Care Coordination in the Medical Home: Integrating Health and Related Systems of Care for Children With Special Health Care Needs

Lipkin, Paul H.; Alexander, Joshua; Cartwright, J. D.; Desch, Larry W.; Duby, John C.; Edwards, D. R.; Elias, Ellen Roy; Johnson, Chris Plauché; Levey, Eric; Murphy, Nancy; Myers, Scott M.; Tilton, Ann; Crider, Beverly; Lollar, Donald J.; Macias, Michelle M.; McPherson, Merle; Skipper, Stephanie Mucha

doi:10.1542/peds.2005-2070

Cited by 237 publications

(54 citation statements)

References 27 publications

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“…1 A key component is care coordination, particularly for children with special health care needs (CSHCN). 2 The scope and definition of "care coordination" have evolved, [3][4][5][6][7] and the 2014 American Academy of Pediatrics policy statement offers a framework, emphasizing patient-and familycenteredness, working in teams across medical and other settings, and enhancing families' capabilities. 8 This was part of a larger study to examine change toward the medical home model.…”

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confidence: 99%

Care Coordination Over Time in Medical Homes for Children With Special Health Care Needs

et al. 2015

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OBJECTIVES: To explore how care coordination changes conceptually and practically in primary care practices when implementing the medical home and to identify reasons for different types of changes.METHODS: Six years after a 2003-2004 national learning collaborative to implement the medical home model for children with special health care needs, we examined care coordination in 12 pediatric practices with the highest postintervention Medical Home Index scores, indicating high level of adoption of the model. Data included interviews of 48 clinicians, care coordinators, and parents and medical record reviews of 60 patients with special health care needs receiving care in these practices.RESULTS: Initially, care coordination activities were prompted by patients' acute problems, and over time activities, tools, and policies were implemented to avert many such problems and expand the scope of services offered to patients. Example activities were making previsit calls with families, writing care plans, developing relationships with community agencies, and tracking referrals. Although some activities were common across practices, the persons involved and efforts toward different activities varied with practice context. Drivers included motivation and creativity of medical home teams, organizational changes, funding to expand care coordinator positions, protected time for such activities, and adoption of electronic record systems. CONCLUSIONS:In high-performing medical homes, care coordination activities changed from being mostly reactive to patients' episodic needs to being more systematically proactive and comprehensive. This shift was promoted by factors external and internal to the practice. Ensuring these factors in medical home implementation may accelerate adoption of proactive care coordination activities. WHAT'S KNOWN ON THIS SUBJECT:Care coordination is a central part of the medical home model. Little is known about how care coordination is implemented in pediatrics and how it changes over time in primary care practices successfully adopting medical home principles. WHAT THIS STUDY ADDS:In high-performing medical homes, care coordination evolved toward designing and carrying out routine activities and policies that aimed to forestall disruptions in care delivery. Investing in medical home teams, engaging electronic medical record systems, and improving workflow supported these changes.

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confidence: 99%

Care Coordination Over Time in Medical Homes for Children With Special Health Care Needs

et al. 2015

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“…Comprehensive and coordinated care models have been shown to lower health care and social costs through reduced hospitalization and fewer days lost from work by parents [16,17,18,19,20,21]. The withdrawal of comprehensive care for these children leads to poor outcomes [22].…”

Section: Discussionmentioning

confidence: 99%

“…The information that is provided by the integrated clinic report from the PNSC Medical Director should assist the primary care physician in being made aware of the extent of the patient's medical and social needs. This would facilitate the medical and resource referrals to provide a more comprehensive patient- and family-centered care [16,17,18,19,20,21]. At the same time, the counseling and preparation for the adult medical home is performed in a timely and efficient fashion.…”

Section: Discussionmentioning

confidence: 99%

Pediatric Neurosurgery Patients Need More than a Neurological Surgeon: A Clinical Experience

James¹,

MacGregor²,

Childers

et al. 2013

Pediatr Neurosurg

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The Division of Pediatric Neurosurgery of the University of Florida College of Medicine Jacksonville initiated and developed a multidisciplinary comprehensive team for the management of patients with a neurosurgical condition other than spina bifida. This report relates the rationale and stages of development of a multidisciplinary team to facilitate the health care and special needs of these children.

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“…A number of models of care have been proposed, including multidisciplinary clinics and care coordination provided by a medical home, to assist families of CSHCN in navigating the complex systems of care [7,10]. Multidisciplinary clinics are resource intensive and are reserved for children with complex medical and rehabilitative health needs, such as children with spina bifida [11].…”

Section: Discussionmentioning

confidence: 99%

Initiating, Developing and Evaluating a Comprehensive Spinal Defects Clinic: A Clinical Report

Aldana

Wood²,

Postlethwait³

et al. 2010

Pediatr Neurosurg

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Objective: The Division of Pediatric Neurosurgery of the University of Florida College of Medicine – Jacksonville developed a multidisciplinary clinic for the better management of pediatric patients with spinal defects. The purpose of this report is to assist neurosurgeons in those regions and countries where there are no spinal defects clinics (SDC). Methods: We induced a staged process to develop a comprehensive multidisciplinary clinic for pediatric patients with spinal defects: phase I – during December 2003 to June 2004, the organizational planning, multiinstitutional recruitment of health care personnel and location of clinic space occurred; phase II – the SDC sessions initiated in June 2004 and have consequently been held on a monthly basis; phase III – this consisted of a quality improvement program during which parents/caregivers were surveyed. Results: Between June 2004 and February 2009, 139 patients/families were evaluated. Diagnoses included: myelomeningocele (102), lipomeningocele (18), meningocele (1), myelocystocele (3), spina bifida occulta (9), spinal trauma (2), spasticity of cerebral origin (2), spinal arachnoid cyst (1) and syringomyelia (1). During this period, 110 parents/caregivers were questioned on how the SDC assisted in the care of their child. A total of 62% (of 53 responders) indicated the SDC allowed them to be better informed about their child’s medical conditions and short/long-term health care plans, 52% stated health care needs were better coordinated than prior to their participation in the SDC, and 26% responded that the initiation of the clinic had reduced their medical care travel. Conclusions: Pediatric neurosurgeons may take the lead in organizing a multidisciplinary clinic for the betterment of these children. Multidisciplinary care settings facilitate health care delivery and lead to better patient care as perceived by parents/caregivers.

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Care Coordination in the Medical Home: Integrating Health and Related Systems of Care for Children With Special Health Care Needs

Cited by 237 publications

References 27 publications

Care Coordination Over Time in Medical Homes for Children With Special Health Care Needs

Care Coordination Over Time in Medical Homes for Children With Special Health Care Needs

Pediatric Neurosurgery Patients Need More than a Neurological Surgeon: A Clinical Experience

Initiating, Developing and Evaluating a Comprehensive Spinal Defects Clinic: A Clinical Report

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