Care coordination clinic provides 'glue' for seriously ill children

Families of children with complex chronic conditions refer to Stephanie Gehres, M.D., as their 'glue doctor' because she helps coordinate care among her young patients' specialists, primary care physicians, hospitals, medical equipment companies, schools and more, according to an article from H&HN Magazine.

Gehres' Pediatric Chronic Care Clinic, which began as an unpaid side job for the then-hospitalist at Presbyterian Hospital in Albuquerque, New Mexico, now serves 150 to 200 patients in the region suffering from serious conditions ranging from congenital heart conditions to cerebral palsy. Many of these children have had multiple surgeries and receive care from up to five sub-specialists.

In addition to Gehres, who is double board-certified in internal medicine and pediatrics, a registered nurse and social worker round out the clinic's team, with everyone pitching in to ease the strain on families and ensure the enrolled children navigate complexities of the health system smoothly.

Gehres, for example, sees the young patients in her clinic for unrushed appointments during which she makes sure all aspects of the children's care work appropriately. Her role includes coordinating appointments with other doctors, ensuring patients get the right tests without redundancy and even helping families get reimbursed for out-of-state travel for medical care.

Meanwhile, the registered nurse, in addition to clinical duties, helps manage prior authorizations and getting medical equipment for families. The social worker helps families with discharge planning, travel arrangements, lodging and mileage. 

As with any care coordination effort, one of the clinic's goals is to keep patients out of the hospital; but when they are admitted, Gehres serves as a consultant and assists with their transition back home.

To learn more:
- read the article