Clinical Component

Navigating the Clinical Component

The Complex Care Center delivers primary care to a medically intricate population inside a highly coordinated team. Patients often carry multiple diagnoses that require input from several disciplines, so the clinic is built to keep providers focused on the patient in front of them while support staff handle much of the surrounding work.

Patient Population

Patients are adolescents and adults with chronic conditions that originate in childhood, including:

  • Intellectual and developmental disabilities
  • Autism spectrum disorder
  • Congenital heart disease
  • Metabolic disorders
  • Spina bifida
  • Sickle cell disease
  • Cystic fibrosis

Because of the complexity, providers carry a smaller panel than a standard primary care practice. The team makes a deliberate effort to balance each provider's panel by both complexity and volume.

Clinical Snapshot

Visit length: 30 minutes standard, with back-to-back blocks available for complex cases

Scheduled volume: 7 to 8 patients per half-day block

Realized volume: About 6.5 patients per block, reflecting a 7% no-show rate

Telemedicine: Widely used and integrated into regular clinic blocks

EMR: Epic, with optional DAX AI documentation or Dragon dictation

Daily Workflow

Each clinic day opens with a team huddle over Zoom, followed by 30-minute patient visits through the morning and afternoon. New patients or highly complex cases may be given extended 60-minute appointments. Telemedicine is a routine part of the schedule rather than a separate session type, and nurses pre-room telemedicine visits so they mirror in-person workflows. Every exam room is equipped for video visits.

Procedures and Services

The role is primary care focused, with a limited set of in-clinic procedures:

  • Gastrostomy (feeding tube) changes
  • Long-acting contraceptive insertion

On-Site Clinical Support

The clinic is designed to give providers maximum support so they can concentrate on patient care. The team even writes Letters of Medical Necessity on behalf of physicians.

Service Detail
Behavioral health Full-time psychologist embedded on site
Infusion Two-chair infusion suite in clinic
Physical therapy On site one day per week
Dental Three-room suite for patients with IDD and complex conditions, including height-adjustable panoramic imaging
Interpretation In-person interpreters plus Language Line for virtual visits

Additional support comes from a PhD collaborator, respiratory therapist, PharmD, and occupational therapist. Home visits are available for truly homebound patients as an option for interested providers, though they are not required.

Call

Call is manageable and phone-based, with layered triage that shields physicians from routine after-hours contact.

Rotation: 1:5, currently 1:4, taken one week at a time

Format: Phone call taken from home

Triage: Nursing team screens calls first and address issues before they reach the physician

Volume: Typically 2 to 3 patient calls per week during the on-call week

Window: 4:30 PM to 8:30 AM on weekdays, plus all day Saturday and Sunday

Overnight calls: Extremely rare

Inpatient Involvement

Inpatient work is not required. The division runs its own inpatient service at Highland Hospital, staffed by its own hospitalists, so admitted patients are managed by a team already familiar with their histories. A physician in this role would very rarely handle a consult at Strong Memorial, only if the Highland hospitalist team is fully occupied, which amounted to roughly two days per provider over the past year. Physicians who want to keep an inpatient skill set can opt into occasional coverage.

Teaching and Research

The academic setting supports both education and scholarship:

Teaching: One lecture per year required, plus interdisciplinary rounds and the opportunity to teach Medicine, Med-Peds, and Family Medicine residents

Research: Growth partnership with the Neuroscience Department, experienced research coordinators and data managers, and support for building national visibility through committees and collaborative groups

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