Currently accepting new patients with high medical complexity. To refer to our clinic please call (512) 628-1833 or fax 512-600-8149 (Attention: Referral to CCC).

The Seton Children’s Comprehensive Care (CCC) clinic is a primary care clinic dedicated to the care of children with complex medical issues. This innovative model creates a cohesive family-centered care delivery system to provide wraparound care for children with challenging medical needs.

The CCC was established in January 2012 with four main objectives in mind:

• Reduce stress and burden on families
• Improve patient outcomes and quality of life
• Reduce preventable emergency room visits
• Decrease avoidable hospitalizations

We seek to bring comprehensive care to each child, offering continuity and coordination while considering family needs for sibling and caregiver support. The foundational premise to this approach is the understanding that in pediatric care, contextual needs are as important as physical needs, remembering that a child lives in the context of family—to support the family is to support the child.

How It Works

The CCC was developed as a pilot project by Seton Healthcare Family to rethink and redesign the way healthcare is delivered to medically fragile children and their families. Many of the children have feeding tubes, require regular infusions or use mobility devices such as wheelchairs. Some require around-the-clock care.

In addition to physical care, the CCC also offers behavioral health services on site in collaboration with Seton Mind Institute and Texas Child Study Center. The program offers psychiatry, psychology and counseling services.

Today, the CCC serves as the medical home for more than 300 children. Medical, behavioral and psychosocial care are all available under one roof, while innovative tools such as telemedicine are used to coordinate care with specialists, cutting down on burdensome travel for families.

Every new child’s case is reviewed by a multidisciplinary team of caregivers who meet with the family to identify care goals and priorities and develop a written care plan. A copy of the care plan, which is reviewed regularly, is then sent to all of the child’s physicians and care team members.

Families have 24-hour phone access to a medical provider on the care team who is familiar with their child’s medical history. In addition, same-day appointments are available. Childcare is available and staff members organize activities with the children while parents meet.

This family-centered approach has helped many CCC kids avoid costly and unnecessary emergency room visits and hospitalizations.

Funding & Demographics

More than 80 percent of CCC patients qualify for Medicaid. Almost one-third come from Spanish-speaking families, and the clinic employs two full-time Spanish interpreters so that conversation can take place in the family’s primary language. The CCC has established two parent advisory boards, one English-speaking and one Spanish-speaking.

The CCC research team has been diligently tracking caregiver burden using a survey tool called the PedsQL Family Impact module. In the first year of the DSRIP, the mean score for DSRIP family members was 60.40. The next year, the mean score increased to 64.88, suggesting less caregiver burden and higher quality of life.

In addition to tracking caregiver burden, the CCC tracks the following metrics:

• Total individuals served: 530*
• Medicaid coverage rate: 85 percent
• Flu vaccination rate: 73 percent

*This includes children who use the CCC as their medical home and children who have a medical home/pediatrician outside the CCC, but are receiving supporting services.

Beyond providing a medical home for CCC patients, DSRIP funding made possible under Medicaid’s 1115 Waiver has allowed the CCC to expand their pilot program and take on more patients. DSRIP funding is also being used to provide services to children referred by local pediatricians. These children have chronic medical conditions and are eligible for services provided by the CCC multidisciplinary care team such as counseling from behavioral health specialists, school advocacy by social workers and home visits by community health workers.

The CCC Team

Our interdisciplinary team includes:

• Physicians
• Nurse practitioners
• Medical assistants
• RN case manager
• Social worker
• Child life specialist
• Dietician
• Family liaison
• Community healthcare worker
• Child and adolescent psychologists and psychiatrists
• Experts in physical medicine and rehabilitation

Contacts:

• To refer new patients with high medical complexity, please call (512) 628-1833 or fax 512-600-8149 (Attention: Referral to CCC).
• Other inquiries can be directed to Kendall Sharp, RN MSN, CPNP AC/PC, Children’s Comprehensive Care Clinic/Clinical Operations Manager at 512-628-1875.

In addition to providing the services of our core team, we facilitate in-clinic consultation with child and adolescent psychology and psychiatry, and with physical medicine and rehabilitation.