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Complex Care Coordination

When your child requires complex care, our team will assist in navigating your child’s health care needs.

Our care team offers support for children with complex chronic medical conditions, providing a link between your child’s specialists, primary care team, and you.

This service is available for children with very complex chronic conditions that require intense in-home care and many visits to see multiple specialty doctors each year.  

Care coordinators are your health care resource so you can spend more time with your family and less time worrying about health care. They provide help in many areas including:

  • Assisting with transportation and other barriers so you can get to your child’s appointments.
  • Providing support after an appointment if you have additional questions or need help setting up follow-up care.
  • Help with problems filling prescriptions and picking up medications or equipment.
  • Working with community partners involved in your child’s care including your child’s school or in-home nurse.
  • Assisting in filling out paperwork and making sure you understand what it is for.
  • Working through issues with the Family and Medical Leave Act (FMLA), insurance and other programs.
  • Providing some mental health and social support.

Your child must meet specific criteria to qualify for care coordination. This service is for children with complex chronic conditions receiving primary care services with Marshfield Clinic Health System. Talk to your child’s primary care provider for more information.

Enrolling in the program

These are the requirements to qualify for the care coordination program:

  • Your child must have more than 10 specialty or sub-specialty appointments a year or 5 or more days in a hospital.
  • Your child must have complex chronic conditions.
  • Your child must receive care from three or more medical or surgical specialists.
  • Your child must receive care for three body systems.
  • There may be exceptions to these requirements for newborns.

If your child qualifies, an appointment will be scheduled when an opening is available. At this appointment, you and your child will meet with our care coordination team to talk about your child’s medical history and current health concerns. Using this information, we will create a care plan for your child. If your child does not qualify, talk to your child’s primary care provider about available resources that may meet your child’s needs.

Program outline

Your child will continue to receive care coordination services if you comply with the program requirements of:

  • Contact every month via phone or telehealth to ensure everything is going well.
  • Regular follow-up visits with a care coordinator every six months. These visits typically are on the same day as your child’s other appointments.
  • Visits when your child is in the hospital or contact after discharge to ensure nothing falls through the cracks.

Your child can stay enrolled with the program until age 26 as long as they transition to a family practice or Med-Peds provider in our system for adult primary care. Your care coordination team will help you decide when your child may be able to formally graduate from the program.


Call us at 715-389-3064.