Pediatric Complex Care Coordination Program

The Pediatric Complex Care Coordination (PCCC) Program is dedicated to serving children whose complicated health conditions require them to see a variety of medical as well as nonmedical providers at UCSF Benioff Children's Hospitals San Francisco. The work of coordinating these visits and treatments commonly falls to families and can be a burden.

We're here to help. We strive to reduce care interruptions, improve communication among providers, and ease the transition from hospital to home. All medical decisions are made by your child's team of specialists or in collaboration with the team.

How we can help

We coordinate care by:

• Working with providers to group appointments on the same day or to schedule urgent appointments when needed
• Communicating with medical equipment providers if your child's needs are not being met
• Advocating on your behalf for support from community agencies, such as regional centers, schools, nursing agencies, in-home support services and California Children's Services
• Assisting with scheduling transportation by ambulance for appointments at UCSF Benioff Children's Hospitals in San Francisco

We ensure continuity of care by:

• Helping your child's specialty and hospital-based teams with discharge planning
• Organizing follow-up through MyChart (UCSF's secure patient portal), including phone, in-person and telehealth visits
• Creating a care coordination plan that identifies your child's medical challenges, members of their care team, and their individual medical needs
• Creating an access plan so that parents or other caregivers can contact the child's providers when needed
• Creating procedure cards (which list tools and other supplies needed for a doctor to perform a specific surgery) for children who have a known or likely need for surgical treatment

We educate and empower families by:

• Counseling them about day-to-day care for their children as the time of discharge approaches
• Partnering with them to develop safe, home-based care plans
• Coordinating education on medical devices (such as gastrostomy and tracheostomy tubes) while their children are still in the hospital
• Assisting them in navigating the health care system, including by solving problems once they're home
• Triaging non-emergency medical concerns and helping them connect with the correct specialists

Program eligibility

To receive services, children must meet certain criteria.

Complexity is assessed by the following:

• Patients have four or more subspecialty doctors at UCSF Benioff Children's Hospital San Francisco.

Patients use at least one of the following technologies (either part- or full-time):

• Respiratory support, such as nasal cannula, noninvasive ventilation (CPAP, BiPAP), tracheostomy, home-based ventilator
• Nutritional support, such as gastrostomy or nasogastric feeding tubes
• Central lines providing intravenous (IV) access (for example, Broviac, port-a-cath and PICC lines)

An unmet need for care coordination is identified due to the following:

• The family has to schedule a variety of inpatient and outpatient care.
• No other source is providing substantive care coordination.