Multidisciplinary Care Coordination Training for CMC

Background Information

Type of Practice: Collaboration between an academic medical institution (Phoenix Children's Hospital) and a state MCH Title V/CYSHCN program

Location: Phoenix, Arizona

Population Served: The care coordination training was conducted with a multidisciplinary audience of families, state MCH Title V/CYSHCN program staff, state American Academy of Pediatrics (AAP) chapter staff (Arizona Chapter of the AAP), practice managers and administrators, care coordinators, executives, physical therapists, physicians, non-physician clinicians (nurses, pharmacists, social workers), among others. All individuals who participated in the training care for children with complex medical needs.

Pediatric Medical Home Implementation Strategies

Notes: The strategies outlined below are specific to care coordination, a critical function of the patient- and family-centered medical home. Participating in a care coordination training is one step in the process of making sustainable changes to improve care coordination. Adaptation and implementation of the curriculum may be an ongoing process with multiple trainings. ​

• Begin by identifying and connecting with motivated leaders within your community that have a vested interest in improving care coordination services for the pediatric population. Typically, a few of these motivated leaders serve as “champions” for the moving this work forward. Other motivated individuals serve as members of an interdisciplinary team who assist champions in care coordination efforts.
• In Arizona, champions for care coordination efforts included a pediatrician who cares for children with medical complexity, a parent of a child with complex medical needs who also serves as the family engagement specialist within the Arizona state MCH Title V/CYSHCN program, and the Arizona Title V CYSHCN director.
• In other communities/states, motivated leaders can include any community member from any background and discipline. Buy-in from organizational leadership, such as departmental chairpersons, hospital administration, or agency heads, is critical to success and sustainability of care coordination and medical home efforts. Motivated leaders can include but are not limited to the following:
  • Families of CYSHCN
  • Youth with special health care needs
  • State MCH Title V/CYSHCN staff
  • American Academy of Pediatrics (AAP) chapter staff
  • Practice administrators
  • Care coordinators
  • Community health workers
  • Durable medical equipment (DME) and home health professionals
  • Pediatricians or any other physicians that care for children and youth
  • Non-physician clinicians (nurses, pharmacists, social workers)
• Identify and leverage resources from existing initiatives, projects, or partnerships to continue care coordination efforts.
  • Phoenix Children's Hospital was previously engaged in a Patient-Centered Outcomes Research Institute (PCORI) project that set the foundation for future care coordination efforts. Participation in the PCORI project ensured that individuals leading the care coordination training had a baseline knowledge of care coordination and understood the value of care coordination and integrated systems of care. Additionally, participation in the PCORI project established relationships between the project's leaders and a network of stakeholders invested in care coordination.
  • This is an important note for any organization/individual interested in implementing the PCCC-Second Edition: successful facilitation of care coordination training is dependent on having fundamental understanding of the core content of the curriculum.
• In collaboration with stakeholders–including but not limited to families, state MCH Title V/CYSHCN, and AAP Chapter staff/members–identify key "pain points" or problem areas in provision of care coordination. These problem areas may help identify decision makers that should be involved in care coordination training and implementation activities. These problem areas can also inform adaptation of the curriculum.
• Plan a care coordination training using the PCCC – Second Edition. Some suggested steps in planning this training based on the experience in Arizona include the following:
  • Identify your specific care coordination needs (based on "pain points" or key problem areas in care coordination provision).
  • Identify your population of focus. This could include pediatric populations (CYSHCN, or condition-specific populations such as children with sickle cell disease) and the professionals who care for the pediatric population you have selected. In Arizona, the training focused on professionals who cared for children with medical complexity.
  • Review all content within the PCCC – Second Edition. It is recommended that this review occurs with a multidisciplinary stakeholder team including families, MCH Title V / CYSHCN staff, AAP chapter staff, and clinicians.
    Convene with the National Center for Care Coordination Technical Assistance (NCCCTA) at Boston Children's Hospital to identify modules in the curriculum you would like to implement and discuss how to adapt PCCC-Second Edition content to your specific needs. The curriculum's "Getting Started" module includes an "Assets and Needs Assessment" section which may help with this process. The NCCCTA is available to provide technical assistance and support to organizations interested in adapting and implementing care coordination training.
  • Curriculum content is adaptable and serves to provide a framework. Adapt content within the module(s) you would like to implement to fit your needs and population.
    • In Arizona, facilitators of the training created four case studies* specific to their population of focus (children with medical complexity) to guide the training.
    • Case studies exemplified and prompted discussion around previously identified "pain points" or problem areas. Furthermore, facilitators in Arizona designed the training so that each of the four case studies were discussed in curated/predetermined small groups. Each group included family representatives and a mixture of key stakeholders involved in that particular case study.
    • Additional examples of how content can be adapted are included in the curriculum.
• Invite multidisciplinary individuals to attend the care coordination training. These individuals should include any/all stakeholders that are involved in the care coordination process for families and children. Additionally, invited individuals and organizational representatives should be ready to make a change in their settings to improve care coordination. Examples of individuals/organizational representatives that may be invited to a care coordination training include but are not limited to the following:
  • Families of CYSHCN
  • Pediatricians and other physicians
  • Non-physician clinicians (nurses, pharmacists, social workers)
  • DME/Home health professionals
  • Administrative practice support
  • Care coordinators
  • Public and private payers
  • State MCH Title V/CYSHCN staff
  • AAP Chapter staff and members

*If your project creates specific case studies to discuss throughout the training, it may be beneficial to invite training participants who have a direct role in some of the scenarios presented in the case studies.

• Conduct outreach multiple times to individuals/organizations that were invited to attend the training. In Arizona, outreach multiple times to each invited individual increased overall attendance and helped ensure each participant understood roles, responsibilities, and expectations throughout the training.
  • Individualized/personalized outreach is encouraged to increase attendance. Leveraging existing professional and personal connections may also increase attendance and engagement.
• Implement the training using selected module(s) from the PCCC-Second Edition. The curriculum includes detailed facilitator notes to assist with presenting content.
  • Co-facilitation with a family member is highly recommended and was a successful strategy implemented by the Arizona team.
• Design evaluation questions for the training based on your project goals and needs. Collect evaluation data/feedback from participants via an evaluation survey. Sample evaluation survey questions are included in the PCCC-Second Edition.
• Ask all participants to complete one concrete action item as a result of the training. In Arizona, participants were asked to complete an Action Grid (tool available in the PCCC-Second Edition). The Action Grid encourages participants to make concrete plans for action in their practice after training and can be used in quality improvement efforts to assist with Plan-Do-Study-Act cycles.

Challenges

• Individuals and organizations who are beginning the process of medical home implementation may benefit from gaining baseline understanding of the concepts of care coordination and value. Resources to assist with this are included on the National Resource Center for Patient/Family Centered Medical Home Care Coordination Web site - (which also includes a link to the first edition of the PCCC). Knowledge about care coordination and implementation of the necessary practice-level interventions can be gained by accessing the PCCC-Second Edition.
• Some modules within the PCCC-Second Edition may take up to two hours to facilitate and finding time for multidisciplinary and diverse stakeholders to attend the training may be challenging.
  • Reviewing PCCC-Second Edition content in advance, identifying and adapting content specific to your project/population needs can help to ensure time allocated for the training is used efficiently and effectively.
  • Modules within the PCCC-Second Edition do not need to be implemented in their entirety in one setting; facilitators may pick and choose only the most relevant content for any given session and may decide to deliver content from one module across multiple training sessions.
• Lack of funding to support future care coordination training and measurement presents a challenge to the sustainability of care coordination activities. Integrating care coordination training into MCH Title V/CYSHCN programs and/or AAP chapter priorities may assist with sustainability. Additional strategies to overcome this challenge include seeking funding from MCH Title V/CYSHCN programs, health delivery systems, and/or payers interested in advancing medical home implementation. Connecting with medical quality improvement activities may also present another opportunity for sustainability.

More Information

• For a printable overview of this promising practice, ​download the one-page summary document.
• For more information about implementation of this project, listen to this recorded podcast featuring leaders from the Arizona care coordination team.
• For more information about care coordination training in Arizona, contact the Arizona care coordination team using the PCCC-Second Edition listed below.
  • Dawn Bailey, Arizona Title V CYSHCN Family Engagement Specialist
  • Wendy Bernatavicius, MD, FAAP, Complex Care Pediatrician, Phoenix Children's Hospital
  • Katharine Levandowsky, Office Chief, Office for Children with Special Health Care Needs
• For more information about the PCCC-Second Edition, visit the National Center for Care Coordination Technical Assistance.