Complex Primary Care

complex care girl 180620_mc_116For some families, coordinating multiple pediatric specialists for your child’s complex conditions combined with medical equipment and hospital stays require a dedicated team to provide the best care possible. At Mary Bridge Children’s, we understand how challenging this can be for families. We are a specialized pediatric primary care team who manage and coordinate care for children who have complex medical needs. Our primary care team includes pediatricians, a nurse care manager, a care coordination assistant, a clinic nurse, and other clinical support. We are the primary “medical home” for children in our program and work closely with your child’s care team specialists, community, home health and school team. Our clinic is located at Mary Bridge Children’s Outpatient Center in Tacoma.

Who can be enrolled in Complex Primary Care?

Children who…

  • have three or more major organ system involvement
  • get care from three or more medical &/or surgical specialists (we do not count behavioral health)
  • have an unplanned hospital stay lasting at least five days or have at least 10 specialty clinic visits in the past year (we count therapies as one specialty visit)

Many of the children and adolescents we care for:

  • use a feeding tube
  • have seizures or other neurologic problems
  • have breathing issues or on a mechanical ventilator
  • take many medications
What is the first step for enrollment?

A parent, guardian, or health care provider can ask for a review of eligibility into our specialty clinic. Please call 253-403-7380 to request this. We will let you know our status of provider openings as sometimes they are closed to new patients.  If we are not accepting new patients, we ask that you call back every 3 months to check on status, if you remain interested. 

If we are accepting new patients, our clinical team reviews your child’s medical information to determine eligibility and will call you to schedule an appointment, if accepted for enrollment.  We ask that your child remain with their current primary care provider until seen by us.

If your child doesn’t meet eligibility for Mary Bridge Complex Primary Care, a letter will be sent to the person who requested the review. You may resubmit a request for review of eligibility, if your child’s condition changes.

Are there barriers to receiving care from the Complex Primary Care team?

Our mission is to serve children and families whose needs we have the expertise and resources to meet and cannot be met by other services or programs.

  • Sometimes, for certain health problems there are other doctors or teams that can best manage and coordinate care.
  • Some examples include cystic fibrosis, pediatric cancer, transplants, and cleft/lip and palate.
  • Sometimes for certain health conditions we do not have the expertise and resources. Examples include mental health disorders and chronic pain.
  • Sometimes our providers are not accepting new patients and we ask that you call back every few months to check on provider status. 
What happens after my child is enrolled in Complex Primary Care?

At the first visit:

  • we talk about your child’s history and current needs. 
  • we listen to your concerns and future needs.
  • we allow 90 minutes for routine visits and 60 minutes for sick visits.  The extra visit time allows a more comprehensive and coordinated service for the best care of your child.
What happens after my child’s visit?
  • We will see your child at least every 4 to 6 months. If your child is due for a physical, we will schedule that as soon as possible and provide catch up vaccines, if needed. 
  • Our nurse care manager or care coordination assistant will reach out to you and schedule a Shared Plan of Care (SPoC) consultation when you and your child’s provider determine best timing for this. SPoC’s are created together with you, your child’s pediatrician, and our nurse care manager, and care coordination assistant. Consultations are about 2 hours long.
  • We provide phone advice and/or clinic visits when your child is ill. We may give advice on how to manage issues at home, see your child for an urgent care visit or contact the emergency department to give some background on your child.
  • Our providers will support you and talk with the inpatient care team for your child, if/when your child is in the hospital.
  • Between visits, please call us if you have questions and don’t know who to ask. We may call you to provide test results, schedule due/overdue appointments, and ask questions about your child’s medical care needs. Please let us know if your phone number or address changes. 
  • We can help you schedule appointments, talk to insurance providers, arrange medical equipment or other supplies, and assist with forms, home health plans, and community resources.
How long can my child be part of Complex Primary Care?

Your child will graduate from our care:

  • when care transitions from pediatric to adult providers, usually around age 18. We help your child with this process.
  • if you find our services are no longer needed/helpful or your child’s medical issues become less complex and can be managed by a general pediatric practice. This will be a shared decision.

Sometimes we find it is no longer working…

  • if your child misses three scheduled Complex Primary Care visits without giving us notice.
  • if we cannot reach you by phone or electronic contact after multiple attempts in a 3-month period.
How can my child be successful in Complex Primary Care?

We believe you know your child best and our goal is to be your partner in caring for your child’s unique needs. Please talk with us if you don’t understand your child’s illness, treatment plan, or you feel the plan is not working.

What is your contact information?

Mary Bridge Children’s Complex Primary Care (CPC) Clinic

311 South L Street – 2nd floor – East Wing

M/S: 311-1-CPC

Tacoma, WA 98405

Phone:  (253) 403-7380

Fax:  (253) 403-7853

Hours:  M-F  9 am – 4 pm