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Pediatric Complex Care Program


Caring for a child with complex medical conditions doesn’t have to be overwhelming. We provide you with the support and services you need to feel confident, comfortable and equipped to make informed decisions about your child’s healthcare.

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This page is for our littlest patients.

This program was made exclusively for kids and their caregivers. 

Simplifying your child's complex care

You may be referred to the Pediatric Complex Care Program (PCCP) if your child has two or more significant chronic conditions that need ongoing care. We take the extra steps to support you and your family as you work to manage your child's healthcare needs. Peace of mind in what can be a stressful situation is what we provide. We support you by:

  • Serving as your point of access 
  • Providing you with consistent care management and coordination
  • Developing an individualized care plan with your child’s doctors
  • Ensuring emergency management plans are effective and realistic for you
  • Educating and supporting your family in decisions and care plans
  • Connecting your family with social services and community resources
  • Assisting with your child’s transitions from a hospital stay or emergency room setting

You don’t have to go it alone. We take a family-centered approach and will provide support as your child is: 

  • Followed by multiple specialists for their complex condition
  • Dependent on medical technology (such as gastrostomy tubes, central venous access lines or tracheostomies) 
  • Seen for a chronic disease with significant developmental, behavioral or social concerns

To join this program, your child's doctor must refer them.

Specialist reading to a pediatric complex care patient who has a disability and is sitting in a wheelchair.
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If my child is enrolled in this program, do I have to change my primary care provider? 

No. We will support your child’s needs with any PCP or home care team. 

Will this program manage my child’s medical technology needs?

Your specialist will still manage and prescribe the technology your child needs. We will support them in any way needed.

When is the PCCP available for questions?

You should not worry about getting your questions or concerns answered. We are available Monday-Friday from 8am-5pm. You should always be in contact with your child’s PCP for preventative or urgent care.

Will the PCCP assist me in coordinating specialist appointments? 

Yes. Convenience is key. We work with you to schedule your Tufts Medicine specialists to fit your needs. For instance, when we can, we try to schedule multiple appointments on the same day so you make less trips. 

Can PCCP assist me with my family’s other non-medical needs (housing, transportation, etc.)? 

We know that getting what may be considered “non-medical” needs can be overwhelming and frustrating. We can help you find community resources to fit your and your child’s needs.


For referring MDs

The Pediatric Complex Care Program (PCCP) partners with families and their providers to offer comprehensive and coordinated care for infants, children and adolescents with complex medical conditions.

A referral form will be completed for children with significant, complex conditions followed by 3+ specialists or are depending on medical technology, including:

  1. Significant Complex Chronic: Defined as a physical, mental or developmental condition that can be expected to last at least a year, will use healthcare resources above the level for a healthy child, requires treatment of control of the condition, and the condition can be expected to be episodically or continuously debilitating.
  2. Chronic Diseases: Commonly lifelong but can be episodic with periods of good health between episodes. They include physical, developmental, or mental health conditions that may persist into adulthood but may also resolve either secondary to the natural history of the disease or as the result of a surgical intervention. These conditions involve a single body system, are not progressive, can vary widely in severity, and result in highly variable health care utilization.
  3. Social Complexity is defined as a set of co-occurring individual, family, or community characteristics that can have a direct impact on health outcomes or an indirect impact by affecting a child’s access to care and/or a family’s ability to engage in recommended medical and mental health treatments.

We provide care for pediatric patients with some of the following needs:

  • Cardiac
  • Craniofacial
  • Dermatologic
  • Endocrinologic
  • Gastrointestinal
  • Genetic
  • Genitourinary
  • Hematologic
  • Immunologic
  • Mental health
  • Metabolic
  • Musculoskeletal
  • Neurologic
  • Ophthalmologic
  • Otologic
  • Pulmonary and respiratory
  • Renal

Referring MD FAQs

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

At Tufts Medical Center at Tufts Medical Center, if patients are enrolled within the Tufts Medicine Care Plan ACO, they may benefit 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 meets the program criteria or has 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.

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.

Who should I refer?

If you have a patient who sees more than two Tufts Medicine specialists, 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.

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.

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.

Will you be managing all durable medical equipment or prior authorizations for patients that are referred to the PCCP?

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.

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 Tufts Medicine. For all other provider groups, it is best to speak directly with the clinics where the patient needs to be seen.

What if I am a specialist and want to refer a patient to the PCCP? 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 with the patient and family prior to completing 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. In addition, our team will begin to make a note of the patients’ upcoming clinical appointments at Tufts Medical Center. 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.

What hours is the complex care team available?

Our team is available Monday through Friday from 8 am to 5 pm. If you have an emergency outside of our business hours, medical and clinical issues should be addressed by your primary care team or specialist provider. You can reach the PCCP team on our main phone line at 617.636.9501 and 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 meets the program criteria or has 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 practitioners, nurse care managers and social workers.

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