Patient Care

The Special Needs Program (SNP) offers comprehensive care coordination for medically complex and fragile children who do not have existing care coordination services. Our goal is to ensure seamless inpatient and outpatient care. The SNP partners with patients/families and primary care providers to help optimize coordination. All patients enrolled in the Special Needs Program have a SNP nurse case manager, and some also have a SNP physician care coordinator. All patients in the SNP are encouraged to have a Primary Care Provider. Families, providers, or any caregiver may refer a child to the SNP.

Care Coordination Services

  • Facilitating communication between providers, such as hospital staff, primary and specialty care providers, durable medical equipment companies, pharmacies, social workers, community agencies and education systems.
  • Providing patients/families with the necessary information to make informed decisions about their child’s health care.
  • Helping patients/families navigate the health care system.
  • Creating and updating comprehensive clinical summaries.
  • Advocating for a patient’s best interests.
  • Providing emotional support to patients/families.
  • Expediting consultations or other services.
  • Organizing and facilitating care conferences.
  • Assisting with managing patients during hospital stay.
  • Coordinating health care appointments.

Program Eligibility Criteria

Individuals, age 21 and younger, with multiple medical needs may be referred to the program.

All Special Needs Program patients have:

  • Ongoing chronic medical problems.
  • Multiple specialists (average is eight per patient).
  • Many clinic appointments and/or long hospitalizations.

Some patients may have:

  • An unknown diagnosis.
  • A long commute to the hospital.
  • A life change that affects their health.
  • Other barriers to care.

How to Make a Referral

Anyone involved in the care of a child with multiple medical needs, including parents or health care professionals, may make a referral to the Special Needs Program. The program staff reviews each referral and will schedule a consultation to determine care coordination needs and program eligibility. Patients who are eligible will be offered enrollment in the program. For general program information, call (414) 266-6943.

To make a referral to the program, call (414) 266-6943 or toll-free (888) 249-7233.

Contact Us

Pediatrics Special Needs
Department of Pediatrics
Children's Hospital of Wisconsin
P.O. Box 1997 MS C350
Milwaukee, WI 53201-1997

(414) 266-6943 | Fax: (414) 266-2926
E-mail us

Pediatrics Special Needs Site Map

Medical College of Wisconsin
8701 Watertown Plank Road
Milwaukee, WI 53226
(414) 955-8296
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© 2015

Page Updated 07/13/2015
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