The Medically Complex Care Program at Children’s Healthcare of Atlanta exists to improve the quality of life for some of our most complex patients by providing patient- and family-centered care that is comprehensive, collaborative and coordinated.
Children in our Medically Complex Program have multiple chronic conditions, including all of the following:
- Severe neurological injury
- Technology dependence
- More than 3 specialists
- A history of hospitalizations
At this time, there are complex patients who we do not treat in our program, including children who have the following primary conditions:
We recognize that these children are equally medically complex but have unique challenges and needs that are best served by their respective specialty programs at Children's.
Other specialty programs (list is not all-inclusive):
- Aflac Cancer and Blood Disorders Center
- Heart Center and outpatient cardiology clinics
- Transplant Programs
The Medically Complex Care Program consists of a multidisciplinary team of physicians, advanced practice providers, nurses, social workers, case managers, respiratory therapists and nutritionists. When your child has complex care needs, there is one team that knows your child across the continuum of care—both inside and outside the hospital.
Our medical providers and clinic staff will help facilitate:
- Discussions with your child’s subspecialist(s), pediatrician, school, durable medical equipment companies and insurance companies.
- Coordination of appointments.
- Medication refills.
- Medication reconciliation assistance during inpatient admissions.
- Clear goals of care.
- A continuum of care across inpatient and outpatient settings that includes a medical passport, an emergency care plan and a medical summary.
- Assistance with outpatient medical concerns and needs to help reduce the number of visits to the emergency department, urgent care and/or hospital.
- Access to community resources and support groups.
Our goals with this program include:
- Optimizing your child’s health.
- Improving the patient and family experience.
- Increasing collaboration of care.
- Margaux E. Charbonnet, MD, Hospitalist
- Jennifer M. Madden, MD, Pediatrician
- Pooja Soni, MD, Hospitalist
- Jodi L. Sindelar, PA-C, Physician Assistant
- Sonal Bahri, PNP, Pediatric Nurse Practitioner
- Heather Blake, RN, Clinic Nurse
We have a waiting list for our program. However, we are accepting new patients through a rolling admission process. All patients enrolled must meet all program criteria in order to be eligible. Please email referrals to email@example.com. If your child is not already in the Children’s System, you should send all pertinent medical records and contact information to the e-mail address provided or fax to our nurse navigator at 404-785-7959. We review these referrals on a regular basis and add patients as capacity allows.