Treatment & CarePediatricsConditions & TreatmentsPediatric Chronic Illness

Chronic Illness Management Program

boy playing on floor

Our Specialized Services

The Chronic Illness Management Program (CIMP) focuses on providing children with the tools they need to effectively manage their illness, maximize quality of life, and achieve family-centered goals of care. It is designed to help patients take control of their chronic condition. The program treats children (up to age 21) with chronic, life-altering conditions including, but not limited to:

Asthma/Other Chronic Respiratory Diseases – Respiratory therapists provide children with personalized education about their asthma or other chronic respiratory disease. They cover everything from medications and treatments to essential daily management. Patients will get the chance to practice managing their asthma in real-life situations, such as swimming in a pool, exercising, walking a dog, and going out into the community. Each patient will receive a customized action plan tailored to their specific needs. Our team works hand-in-hand with Newark Beth Israel who has delivered proven success with this program model.
Autoimmune Disorders – Autoimmune disorders come in many forms, each with its own set of treatments, lifestyle adjustments, and challenges. Our program focuses on helping each child learn how to live with their specific condition. Patients practice everyday skills such as playing, exercising, cooking, and making healthy food choices, while connecting and interacting with peers. They also receive education from the medical and nursing team on how to safely manage their condition. The team ensures they’re following the best treatment plan by closely working with the child’s entire healthcare team.
Cystic fibrosis – The cystic fibrosis program addresses any nutritional concerns with a big focus on making sure the child is growing, eating well, and fueling their body. Patients will also receive an individualized plan, work with a respiratory therapist, and the medical/nursing team to learn more about managing their conditions. The team coordinates care with all of the child’s medical providers and creates an individualized plan to monitor and manage cystic fibrosis.
Diabetes – The diabetes program provides patients with the opportunity to meet other kids with diabetes, while learning to manage their diabetes. Patients will work with the team on glucose monitoring and managing their insulin pumps. Participating in the diabetes program has resulted in consistent reductions in A1C and fructosamine, improvement in diabetes knowledge, enhanced access to diabetes care and other medical and therapy services, reduced hospital admissions, improved quality of life and has demonstrated improvement in the psychological wellbeing of both patients and their parents.
Heart Disease – The heart disease program focuses on exercise, lifestyle changes, nutrition, and understanding medications.
Metabolic Disorders - The metabolic disorders program focuses on growth monitoring, education for families to follow up with specialists, understanding family lineage, neurodevelopment support, exercise, and nutrition. The team helps the patient understand what’s getting in the way of you feeling like your best self.
Organ Transplants – Patients who experienced an organ transplant work closely with our pharmacy team for medication management. Psychologists work with patients on coping with being on new medications and having a surgery and all the changes. The team educates patients and their families on what life post-transplant looks like and works closely with the child’s transplant team.
Sickle cell - The Sickle Cell Program helps patients better manage symptoms, understand pain triggers, and build sustainable routines for daily wellness. When appropriate, we also support patients in safely adjusting their medical plans while enhancing overall quality of life.

An Individualized & Behavioral Approach

All participants in the Chronic Illness Management Program undergo an enhanced evaluation, which is completed by the clinical team to assess the patient’s physical, emotional, mental, and psychological status. The team will then make recommendations for ongoing treatment; this may include ongoing outpatient services, referral for a follow-up with specialty providers, referral for mental health services, and/or admission to the inpatient Chronic Illness Management Program located in New Brunswick, NJ. The inpatient program is typically four-weeks.

The Chronic Illness Management Program takes a comprehensive behavioral approach focusing on empowering individuals to manage their condition effectively. This includes direct instruction to develop new skills and knowledge, shaping appropriate behaviors, and reinforcing positive behaviors. We emphasize experiential learning, the generalization of skills across activities and settings, the use of visual tools, medical education, structured nutritional counseling and instruction, and supportive psychological counseling.

Inpatient Interventions

The four-week inpatient treatment plan focuses on disease-specific management, nutritional knowledge, lifestyle choices, and family decision-making. A typical inpatient stay includes both physician and nursing care, as well as the following services:

Aquatics/Movement Group
Child Life Services
Cooking Group
Communication Group
Community Outings
Dietitian Support
Discharge Planning
Family Education and Counseling
Intensive and Varied Daily Exercise
Medication and disease-specific education
Medical Oversight
Mindfulness Group

Nutrition Counseling
Nursing Education
Occupational Therapy
Patient Care Coordination
Physical Therapy
Psychological Therapy
Recreational Therapy
Reflection Writing Group
Respiratory Therapy
School, Tutoring, Individual Testing
Speech & Language Therapy
Support from Nurse Practitioners and Social Workers

Continuation of Care

At the conclusion of an inpatient stay, our expectation is that each patient is significantly more independent at managing their medical condition. A principal goal of the program is to ensure a healthy transition back into the community. This means we help patients work with their outpatient medical treatment team, school, and community-based agencies to ensure success once they return home.

All patients who participate in the inpatient program attend follow up appointments at three, six-, and 12-months post-hospitalization. These follow up appointments are with the clinical team to promote continued success in managing the chronic condition.

Call 732-258-7150 or email SpecialtyPrograms@childrens-specialized.org to request more information about the Chronic Illness Management Inpatient Program.

Outpatient Program

Our Outpatient Chronic Illness Management Program is offered at Children's Specialized Hospital outpatient sites throughout NJ and consists of individual or group mental health support, nutrition support, and physical and/or occupational therapy evaluations and treatment.

What to expect?

Our outpatient psychotherapy services are designed to support children and adolescents through these challenges, providing a compassionate space where they can share their experiences and feelings.

Learn effective techniques to manage worry and frustration
Develop resilience and emotional strength
Discover healthier ways to cope with stress and frustrations of daily life
Practical tools and strategies to help navigate challenges
Addresses emotional psychological health, enhances spiritual and physical health
Dedicated therapist who meets you were you’re at and who truly listens and understands chronic illness impact on mental health

To access Chronic Illness Management outpatient services, please call Specialty Programs at 732-258-7150 and leave a voicemail or email SpecialtyPrograms@childrens-specialized.org. Providers can also fax referrals to (609) 991-6145.