Bringing peace of mind to complex care.

The Center for Children with Complex and Chronic Conditions (C5) is a comprehensive, child-centered program developed by Maynard Children’s Hospital and the Brody School of Medicine at East Carolina University. The C5 program provides care coordination for children with complex medical conditions, including resources and a support system that links the child, family and primary medical home to ensure the patient has access to all available and appropriate services and equipment.

C5 Model of Care

The C5 model of care provides resources and support systems that link the child, family, primary care medical home, appropriate medical specialists and the patient’s community care agencies. Together, C5 recognizes the importance of the family and the central role they play in a child’s care.

The goals of the C5 model of care are to:

  • Provide a seamless transition from hospital admission to home care, with a coordinated and interactive education program for caregivers.
  • Improve the quality of life and care for the child with complex and chronic medical needs and his or her family.
  • Create and coordinate a seamless system of care through increased communication between all subspecialists and primary medical home.
  • Serve as a resource to enhance the ability of primary care medical homes in eastern North Carolina to care for children with complex and chronic conditions.

Some of the services that we provide include:

  • Regular and scheduled home visits to include extensive social and clinical assessments and care coordination.
  • Providing prompt assistance to help manage and triage acute chronic complex medical needs to prevent unnecessary emergency room visits and hospital admissions.
  • Advocating for a child’s health care needs by maintaining constant communication with private duty nursing companies, durable medical equipment companies, outpatient therapies and community partnership agencies.
  • Consulting with new patients and families in the hospital prior to discharge to promote continuity of care with the transitions of discharge.
  • Connecting families to community resources, support groups, financial resources, quality of life activities and bereavement.
  • Assisting families with a child’s transition into adulthood, guardianship and transition to adult providers.

Patient Highlight – Leonardo Aquilar

Leonardo Aquilar was born prematurely at just 30 weeks with many issues along his gastrointestinal tract. He had surgery the day he was born and again at 3 days old, to fix a fistula. He eventually had a g-tube, ostomy and surgeries to fix his hernia and esophagus. Leonardo was able to go home after about 3 months.

“They pretty much became a family,” Maria Aquilar-Mendoza said. “The whole staff, especially the doctors, they became like a family to us. It was a really great experience.”

When he was 8 months old, Leonardo was admitted back to the hospital for respiratory distress and ended up spending another 4 months in the care of Maynard Children’s Hospital, including having a trach put in. He was eventually discharged and able to go home on a ventilator. During that precious time at home, Leonardo’s family really got to see their boy grow into a fun-loving child. He has since been able to wean off his ventilator and is now able to vocalize and eat by mouth! The C5 team has been an integral part of his care and outcomes along the way.

Care Coordination

The C5 team provides continuity of care by assisting with complex and chronic care needs with extensive care coordination and medical home management needs. C5 Care Coordinators assist the patient and family in identifying their needs and partnering with the families in advocating and managing the child’s complex medical needs, as well as locating resources to meet those needs.

The Care Coordination team can help with arranging therapies, educating caregivers, facilitating medical refills, accessing the emotional health needs of the caregivers and coordination of communication and documentation required by the entire patient care team.

Our highly skilled Care Coordinators provide home visits to continue evaluating the immediate and long-term care needs of the patient and assist the family and providers in meeting those needs.

C5 Outpatient Follow-Up Clinic

Our program’s outpatient follow-up clinic is located in the ECU Pediatric Specialty Clinic. Given we are constantly engaged in our patients’ care needs, we offer a bi-weekly outpatient follow- up clinic aimed at coordinating care with subspecialists to review and update plans of care. It is at these follow-up appointments where you will have face-to-face interaction with a medical provider skilled in the assessment, care and coordination of children with complex and chronic conditions.

Our Team

Our C5 team currently consists of a nurse practitioner, clinical care coordinators and a social worker. Our skilled team is dedicated to reducing unnecessary emergency room visits and hospital admissions by partnering with patients, caregivers, primary medical homes, subspecialists and community agencies to promote high quality care of the complex, chronic, technology-dependent pediatric in the home setting.