Ambulatory Complex Care Coordination Program

Who We Are

The Ambulatory Complex Care Coordination Program (AMB-CCP) helps families with children living with medical complexity (CMC). These children often need to see different medical specialists and get most of their care in their community.

How We Can Help

The AMB-CCP team includes Care Coordinators who help patients and families navigate the health care system and access needed services. They provide pediatric care coordination, focusing on the needs of children and youth while supporting families and care teams. The Care Coordinators work with the referring care team to manage medical, social, developmental, educational, and financial needs, aiming for the best health and wellness outcomes for patients and their families.


Referrals are accepted from community physicians, ACH subspecialists, and ACH clinics.

After the referral is accepted, a Care Coordinator will meet with the family to talk about current needs. Needs can be related to health, community services, social/financial or education. Our care coordination model takes into consideration the needs of the entire family, recognizing that this results in the best outcomes for the patients in our project.

Care coordination is team-based, meaning that the Care Coordinator will also meet with members of the care team to talk about care goals and needs. Members of the care team may include community pediatricians, medical specialists, mental health providers, physical or occupational therapists and teachers or other school-based professionals.

The Care Coordinator acts as an information hub, connecting with other care team members to develop and assist with implementation of a care coordination plan, based on the identified goals of the family and care team.

Our model is designed to improve outcomes by meeting the current needs of children and youth. At the same time, there is a focus on enhancing the caregiving capabilities of parents and caregivers through connections to respite care, community resources and education/information.