integrated care for medically complex children

Understanding integrated care

Integrated care offers a unified approach to medical, behavioral, and mental health

Across the healthcare landscape, there is growing recognition that traditional, fragmented models of care often fail to meet the needs of individuals with complex health conditions. Many children and adults require more than just medical intervention — they may also need behavioral support, mental health services, or rehabilitation. For these individuals, integrated care has emerged as a crucial, evidence-based approach.

While definitions vary¹, Integrated care is, broadly speaking, a comprehensive model that involves the coordination of services across multiple disciplines to address the full spectrum of a patient’s needs. It is especially vital for people with medically complex conditions — those who are managing multiple chronic illnesses, physical impairments, developmental disabilities, and mental or behavioral health concerns.

This page explores what integrated care is, why it matters, and how it benefits patients with complex conditions, as well as the challenges that can arise when care is not coordinated effectively.

What is integrated care?

Integrated care refers to the systematic coordination of medical and behavioral healthcare, along with other services that support overall wellbeing. Rather than treating individual symptoms or diagnoses in isolation, integrated care emphasizes whole-person treatment planning through collaboration among healthcare providers.

The defining features of integrated care

An interdisciplinary team of clinicians
Frequent communication and collaboration among team members
Shared treatment goals
Patient- and family-centered care planning
Coordinated transitions between levels of care

Integrated care can take place in a variety of settings, including hospitals, outpatient clinics, rehabilitation centers, and long-term care facilities. It often involves the integration of medical, psychological, and social services to ensure that all aspects of a patient’s health are comprehensively addressed.

physicians &

sub-specialists

The average number of clinicians treating medically complex children ²

Why integrated care is necessary for medically complex individuals

Adults and children with medical complexity live with a combination of conditions that affect multiple systems of the body. These may include physical, neurological, developmental, behavioral, or mental health conditions. As a result, they typically interact with multiple specialists and services across the healthcare system. An uncoordinated approach can result in disjointed treatment, conflicting recommendations, and additional unnecessary stress for both patients and caregivers.

A medically complex patient may:

Take several medications for various conditions
Require assistive technology, such as ventilators or feeding tubes
Visit numerous healthcare providers regularly
Experience frequent hospitalizations or emergency room visits
Live with physical and/or cognitive impairments
Need behavioral or mental health support
Struggle with activities of daily living and independence

Each of these elements adds a layer of complexity to care, and when they are addressed separately — without sufficient communication among providers — the results can be detrimental. Patients may receive duplicative or conflicting treatments, experience side effects from drug interactions, or receive insufficient treatment for mental or behavioral health needs.

For example, a child with severe autism and Type 1 diabetes may struggle to follow a prescribed insulin regimen due to sensory sensitivities, communication barriers, or emotional dysregulation. Without coordinated care between endocrinologists, behavioral therapists, nurses, and caregivers, this patient would be at high risk for repeated hospitalizations, poorly managed symptoms, and long-term health complications.

In an integrated care setting, on the other hand, these professionals would work together to build a plan that addressed behavioral barriers to medication adherence, provided education tailored to the patient’s learning needs, and supported the family with consistent strategies and communication. This unified approach would improve medical outcomes and enhance the child’s overall quality of life.

physicians &

sub-specialists

The average number of clinicians treating medically complex children ²

Let's take a closer look at the symptoms of severe autism

Core components of integrated care

Integrated care typically includes several interwoven elements designed to support collaboration among professionals and improve patient outcomes:

Interdisciplinary teams

At the heart of integrated care are interdisciplinary teams  that may include:

Primary care physicians
Specialists (e.g., cardiologists, pulmonologists, and neurologists)
Psychologists and psychiatrists
Nurses and nurse practitioners
Social workers and case managers
Physical, occupational, and speech therapists
Behavioral health professionals

These clinicians work together to develop and implement unified care plans based on patients’ individual needs  and goals

Care coordination

Coordinating care means managing the flow of information and treatment plans across providers and services. It often includes:

Scheduling and organizing appointments
Managing medication regimens
Communicating changes in condition across providers
Ensuring smooth transitions between levels of care (e.g., from hospital to home)

Effective care coordination reduces medical errors, improves patient outcomes, minimizes readmissions, and lowers costs by avoiding unnecessary duplication of services.

10%

17%

lower odds of 30-Day hospital readmission

lower odds
of 30-Day
mortality

16%

lower odds 30-Day healthcare costs³

Whole-person assessment

Integrated care requires looking beyond clinical symptoms to assess other important aspects of a person’s life, including:

Mental and emotional health
Cognitive functioning
Daily living skills
Environmental and social support
Financial and caregiver stressors

Understanding the full context in which a patient lives allows providers to tailor interventions more effectively.

Shared decision-making

Patients and their families are essential partners in integrated care. By including them in decisions about goals and treatment strategies, care teams can build trust and ensure that plans are realistic, meaningful, and aligned with the patient’s values and preferences.

How integrated care benefits patients and caregivers

Research and clinical experience both show that integrated care models lead to better health outcomes and greater satisfaction for both patients and their families.  Some of the most significant benefits include:

Improved health outcomes 
By addressing all aspects of a patient’s health simultaneously, integrated care helps stabilize chronic conditions, reduce hospital readmissions, and improve overall quality of life.

Fewer care gaps
Because communication is centralized and coordinated, patients are less likely to fall through the cracks or miss out on necessary services.

Reduced caregiver burden
For families caring for medically complex children or adults, navigating the healthcare system can be overwhelming. Integrated care streamlines appointments, reduces duplication, and often includes caregiver training and support, helping families feel more confident and less alone.

Better mental and emotional support
Behavioral and emotional needs are often overlooked in traditional models of care. Integrated care models place equal emphasis on mental health, ensuring that patients are supported emotionally as well as physically.

38.8%

of caregivers experience depression

28.6%

of caregivers have
anxiety⁴

Financial savings 
Studies have shown that integrated care can reduce overall healthcare costs by minimizing unnecessary procedures, improving medication management, and avoiding complications that result in emergency care.

Integrated care models reduce care costs by

16–30%⁵

Challenges when integrated care is missing

When patients with complex health needs are treated in fragmented systems, the risks increase significantly. Without coordination, common challenges may include:

Contradictory treatment plans from different providers
Missed diagnoses or unmanaged conditions
Confusing or conflicting medication regimens
Delayed or inappropriate care
Increased caregiver burnout
Higher likelihood of avoidable hospitalizations
Poor patient adherence due to lack of clarity or trust

For individuals with overlapping medical and behavioral conditions, the stakes are particularly high. For example, a patient with epilepsy and depression might receive neurological treatment from one provider and behavioral health treatment from another, without the two ever communicating. This can lead to the prescription of contraindicated medications or an incomplete understanding of the patient’s overall condition.

The evolving future of integrated care

As healthcare systems recognize the limitations of traditional siloed care, integrated care is gaining traction as the standard for treating patients with complex needs. Individuals at the national and state levels are working to improve care coordination, incentivize team-based approaches, and develop policies that support comprehensive service delivery.

Technological advancements, such as shared electronic medical records (EMRs), telehealth platforms, and virtual case conferencing, have also made integrated care more feasible and accessible. While implementing an integrated model requires upfront investment in training, communication, and infrastructure, the long-term benefits—for patients, families, and healthcare systems — are substantial.

At the Changing Care Together Summit, clinicians, referral partners, and a host of other stakeholders meet annually to discuss the critical need for increased access to comprehensive, integrated care.

Integrated care at Nexus Health Systems

At Nexus Health Systems, integrated care is not a theoretical model—it’s a daily practice. Nexus serves children, adolescents, and adults with complex medical, behavioral, and neurological conditions, many of whom have experienced lengthy hospital stays, repeated setbacks, or difficulty finding appropriate care elsewhere.

By bringing together a wide range of specialists under one system, Nexus creates a seamless treatment environment that supports physical healing, behavioral progress, and mental well-being. Patients benefit from coordinated care plans developed by interdisciplinary teams that include physicians, therapists, nurses, psychologists, and social workers. Families are actively involved in the process, and programs are tailored to the evolving needs of each individual.

Whether recovering from a traumatic brain injury, navigating the challenges of severe autism, learning to live with a rare condition such as Prader-Willi syndrome, or adjusting to the realities of life with a medically complex diagnosis, patients at Nexus are supported every step of the way — through a model of care that is truly integrated.

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