UF Health Pediatric Care Coordination Program

UF Health’s Pediatric Care Coordination Program (PCCP) is a family-centered, community-based model for the care of children with special health care needs.

Patients enrolled in the PCCP generally have multisystem organ disease, technology dependence and frequent hospitalizations. The premises upon which the program was designed include:

• The home is the best place for a child to heal, to grow and to develop.
• A pediatrician providing primary care is essential, even when the child is seeing many specialists. That pediatrician should have the support of, and access to, the specialists at the medical center.
• The family should have the opportunity to identify their priorities, concerns and resources in relation to the care of their child.
• The family and the primary care provider should have input on the goals of care. All professionals who are involved with the child should know what those goals are.
• Coordination of care promotes the attainment of those goals, while it increases the satisfaction of the family and professionals involved.

With those premises in mind, the PCCP offers the following benefits:

• Case coordination: A nurse case manager is available to the family and professionals to organize services in the community and in the hospital, if necessary.
• Access to services: A 24-hour phone line is available to the family and professionals to provide assistance. One of the PCCP staff members is always on call and can advise the parent, the home care nurse, or the physician on issues of care.
• Continuity of assessments: Under the standard method of care, professionals may do independent evaluations of the motor abilities, cognitive abilities, speech abilities or health status of the child without having the proper channels to share it with other professionals. The PCCP ensures that evaluations are shared with the entire team working with the child and promotes interaction of those team members through periodic meetings and communiqués.
• Preadmission planning and discharge planning: The PCCP staff notifies all services in the hospital of a child's impending scheduled admission. Tests and therapies that can be carried out while the child is hospitalized are scheduled, thus avoiding unnecessary hospitalizations and clinic visits. As patients are discharged, the PCCP arranges for community services and assists homecare staff in devising a child care plan.

The PCCP is dedicated to making the lives of children with special health care needs, and the lives of their families, a little easier

Make a Referral

Criteria for UF Health Pediatric Care Coordination Program Referral

Physician referral is appropriate if:

• Two or more body systems with significant chronic conditions (significant chronic condition is defined as a physical, mental or developmental condition that can be expected to last at least a year, will use health care resources above the level for a healthy child, require treatment or control of the condition, and the condition can be expected to be episodically or continuously debilitating)
• OR a progressive condition that is associated with deteriorating health with a decreased life expectancy in adulthood
• OR continuous dependence on technology, or expected dependence, for at least six months
• OR frequent or prolonged hospitalizations and/or pediatric emergency room visits
• AND parental willingness for the Pediatric Care Coordination Program to assume primary care of the child
• AND primarily use UF Health Pediatric Specialists for care
• AND must reside within a 60-mile radius from Gainesville
• AND have reliable transportation and a working telephone service