The Boston Medical Center project will test a Collaborative Care Coordination and Consultative Model for Complex Kids (the 4C, or "Foresee" Program) which pairs Complex Care Nurse Care Coordinators and Pediatricians at MACC sites in Boston and Springfield with pediatricians in the community to enhance and improve the care delivered to children with medical complexity in local medical home-like settings. Prior to enrolling in the MACC, families will undergo a comprehensive process of intake, multi-disciplinary assessment and care planning which will be used as the basis for a Comprehensive Care Plan for the child and family.
All local pediatricians referring children to the MACC will also have access to consultation by a Psychiatrist, Developmental/Behavioral Pediatrics Specialist, Clinical Social Worker, and Nutritionist. Families will have access to the services of a Family Navigator to help them overcome access barriers, advocate for them, and coordinate among multiple agencies. Families will also have access to behavioral health services provided by the MACC for those in proximity to Boston Medical Center and Baystate and by referral for families in outlying areas. The complex care Pediatrician will see the patient at least once every six months and the Comprehensive Care Plan will be reviewed and revised at least once annually.
