for their patients, and these processes will continue; however, we are happy to help assist with any questions that you may have. If there is an issue with a prior authorization for a complex care patient, the nurse care manager or a member of the team will review and help support by directing the questions to the appropriate person or agency.

As many of our patients have medical technology needs, our team will help support and develop emergency management plans when appropriate, but the program does not assume responsibility of managing and prescribing specialty medical equipment. We will collaborate and work with specialty services, but given the nature of management, specialty services will continue to order and prescribe for patients.

7. What if a patient is admitted to Tufts Children's Hospital at Tufts Medical Center? How will the Pediatric Complex Care Program be involved with families during their stay?

The PCCP team will check-in with patients and families known to the complex care program when admitted and be available for support for their transition to the hospital and back home. The Inpatient Attending and team is able to decide at any time to place a referral to the complex care program if they feel a patient would benefit from PCCP’s services and is not yet enrolled. Once the team has reviewed the referral form and assessed the patient’s needs, the complex care team will introduce themselves to the family and patient. Then, the team will help support the transition to home following discharge and will also make a plan to meet and speak to the patient and family when they return for a follow-up visit or via phone.

8. What if a patient ONLY needs coordinating of specialist appointments?

The complex care team is not intended to only and exclusively provide coordination of appointments. If you have a patient that needs to schedule appointments all on one day and has no other needs, there is a physician access line available for this service to providers within Wellforce (provide phone number)For all other provider groups, it is best to speak directly with the clinics where the patient needs to be seen.

9. What if I am a specialist and want to refer a patient to the Pediatric Complex Care Program? Is this possible and how do I do this?

The referral process is the same for both internal and external specialists. If you want to refer a patient to our program, we ask for you to discuss the program to the patient and families prior to completing out the referral form. This helps families anticipate that a team will be contacting them and helps us create a smooth introduction to our program when we approach and reach out to the families and their Primary Care Provider (PCP). In addition, our team will begin to make a note of the patients’ upcoming clinical appointments at Tufts Children's Hospital. We will schedule time to meet with the patient and family when they are here to introduce ourselves in person and our role in their care. The team will also schedule an appointment for a full comprehensive assessment for the family and patient at the start of enrollment of the program, as well as review our complex care mission, values, goals and family/program agreement.

10. What hours is the complex care team available?

Our team is available Monday through Friday from 8:00 am to 5:00 pm. If you have an emergency outside of our business hours, medical and clinical issues should be addressed by the PCP, primary care team, or specialist provider. We are happy to support providers and families by directing them to the most appropriate provider or person if needed while we are in the hospital. You can reach the PCCP team on our main phone line at 617-636-9501 and/or fax documents and requests to 617-636-4499.

The Pediatric Complex Care Program (PCCP) supports patients regardless of who their insurance provider is. If a patient or family meet the program criteria or have been recognized as a patient who would benefit from our services, then someone from the complex care team will assist. The PCCP team is composed of medical directors, nurse practitioner, nurse care manager, and social worker.