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Gillette Complex Care Clinic Creates Roadmap to Wellness

Madeleine Gagnon, MD, recently assumed a role as a complex care pediatrics physician at Gillette Children’s. Now that she’s been on staff for a bit, we sat down with her to talk about the role the Complex Care Clinic will serve at Gillette.

Q: Just to get started, what does the Complex Care Clinic do?

Madeleine Gagnon: In the Complex Care Clinic, we focus on centralizing and coordinating care for children and young adults who have chronic and complex medical conditions. Our goal is to maximize the quality of life for our patients, but rather than focusing on one primary area (Rehabilitation, Orthopedics, Neurology, etc.), we’re looking at the whole patient, from head-to-toe. We use a multidisciplinary, systems based approach to assess current problems as well as anticipate future needs, and then we partner with our patients' guardians, primary care providers and sub-specialty physicians to put together a plan to quarterback their care for the coming year.

Complex care pediatrics can help children who have complex conditions maximize their health.

Q: That sounds like it would involve quite a few people?

MG: Yes! Our primary team is made of physicians, nurse practitioners, nurses, dieticians, social workers, administrative assistants, and schedulers. It’s not just medicine, a lot of it is logistics. But the beauty of this care model, is that it provides support for our guardians and caregivers by establishing us as a centralized point-of-contact for both inpatient and outpatient care providers.

Q: I would imagine that this care model relieves a lot of the scheduling burden for families?

MG: Absolutely. The thing is, there is a big difference between hospital life and real life. I think our staff already does a great job in terms of making sure that our patient’s “hospital lives” go as smoothly as possible. It’s really my view that Complex Care is here to complement and enhance the great services we currently provide every day at Gillette, both outside and inside our walls.

Q: So, you’ve talked a little about working with our staff internally in the hospital, how does that relate to working with external or referring providers?

MG: First and foremost, what I try to get across when working with external providers, and frankly with our families as well, is that we view the care process as a partnership. Everyone wants the best outcome for our patients, but we can’t all be everything to everyone all the time. We each have a role to play, because these kids often have a lot going on, and issues overlap to an extent that it’s easy to become overwhelmed. What we try to do is to plan for everything that we can, and that can relieve a lot of stress when unexpected issues arise.

We know that our patients are going to need help with scheduling therapies, acquiring nursing, primary care assistants, medical equipment and securing benefits. They’re also going to need to get their eyes checked, receive dental care and get help with feeding. All of that is put into our checklist when we plan out our roadmap of care, which is then shared with our families as well as their primary care providers.

There can be a lot of cooks in the kitchen at times, but we’re always happy to pick up the phone and get things figured out. We’re all working towards the same goal, which is to transform disability into ability, and the Complex Care Clinic is just one more way we can help our patients get to where they need to be.