The Comprehensive Care Program (CCP) at Boston Medical Center is a primary care pediatric program supporting families of children with chronic medical conditions, developmental disabilities and complex issues. Our patients also include “NICU graduates” – babies born prematurely (preemies).

We are a team of clinicians working to enhance the quality of health services and social support for these children and their families. We are 3 primary care doctors with an interest in children with special health care needs and medical complexity. We have a consistent nurse, navigator and care management to help us help you.  We take our own call so you will reach one of the 3 of us when you need our attention.  CCP is an integral part of primary care pediatrics at BMC where exceptional care is provided, without exception.

The Comprehensive Care Program is guided by the following principles:

  • All parents need a “medical home” to bring their child to for health care that can address their many needs.
  • The family is recognized as the principal caregiver who provides strength and support for their child and .
  • CCP as the medical home enhances a child’s health care and helps connect families to different supports.
  • The medical home must serve to coordinate all of the input and opinions from the many nursing and medical providers, specialists and school personnel into a coherent story.
  • This medical home should meet all the child’s health care and developmental needs.
  • Families will have continuity with deserve ready access to their 3 known primary care medical providers and team, not to a stranger, especially when their child is ill.

The Comprehensive Care Program provides “one-stop shopping” for health care for families who need it the most. We make every efforts to schedule visits with many all of the specialists you may need to see on the same day when we can. at the time of your visit. We know the families of children with complex medical needs are juggling many demands and that your time is valuable.

Accordingly, we try to minimize the need for multiple visits to the hospital. This may be especially helpful for families who have difficulty arranging transportation to the hospital, who have other children to care for or whose work or family schedule make it hard for them to make repeated visits.

A pediatric program for families of children with chronic medical conditions or developmental disabilities.

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Treatments & Services

The Comprehensive Care Program (CCP) provides patient-centered, pediatric primary health care for infants, children and young adults with special health care needs and medical complexity. We practice state-of-the-art, evidence-based medicine for children from birth to 23 years of age with developmental disabilities, chronic illnesses and/or complex medical conditions.

We offer the following special services:

  • Enhanced Primary Health Care for preventive and routine health care with continuity
  • Family Support 24/7 for Children with Special Needs, including on-call coverage for medical issues
  • Case Management for Children with Disabilities to coordinate various aspects of medical, social, nursing and support services
  • Child Advocacy to help parents advocate more effectively for services through public and private agencies
  • Multidisciplinary Coordination of Care and Specialty Visits with other pediatric services when possible, including Pulmonary/Allergy, Cardiology, Endocrinology, Gastroenterology, Hematology, Neurology, Occupational Therapy, Nutrition, Social Work and Advocacy, Otolaryngology, ophthalmology, audiology, dental
  • Transition Services to help families of young adults prepare for an adult life after high school with completion of applications for guardianship, social security, DDS, vocational health rehab, mass health.

Our Team

Nurse Coordinator

Lydia Martin, RN

CCP Administrator/Navigator

Jael Monteiro

Transition Policy

The Comprehensive Care Program (CCP) at Boston Medical Center (BMC) is committed to helping our patients make a smooth transition from pediatric to adult health care. This process involves working with young adults and their families to prepare for the change from a “pediatric” to an “adult” model of care. This means that after a young adult turns 16 years old we may ask you to attend at least 2 appointments every year - one for their yearly check up and one to discuss transition needs.

For some of our families your young adult may not have the capacity to make independent medical decisions. In this situation we and your young adult’s school will assist you with what we call the turning 18 checklist.  This may include applying for guardianship, reapplying for adult social security income and for DDS (Department of Developmental Services) or applying for a state level picture ID.   There are other items not listed here that we are happy to discuss with you.

For other families, we may help you switch to an adult model of care where your young adult will take full responsibility for decision-making and doesn’t need guardianship. This may mean that we spend time during the visit with your teenager without the parents present.  We will assist them in setting health priorities and supporting them in becoming more independent with their own health care decision making.

Please realize that in the United States at 18 years, young adults legally become adults. We respect that many of our young adult patients choose to continue to involve their families in health care decisions. Only with guardianship or the young adult’s consent will we be able to discuss any personal health information with family members.

We will collaborate with young adults and families regarding the age of transfer to an adult primary care provider. We recommend that transfer occurs between 22-23 years of age. We will assist with this transfer process by helping to find an adult provider, sending medical records and communicating the unique adult health needs of our patients. Please note that we will definitely miss you after your transition to a new doctor and we encourage you to be in touch if we can assist in any way after this happens.

At any age:

Birth - 8 years:

Age 6-17:

At age 14 consider applying for:

At age 16:

At age 18 consider applying for:

Age 22 years:

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