Practices may want to consider implementing the following system supports to improve care of CMC and their families: strengthening relationships, making your practice readily accessible, implementing a registry, utilizing electronic health records, developing a list of community resources, implementing payment and reimbursement mechanisms, recruiting practice team members to provide team-based care reassessment of practice changes.

Additional information about each system support and resources/tools to help with implementation within your practice are included below.

Relationships that are patient/family-centered and equitable.

Ready access to a patient/family-centered medical home.

Registry to track CMC patients and assist with care coordination and care planning.

Electronic Health Records and patient portals to communicate between and among health care professionals and with families.

Knowledge of Resources within the community to support patients and families, including state Title V/CSHCN programs, early intervention services, school programs, home health care providers, recreational opportunities, and more.

Adequate Payment/Reimbursement for services provided.

Recruitment of a wide array of practice team members in building a practice’s capacity to care for CMC and their families in partnership with the broader community.

As the definitions and care standards for CMC are refined, reassessment and continuous quality improvement practices should be applied to incorporate new knowledge and ensure the needs of CMC and their families are being met.

General Resources

Last Updated



American Academy of Pediatrics