The Pediatric Visiting Doctors and Complex Care Program was founded in July 2013 and it is an extension of the Cohen Center for Pediatric Comprehensive Care. Our purpose is to provide comprehensive primary care to children with the most complex conditions. Inspired by the Mount Sinai Visiting Doctors program, the pediatrics-specific program serves children with medical complexity both at home and in the office.

We offer patient, family, and community-centered care, partnering with local organizations and pediatric subspecialists to create individualized care plans in coordination with our patients’ caregivers. Our team includes physicians, nurses, social workers, and coordinators.

Our mission is to improve the health and well-being of children with medical complexity by providing increased access to patient- and family-centered care. By delivering care at home and collaborating with the community, we hope to empower our patients and families to live healthier lives.

Conditions We Treat 

We provide primary care to newborns discharged from the Mount Sinai Neonatal Intensive Care Unit (NICU), children who require technology (gastrostomy tube, tracheostomy or ventilator, wheelchair, central line, etc.), and children with two or more chronic conditions including:

• Congenital heart disease
• Chronic lung disease
• Neuromuscular disease
• Metabolic syndromes
• Prematurity
• Cerebral palsy
• Seizure disorders
• Genetic conditions

Services We Provide

The Pediatric Visiting Doctors and Complex Care team provides primary care services through a multidisciplinary approach. We provide home-based medical care for families living in East and Central Harlem. Physicians, social workers, and care coordinators go to the homes of our patients to deliver medical care (including vaccinations, well child checks, and urgent visits) and assess for any social needs.

We coordinate care with families by assisting with scheduling subspecialty appointments and communicating with schools, community groups, and other ancillary services. For families who live outside of our catchment area, they have full access to our team with extended office visits and enhanced care coordination. We also work closely with subspecialty and inpatient teams to ensure smooth transitions for our patients in and out of the hospital. Our program is a part of the Mount Sinai Pediatric Associates Clinic and our patients have access to full services of the clinic as well as our team.

Our Outcomes

Families report a high level of satisfaction in our program due to increased care coordination, personalized attention, and health education. Patients also experience fewer emergency department visits, hospitalizations, and lengths of stay in the hospital after enrollment in the program. Through our Population Health Department, we also observed decreases in total costs of care for patients in the program due to reductions in inpatient medical services.