Complex Medical Care Program
A family-centered approach to caring for children with complex medical needs in St. Louis.
Having a child with complex medical needs can transform family life into a flurry of appointments and hospital visits. It can stretch even the most dedicated families, emotionally, physically, and financially.
A first-in-the-region program
The Complex Medical Care Program at SSM Health Cardinal Glennon Children’s Hospital, led by SLUCare Physician Group, is the first of its kind in the region. We provide peace of mind through a cooperative, team-based approach that ensures every aspect of your child’s care is addressed.
What do we offer?
Our team coordinates and optimizes care to help families thrive through our:
- Multidisciplinary team of pediatricians, nurses, social workers, dietitians, respiratory therapists, and administrative aids
- Streamlined care coordination across specialists and health care settings
- Reduced hospital and emergency room visits through proactive planning
- Support throughout your child’s medical journey, from clinic to home
Who do we serve?
We care for children in St. Louis and surrounding communities who:
- Are 14 years old or younger
- Receive care from four or more subspecialists
- Have frequent or extended hospital stays
- Are not receiving coordinated care through another service
Many of our patients have rare genetic conditions, birth injuries, or other traumatic injuries. Children often enter the program after time in the NICU or PICU, through referrals from primary care providers, specialists, or support groups.
How do we help?
Our program is designed to ease the burden on families by improving care coordination and reducing:
- Average length of hospital stays
- Time spent in critical care environments
- Number of emergency room visits
We do not replace your child’s primary care physician or specialists. Instead, we provide an extra layer of support to streamline treatment and communication across providers.
Which services do we provide?
Our team works together to deliver comprehensive care through:
- Team-based clinic visits to reduce the number of appointments and copays
- Individualized care plans documenting conditions, medications, psychosocial needs, and treatment history
- STARS alert system to flag medically complex patients upon hospital arrival
- Appointment coordination across hospitals, outpatient clinics, long-term care facilities, and home health providers
- Support with non-clinical needs, including school forms, work notes, and insurance claims
- Education for caregivers to confidently manage care at home
- Ongoing communication with families, primary care providers, and specialists
About our team.
During a complex care visit, families may meet with:
- SLUCare pediatricians
- Complex care nurses
- Social workers
- Dietitians
- Respiratory therapists
- Care coordinators
- Administrative aids
Additional specialists may include:
- Physical and occupational therapists
- Wound care nurses
- Palliative care experts
- Clinical pharmacists
- Mental health professionals
Supporting families in St. Louis.
We understand the emotional and psychological strain of caring for a medically complex child. Our team is committed to strengthening the voice of every child and family, respecting each child’s unique needs and nurturing the factors that support their health and well-being.
Frequently Asked Questions
The Complex Medical Care Program is based at SSM Health Cardinal Glennon Children’s Hospital in St. Louis, Missouri. Families from surrounding areas may be eligible depending on their child’s medical needs and care coordination requirements.
Yes, your child still needs a primary care physician. Our multi-disciplinary team does not take the place of a child’s primary care physician or pediatrician. Our program is an opportunity for your child to be seen by multiple team members with different health care skills.
Our scheduler / care coordinator can assist with appointments at SSM Health Cardinal Glennon or affiliated SSM Health locations. While same-day scheduling is not guaranteed, we work hard to accommodate family schedules.
The Special Needs Tracking and Awareness Response System (STARS) is an alert system that flags medically complex patients upon arrival at the hospital, ensuring the complex care team is engaged immediately. Learn more about STARS for special needs kids.
Children typically qualify if they are 17 years old or younger, have four or more subspecialists, and experience frequent or extended hospital stays. Many have rare genetic conditions, birth injuries, or other traumatic injuries.
We help families manage both clinical and non-clinical aspects of care, including education, insurance paperwork, school forms, and emotional support through a multidisciplinary team.
