Helping Fairfield County families navigate complex and ongoing medical needs, from one trusted practice.

When a child has a chronic condition, a developmental concern, or needs to see multiple specialists, managing that care can quickly become a full-time job for a family. At Center for Pediatric Medicine, care coordination is part of how we practice. Our team works alongside families to connect the right providers, communicate across specialties, and make sure nothing falls through the cracks.

CPM earned Patient Centered Medical Home (PCMH) recognition in 2014, a designation that reflects our commitment to coordinated, whole-child care. For families with children who have complex or ongoing needs, that designation is not just a credential. It is a standard of practice that shapes every interaction.

What is pediatric care coordination?

Pediatric care coordination is the process of organizing a child's care across providers, specialists, schools, and support services so that everyone involved is working from the same information toward the same goals. For children with straightforward health needs, most of this happens naturally at a well visit. For children with more complex needs, it requires active management.

At CPM, care coordination means:

• Specialist referrals and follow-through. When your child needs to see a cardiologist, neurologist, developmental pediatrician, or any other specialist, CPM initiates the referral, communicates your child's history to the receiving provider, and follows up on outcomes.
• Centralized medical records. CPM serves as your child's medical home, holding the complete picture of their care across every provider they see. Parents do not need to re-explain history at every appointment.
• School and community coordination. For children with IEPs, 504 plans, or developmental support needs, CPM providers can communicate with schools and community services to support consistent care plans.
• Chronic condition management. Children with asthma, diabetes, ADHD, anxiety, or other ongoing conditions receive structured follow-up care at CPM, not just acute visits when something goes wrong.
• Medication management and monitoring. For children on ongoing medications, CPM tracks prescriptions, monitors for side effects, and coordinates dose adjustments across providers as needed.

Which children benefit from care coordination at CPM?

Care coordination is not only for children with rare or severe diagnoses. Families often find it most valuable when their child:

• Has been diagnosed with a chronic condition such as asthma, epilepsy, Type 1 diabetes, or a heart condition
• Has developmental delays, autism spectrum disorder, or a learning disability requiring school-based support
• Sees two or more specialists and needs a primary care provider to hold the full picture
• Has been recently diagnosed and the family is still navigating next steps
• Has behavioral or mental health concerns being managed alongside a physical condition
• Is transitioning from a pediatric specialist to adult care as they approach age 18 to 21

If you are not sure whether your child's needs qualify for care coordination, call us at (203) 790-0822. Our team will talk through what your child needs and whether CPM is the right fit.

CPM as your child's medical home

The Patient Centered Medical Home model is built around the idea that every child deserves one practice that knows them completely: their full history, their ongoing concerns, their specialists, and their family. CPM has operated as a recognized medical home since 2014.

What that means in practice:

• One point of contact. Families with complex care needs do not need to navigate multiple front desks to coordinate appointments. CPM staff can facilitate scheduling and communication across providers.
• Consistent providers. CPM's team structure means your child sees familiar faces at every visit. Providers who know your child's baseline are better positioned to notice changes.
• After-hours access. A CPM doctor is available 24/7 for after-hours calls. For families managing a chronic condition, this means reaching a provider who knows your child's history, not a generic triage line.
• Telemedicine for follow-ups. Routine care coordination follow-ups, medication checks, and specialist debrief conversations can often be handled via CPM's telemedicine service, saving families an in-office visit.

For more on CPM's telemedicine options for ongoing care management, visit our telemedicine page.

Getting started with care coordination at CPM

If your child is new to CPM and has existing specialist relationships or a complex medical history, the first step is a new patient visit. Bring as much documentation as you have: recent specialist notes, current medication lists, school evaluations, and any existing care plans.

At this visit, your CPM provider will:

• Review your child's full history and current care team
• Identify any gaps in coordination or follow-up that need to be addressed
• Establish CPM as the primary point of contact for coordinating ongoing care
• Discuss a care plan tailored to your child's specific needs

Existing CPM families whose child's needs have become more complex can request a care coordination appointment at any time. Call (203) 790-0822 or visit our new patient page if you are joining us for the first time.

Why Fairfield County families choose CPM for complex care

• Patient Centered Medical Home since 2014. A nationally recognized model of coordinated, whole-child care.
• Board-certified physicians (FAAP). All CPM physicians hold FAAP certification with decades of combined experience managing complex pediatric cases.
• On-site specialists. IBCLC lactation consultant, registered dietitian, and ADHD care available in-house, reducing the number of outside referrals your family needs to manage.
• Four locations, open 7 days a week. Danbury and New Fairfield, with late evening hours and after-hours doctor coverage 24/7.
• Telemedicine available. For families managing ongoing care needs, telemedicine follow-ups reduce the burden of in-person visits for routine check-ins.
• Care through age 21. CPM supports families through the transition from pediatric to adult care, including coordination with adult providers when the time comes.