Stephanie Gehres, M.D., was working as a hospitalist at Presbyterian Hospital in Albuquerque, N.M., when she met a young boy whose complex medical needs meant he’d spent most of his short life in the hospital. His diagnosis, gastroschisis, is a rare congenital condition in which the intestines are located outside the body.

“He’d had a lot of surgeries,” Gehres says, “and he required all his nutrition through a tube, so he had to have a doctor ready to renew his feeding orders every week. One of the reasons he couldn’t go home was because he needed a physician willing to do that.” That is, until Gehres agreed to be that physician.

Once home, the young boy required care coordination between Presbyterian Hospital and an intestinal rehabilitation facility, a specialized center with gastroenterologists and transplant facilities, in Omaha, Neb. “There was a lot of coordination needed — getting him out there for visits, nutritionists following up with me when he was home, and so on,” says Gehres.

The child eventually had a liver, small bowel and pancreas transplant and is now doing very well, but he isn’t the only child in Albuquerque with complex medical needs. “The gastroenterologists had a few other patients who were also very complex in terms of their feeding regimens,” the physician says. “They asked if I would take on those patients as well.” And she did. For a while, Gehres saw a handful of patients on Fridays, without compensation, while she continued her work as a hospitalist.

Then, about two years ago, she expanded to a part-time clinic, seeing about 20 patients with diagnoses ranging from congenital heart conditions to Down Syndrome to cerebral palsy. Many of her patients are infants who were in the neonatal intensive care unit and now see four or five subspecialists for care.

Gehres’ role is to provide support for families and coordination among their specialists. Children still see their primary care physicians, but appointments with Gehres can be longer than typical, and she has established connections with the companies who provide medical equipment, supplies for feeding, intravenous nutrition, oxygen and more. “If the family is having issues and needs their orders changed, I deal with it, so they don’t have to get on the phone and spend a lot of time doing that,” she says.

Jennifer Landman, the children’s service line administrator at Presbyterian, says the work “helps bridge the gap for families. One of the parents describes Dr. Gehres as her ‘glue doctor,’ because she helps them hold it all together.”

Many families travel up to several hours to Albuquerque for care, so Gehres is able to help them coordinate appointments and tests to make the most of each visit. She also can help families get reimbursement for traveling out of state for specialty care.

Within a year of starting the part-time clinic, it became apparent to Gehres that the need for this type of care coordination was greater than anticipated. So in April of 2014, the Pediatric Chronic Care Clinic expanded to full-time and now serves 150 to 200 patients. A registered nurse and a social worker round out the team. The RN helps Gehres manage the often time-consuming process of prior authorizations and getting medical equipment for families, as well as providing typical RN duties. “The social worker helps with discharge planning, travel arrangements, lodging and mileage. We are also able to help with [individual education program] meetings and school coordination now,” Gehres says.

One of her goals is to keep her patients out of the emergency department and hospital as much as possible, but if they do need to be admitted, she serves as a consultant, ensuring that their medications and feeding regimens are correct and that tests aren’t unnecessarily repeated. And as they transition home, she helps make sure it goes smoothly.

“She’s terrific,” says Landman. “She’s done things like, if parents run out of formula or supplies, she’ll drive out to their house to drop off supplies. She goes way above and beyond.”

Gehres is double boarded in both internal medicine and pediatrics, which allows her to follow children as they become adults and continue to need specialty care. “She’s been able to help older teens make that transition much more smoothly, as she has relationships with subspecialists in both pediatric and adult care,” says Landman.

Gehres says she feels that she has found her niche; she has always enjoyed working with patients with more complex needs, but has also always loved kids. “It’s a perfect mix for me,” she says. And what’s most satisfying is being able to build relationships with families over years. The young boy who inspired her is now doing well with his transplant. “He’s eating real food and able to enjoy it,” Gehres reports. “He started kindergarten. He plays soccer with his brothers. It’s been amazing to watch him do all these things that other kids are doing.”