Complex Care

Complex Care at Gillette is a program with a comprehensive team looking at the whole individual.  We aim to coordinate health care, and partner with patients and families to work towards physical, emotional and social well-being. We work with individuals and families to develop reachable goals related to medical and non-medical needs, identify gaps in care, and plan next steps. 

To help ensure we meet the needs of each individual, we partner with many different experts and resources in the community. Your Complex Care team closely collaborates with:

• Different specialties across Gillette, like Social Work or Dieticians
• Your specialists outside of Gillette 
• Your primary care team
•  Community support services

Complex Care Clinic at Gillette is specifically designed for children or young adults ages 0 to 26 who have multiple chronic, health conditions or complex medical needs such as neurodevelopmental disabilities or are technology dependent.

The Gillette Complex Care team can provide care for your child in the following ways: 

• Complex Care Clinic - focuses on centralizing and coordinating care for the most medically complex patients.
• Quick Care Clinic - focuses on treating patients who are experiencing minor illnesses that require non-urgent care from providers who have training and experience in acute complex pediatrics.
• Presurgical Patient Assessment and Risk Evaluation (PrePARE) - provides comprehensive, specialty-focused risk assessment and guidance for patients who have upcoming, high-risk surgical procedures.

Your child’s provider will do an extensive review of your child’s medical records that are available prior to your appointment.

Your child’s initial Complex Care Clinic visit will take approximately 2 hours. Our team will want to talk about your child’s medical history, current health status, and services (home, school and community) and understand any current concerns. We will complete a full physical exam, and then working with caregivers, we’ll coordinate
a care plan of services (such as lab work, imaging, and referrals). Your child might need these services in the coming year, including follow-up in our Complex Care Clinic.

Follow-up appointments will be 1 hour as we review the current plan, current conditions, and update your coordinated care plan. As part of your coordinated care plan we can help to complete documents for community services or supplies. As your child ages, we will also help with the transition to adult care services.

Our Complex Care model puts your child at the center of care, supported by coordinated work with your primary care provider and other subspecialists. With Complex Care, you have a point person to help coordinate care for your child.

Instead of focusing on one primary area such as orthopedics or neurology, we look at the whole child. We partner with the family and/or primary caregiver to proactively meet the needs of your child.

• Assesses your child head-to-toe using a comprehensive whole child approach 
• Partners with you and your child to identify and proactively address your concerns 
• Recommendations and if needed, referrals for specialty care, home care and community services 
• Provides help coordinating the multiple aspects of your child’s health 
  • Direct access to patient navigators for scheduling all your Gillette appointments 
  • On-going communication with complex care nurse care coordinators to:
    • Understand your child and family’s strengths and priorities 
    • Carry out the plan set during your child’s complex care visit 
    • Address new concerns  
    • Communicate with your child’s primary care provider, school and home health or supply agencies 
• Assess urgent changes in your child’s health in Gillette’s Quick Care Clinic 
• Assess your child’s health prior to planned surgery in Gillette’s PrePARE clinic 

If your child has a complex condition, you can count on the Gillette Complex Care team to bring together services in a way that’s both comprehensive and convenient.

Complex care specialists often collaborate and partner with providers in:

• Dentistry and orthodontics.
• Gastroenterology.
• Neurology.
• Neurosurgery. 
• Nutrition and feeding.
• Orthopedics. 
• Pulmonology and respiratory care.
• Rehabilitation therapies.
• School services. 
• Sleep medicine. 
• Social work. 

Patients can get an appointment through self-referral or referral by their primary care provider, specialty provider.

To make an appointment or to learn more about Gillette’s Complex Care Program: 

• Patients/Families: Please call 651-310-1807  
• Providers: Please call 651-325-2200