Recommendations for entities interested in implementing a similar project to improve the systems of care through the medical home lens:
- Be flexible with your goals.
- The system providing care and support for CYSHCN is complex. Being flexible allows a more responsive pathway to engage with and streamline the efforts of several entities who may be implementing similar work. Additionally, remaining flexible allows a program to adjust and shift as information is learned along the way.
- Example: Several entities within Vermont have worked separately on improving coordination of care for CYSHCN. As the Vermont team connected with these entities, they remained flexible to account for different mandates and funding requirements.
- Example: Early efforts in this work included interviews with family partners. As themes and trends from these interviews emerged, the Vermont team adjusted to incorporate feedback from the family partners to have program goals that addressed things that were more important to families.
- Engage “boots on the ground” partners and stakeholders early in the process.
- Partners for this work include those providing care coordination, families accessing care coordination, and CYSHCN self-advocating for needed care coordination services. Engaging with these partners highlights areas of shared understanding of barriers and what is working. Engage with partners during informed project planning to establish themes to provide direction for the work.
- Example: Learnings from family interviews early on in this work (as mentioned above) continued to provide guidance on project planning. Because of this connection to family partners early in the process, the Vermont team did not overburden families by going back to them repeatedly.