The Infant Transitional Care Program (ITCP) is implementing an innovative model of care to optimize the health, quality of life, and well being of infants with complex medical conditions (CMC) who are transitioning from the neonatal intensive care unit (NICU) into their homes and the community. This model employs elements of complex health care theory with the goal of enhancing systems of care that serve infants with CMC. This ITCP includes several innovative components, including: (1) restructuring the patient centered medical home into a family-centered medical and neighborhood health home (FCMNHH); (2) establishing a consultative practice model for children with less severe medical complexities, (3) adapting principles of Health Care Transition to infants with complex care needs; (4) integrating community based palliative care as a component of the system of care; and (5) equipping and empowering parents and families to assume leadership roles in every aspect of their children’s care.