Families who raise children and youth with special health care needs deserve a medical home. They expect a team approach to health care, with coordination across multiple services and settings. Children, youth, and families benefit from the organization of critical information into written care summaries and action plans. If primary care pediatricians, family physicians, and internists are to achieve optimal health care quality and improvement of existing health care delivery, care coordination will be an essential contributing process to their team approach. Several national health policy recommendations identify care coordination as a cross-cutting intervention to fill the gap between what exists and what is needed in health care today. A practice-based care-coordination model, including a definition and vision for care, a framework of structures and processes, and a position description with specific competencies, is needed. Improvement methodology provides an effective means for health care teams to implement and evaluate practice-based care coordination within their medical home. The improvement approach and model must be flexibly applied to have utility across diverse health care organizations. A medical home team approach, with fully developed practice-based care-coordination services, will enhance health and cost outcomes for children, youth, and families and heighten the professional satisfaction of those delivering health care.
Efficiency and effectiveness of care coordination depends on a match between the needs of the population and the skills, scope of practice, and intensity of services provided by the care coordinator. There is limited existing literature that addresses the relevance of the APN role as a fit for coordination of care for children with SHCN. The objective of this paper is to describe the value of the advanced practice nurse’s (APN’s) enhanced scope of knowledge and practice for relationship-based care coordination in healthcare homes that serve children with complex special health care needs (SHCN). The TeleFamilies project is provided as an example of the integration of an APN care coordinator in a healthcare home for children with SHCN.
<p>Many practitioners have been advocates for the medical home to serve as a foundational model for transforming the primary care system in the United States. Care coordination has been described as an essential element of a high-quality healthcare system and is essential to building a viable medical home. The recent movement toward practice redesign via the family-centered medical home model provides exciting opportunities for innovations around care coordination that is supportive of comprehensive, community-based, family-centered, and culturally effective care.</p>
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