Continuity of Care for Pediatric Heart Patients

Caring for a child with a complex heart or medical condition doesn’t end when you leave the hospital. Our Continuity of Care coordinators help you manage your child’s ongoing needs, connecting you with resources, care coordination, and the same supportive team you know and trust.
Request an Appointment
For all requests:
1-888-573-5437

University of Iowa Health Care Stead Family Children’s Hospital’s Continuity of Care program provides comprehensive, interprofessional, and family-centered support for children with complex or long-term medical needs. We are here to make your child’s transition from hospital to home as smooth as possible. 

If your child qualifies for the program, you’re paired with a dedicated care coordinator who becomes your family’s main point of contact. This person helps manage communication between providers, assists with discharge planning, and connects you to the services, equipment, and community resources your child needs to thrive at home. 

Our approach

Our approach centers on partnership. You’ll always have one consistent contact who understands your child’s medical history and your family’s needs.  

Your care coordinator joins the care team while your child is still in the hospital, participating in daily planning rounds to help set short- and long-term discharge goals. They identify any delays in services and work quickly to resolve them so your child can go home safely and on time. They'll help you build networks and self-advocacy skills that make ongoing care more manageable. 

After discharge, your coordinator will continue to follow your child’s care, helping coordinate follow-up appointments, answer questions, and stay involved if your child needs to be readmitted.

Services we provide

Services we provide

Our team helps you manage your child’s care from hospital to home and beyond. Services include: 

  • Hospital discharge planning and coordination 
  • Long-term follow-up and case management 
  • Transition support between pediatric and adult cardiology 
  • Assistance with waiver programs and community resources 
  • Coordination of home nursing and therapy services 
  • Referrals for durable medical equipment (DME) and supply companies 
  • Completion of paperwork for waiver, SSI, or disability applications 
  • Organization of family care conferences as needed 

Your coordinator also serves as a clinical nurse expert for your child’s care, helping you understand treatment plans and navigate insurance and resource systems. 

Additional support for families

Managing a lifelong condition requires more than medical care. Your coordinator can connect you with mental health support, parent groups, financial counseling, and education resources to help your family adjust and feel empowered. We work closely with social workers, community agencies, and home health providers to make sure every aspect of your child’s care is addressed. 

Who can qualify 

Your child may qualify for the continuity of care if they have a condition expected to last at least one year or require coordination across three or more specialty services. The program serves many children with congenital or acquired heart disease, as well as those with other complex medical conditions requiring long-term care coordination. 

Need help managing your child’s long-term care?

When you call 1-888-573-5437 we’ll connect you with a Continuity of Care coordinator who can answer your questions.
Call 1-888-573-5437 Browse our Providers