Care Management Department

The Care Management team at Children's Hospital of Philadelphia (CHOP) helps families coordinate care for children with complex medical needs. We focus on the big picture by partnering with families to manage many of the important factors that affect health. You must be referred by a CHOP provider to receive care management services. If interested, please contact your CHOP care team for more information.

Who we treat

Care management is for children who have:

  • Complex medical conditions affecting multiple body systems
  • Doctors from many different specialties at CHOP
  • Several inpatient or emergency visits a year at CHOP
  • Goals that care management can help meet

Services we offer

A nurse care manager will partner with families and care teams to:

  • Improve communication among healthcare providers
  • Advocate for the child's healthcare needs
  • Help coordinate the plan of care, including outpatient visits
  • Support transitions across care settings, such as discharge from the hospital
  • Answer questions between visits about the child’s care at home
  • Teach families skills for self-management and navigation of the healthcare system

All care management interventions are time limited. Patients are discharged when goals are met. Our purpose is to teach families how to manage care for their children and navigate the healthcare system independently, focusing on achieving patient-centered goals.

Care Management Programs

CHOP Compass Care Program

This consult team and clinic is for children from birth to age 17 who see many CHOP specialists. This team does not provide primary care. Patients are encouraged to continue their relationship with their existing primary care provider. In Compass Care, a multidisciplinary team will coordinate your child's care during office visits and between appointments. This consult team also follows patients during hospitalizations at CHOP. To learn more, visit the Compass Care website.

Adult Care and Transition Team

The Adult Care and Transition Team connects young adults (age 18 and older) who have complex medical needs with many CHOP specialists. This interdisciplinary consult service works with adult patients, families and healthcare teams to improve the quality and safety of the transition from CHOP to adult healthcare. A multidisciplinary team coordinates care for these patients during office visits, between appointments, and assists with the transition to adult care. To learn more, visit the Adult Care and Transition Team website.

Care Management in Primary Care

Care Management in Primary Care is for children who have medically complex conditions and receive primary care at CHOP. Nurse care managers partner with primary care providers to help families coordinate the child’s plan of care during and between office visits. To learn more, visit Care Management in Primary Care

Care Coordination for Asthma Patients

Nurse care coordinators can help families manage their child's asthma plan and support transitions from hospital to home after asthma flare-ups. Nurse care coordinators work with patients diagnosed with asthma at three CHOP locations Karabots Pediatric Care Center in West Philadelphia; Primary Care, South Philadelphia; and Primary Care, Cobbs Creek.

Care coordinators may partner with community health workers for in-home education and support through CHOP's Community Asthma Prevention Program. Learn more about comprehensive services provided through CAPP.