Updates

Refer a Patient Complex Care Clinic

If you are a patient, please visit the Complex Care Clinic for more contact, scheduling, and location information.

Referring Provider Instructions

The Complex Care Clinic offers two distinct care options.  Please review guidelines and select the option that best meets the needs of your patient based on such guidelines.

Requirements for Transitioning to a Complex Care PCP

  1. Review guidelines

To ensure that your patient receives the best possible care, please review the referral guidelines below and submit the requested information with the online referral form.

  • Patient must meet the minimum requirements here for consideration of admission:
    1. Referral by current PCP or subspecialist.  Self-referrals not accepted.
    2. Must meet all categories listed below:
    3. Medical Complexity
      1. Complex medical diagnoses
      2. Technology dependence – requires one
        • Respiratory – invasive ventilation, NIPPV, tracheostomy
        • Nutritional/gastrointestinal – gastrostomy tube, gastrojejunostomy tube, ostomies, TPN
        • Vascular – central line (case by case basis dependent on diagnosis)
        • Cardiac – complex cardiac support devices (LVAD)
      3. Greater than 2 core specialists that are seen on a routine basis, i.e., every 3-6 months and the specialists are actively engaged in the care plan OR
      4. Severe functional limitations that impact ADLs (inability to provide basic self-care)
    4. Live within a 75-mile radius of the clinical site
    5. Exclusions
      1. Primary mental health/behavioral health diagnosis
      2. Lives beyond 75-mile radius
      3. >17 years of age
      4. Family declines referral
    6. Clinic Overview
    7. The CCC will serve as the Primary Medical Home for the child with medical complexity and assume the role of PCP.
    8. Services included:
      1. PCP care with Pediatrician or Nurse Practitioner
      2. Embedded care coordination teams for every patient
      3. Clinical dietitians
      4. Social Work
      5. Clinical staff experienced with children with medical complexity
      6. Child and Adolescent Psychiatrist
      7. Respiratory therapist in clinic
      8. 24 hour on-call service
      9. In person and Telemedicine appointments
      10. Well child care, routine follow up and urgent visits available
  • The Complex Care Clinic will serve as centralized provider and the ongoing Patient-Centered Medical Home for complex patients.
  • When all required information has been received, the nurse coordinator will contact the referring physician and/or patient's family once a decision is made regarding acceptance within 2 weeks.

**Please ensure that all appropriate caregivers have been notified of this referral PRIOR TO initation with the Complex Care Clinic**

  1. Complete the online referral form or submit via Texas Children's Link
  1. Provide patient with scheduling instructions
  1. Follow your patients’ care
    Request access or log in to Texas Children's Link, an online provider portal connection to Texas Children’s electronic medical record. With Texas Children's Link, you are able to place and cancel orders and referrals, access patient medical records, view images, receive updates and notifications, and more.

Requirements for Complex Care Consult Service

  1. Review guidelines

Texas Children’s offers a Complex Care Consult Service for patients who may not meet the complexity requirements for the Complex Care PCP clinic but who still need support. All appointments for the Consult Service can be held via telemedicine.

To ensure that your patient receives the best possible care, please review the referral guidelines below and submit the requested information with the online referral form.

  • Patient must meet the minimum requirements here for consideration:
  1. Referral by current PCP or subspecialist.  Self-referrals not accepted.
  2. Patients must also reside in Texas meet at least one of the following criteria:

•Medical Complexity: Multiple chronic conditions requiring coordination across providers OR a single complex condition with significant care coordination need

•Technology Dependence: Tracheostomy, invasive ventilation, NIPPV (BiPAP, CPAP), gastrostomy tube, GJ tube, ostomies, TPN, central line, or complex cardiac devices (e.g., LVAD)

•Care Coordination Complexity: Followed by >1 core subspecialist every 3–6 months, OR significant functional impairments affecting ADLs, OR unresolved medical concerns requiring CCC support

Exclusions: Primary diagnosis is behavioral/mental health without complex medical comorbidities, high-risk social situations without medical complexity, older than 17 years, lives outside of Texas, and/or family declines consultation 

2. Complete the online referral form or submit via Texas Children's Link

  1. Provide patient with scheduling instructions
  1. Follow your patients’ care
    Request access or log in to Texas Children's Link, an online provider portal connection to Texas Children’s electronic medical record. With Texas Children's Link, you are able to place and cancel orders and referrals, access patient medical records, view images, receive updates and notifications, and more.

Need Help?

If you are a referring provider’s office needing referral assistance or a provider needing to speak to an on-call specialist, please contact the Provider Connect team, M-F 8a-5p, excluding holidays:

  1. Phone: 832-TCH-CARE (832-824-2273)
  2. Toll-Free: 877-855-4857
  3. Email: providerconnect@texaschildrens.org
Learn more