Special Needs Patient Care
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.
Department of Pediatrics
Children's Hospital of Wisconsin
P.O. Box 1997 MS C350
Milwaukee, WI 53201-1997
(414) 266-2926 (fax)