Pediatric Complex Care Coordination Program

The Pediatric Complex Care Coordination (PCCC) Program serves children with complicated health conditions who also need special medical equipment, such as ventilators, central lines or feeding tubes.

We understand that our patients and their families must navigate a web of programs, medical teams, equipment suppliers, pharmacies and community agencies, and so we offer support by organizing visits and coordinating treatments at UCSF Benioff Children's Hospital San Francisco. We also help families work with the various teams caring for their child. Our goal is to prevent interruptions in treatment, improve communication among health care providers, and ease the move from hospital to home.

How we can help

We coordinate care by:

• Trying to arrange appointments on the same day, scheduling urgent appointments when needed, and arranging medical transportation for appointments at UCSF Benioff Children's Hospital San Francisco
• Communicating with medical equipment providers when the child's needs for such devices are not being met
• Advocating for support from community agencies, including regional centers, schools, nursing agencies, in-home services and California Children's Services

We provide continuity of care by:

• Facilitating discharge planning by the child's specialty and hospital-based teams
• Organizing follow-up care, including phone, in-person and telehealth visits
• Creating a care coordination plan that identifies a child's medical needs and challenges and their care team members
• Creating access plans so that parents or other caregivers can contact the child's providers when needed

We educate and empower families by:

• Providing information that helps families anticipate their children's day-to-day needs as the time of discharge approaches
• Partnering to develop safe home-based care plans
• Assisting families in navigating the health care system, including help with solving problems once they're home
• Triaging nonemergency medical concerns and connecting families with the correct specialists

Program eligibility

To receive PCCC services, children must meet three criteria.

1. Medical complexity: Patients must have four or more medical or surgical subspecialty doctors at UCSF Benioff Children's Hospital San Francisco.

2. The need to use one or more medical technologies:

• Respiratory support, such as a nasal cannula, noninvasive ventilation device (CPAP, BiPAP), tracheostomy or home-based ventilator
• Feeding tube, such as a gastrostomy or nasogastric tube
• Central line providing intravenous (IV) access, such as Broviac, port-a-cath or peripherally inserted central catheter (PICC) line

3. An unmet need for care coordination, as demonstrated by both of the following:

• The patient requires a variety of care appointments in the hospital as well as the clinic.
• No other program provides wraparound care coordination.