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Effective: 4/22/2025

C7.5 Designation as Medically Complex

Legal Authority

Introduction

​​​​​​​​​​Medically complex refers to a designation for children who have significant medical needs that require specialized attention, resources, and care coordination. This designation applies to children with chronic or severe health conditions that impact their ability to function and thrive without intensive medical support. Obtaining the medically complex designation ensures that the child receives the frequency and intensity of services necessary to meet their medical needs, as well as ensuring caregiving arrangements are appropriate to meet their needs. The decision to designate a child as medically complex often depends on the severity of the child’s illness and/or the frequency of their symptoms. Some medical diagnoses present to a greater or lesser degree in a child. This can influence the determination of a medically complex designation. The designation may be either short or long-term and should be re-evaluated periodically to ensure it reflects the child’s current medical needs. ​​

Practice Guidance

  • ​Here are the basic categories that typically warrant a medically complex designation:
    • Kidney problems requiring dialysis;
    • Organ transplants;
    • Open heart surgery;
    • Cancer;
    • Severe chronic respiratory disease;
    • Terminal illness;
    • Head Injuries;
    • Seizure disorders that are not well controlled by medication;
    • Severe disability that requires medical technological assistance;
    • Insulin-dependent diabetes;
    • Neurological or physical impairments to a degree that the child is non-ambulatory and requires twenty-four-hour (24) monitoring; 
    • Feeding problems that require nasogastric (NG) or gastrostomy tubes (G-tube);
    • Tracheostomy requiring frequent suctioning and changing;
    • Neurological issues related to prenatal substance use that require close monitoring by health personnel; 
    • Need for continuous nasal oxygen administration;
    • Need for intravenous medication therapy;
    • Need for deep intramuscular injections; 
  • ​All medically complex consultations begin regionally between the SSW and the regional nurse consultant. The regional nurse consultant contacts the Medical Support Section for any additional guidance. 
  • When a medically complex child is hospitalized, Department for Community Based Services (DCBS) staff should be available to receive regular updates and to meet with hospital staff regarding the child’s medical treatment plan. The hospital should always have access to a DCBS representative, even on weekends, holidays, and after hours. 
  • When a foster parent, SSW, or private agency staff is not available to stay with the child:
    • A biological relative may be considered (on a case-by-case basis); or 
    • A contract with an agency may be initiated to have a responsible adult remain with the child (e.g., a sitter from a nursing pool or home health agency). The sitter does not have to provide direct medical care, but is to be in the room to facilitate access to medical personnel and provide support to the child when needed; and
    • No caregiver or outside sitter is needed if the child is in the intensive care unit (ICU). 
  • The regional nurse consultant may consult with the Medical Support Section if there are questions regarding the child’s medical treatment. 
  • It is recommended that the SSW and regional nurse consultant or contracted managed care organization (MCO) nurse case manager attend appointments involving a medically complex child when decisions regarding treatment plans are discussed.


Procedure

​The SSW:

  1. Seeks a medically complex designation if the child has a medical condition diagnosed by a physician, which includes: 
    1. Significant medically oriented care needs related to a serious illness or condition diagnosed by a health professional that may become unstable or change abruptly, resulting in a life-threatening event; 
    2. A chronic condition that is expected to be life-long and progressive and will require additional oversight;
    3. An acute, time-limited condition requiring additional oversight; or 
    4. A severe disability that requires the routine use of medical devices or assistive technology to compensate for the loss of a vital body function needed to participate in activities of daily living and significant and sustained care to avert death or further disability. 
  2. Obtains documentation of the child's medical condition from a physician and other healthcare providers; 1 
  3. Consults with the following people to determine if the child has a medical condition that meets medically complex criteria:
    1. Current medical providers; 
    2. The family services office supervisor (FSOS); 
    3. The regional nurse consultant; 
    4. MCO case manager; and 
    5. The Medical Support Section; 
  4. Compiles the following documentation when requesting a medically complex designation: 
    1. The DPP-106B Initial Physical and Behavioral Health History; 
    2. Copy of the custody order; and 
    3. Any other supporting medical documentation. 
  5. Provides all relevant documentation to the regional nurse consultant to be forwarded to the Medical Support Section;
  6. Seeks placement for the child in an approved medically complex home. Please see SOP C7.6;
  7. Verifies that the caregivers are willing to continue to care for the medically complex child if the placement occurred before designation; 
  8. Works in partnership with the regional nurse consultant and MCO nurse case manager to arrange the initial individualized health plan meeting within thirty (30) calendar days of the medically complex designation;
  9. Notifies the regional nurse consultant, who then notifies the Medical Support Section within seventy-two (72) hours; and
  10. Ensures that a responsible adult, excluding hospital staff, is always with the child while in the hospital. 2 


​​F​ootnotes

  1. Phone verification with the physician, nurse, or hospital social worker is acceptable documentation for confirming the child’s diagnosis. If the SSW encounters issues, the regional nurse consultant may be contacted to assist with securing this information. 
  2. If the child is in an ICU, a responsible adult is not required to be present at all times.​


Documents

Revisions