Medical Home Care Coordination Resources

• ​Policy
  • Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems: This American Academy of Pediatrics policy statement provides a definition and framework for implementing care coordination.
• Definition
  • Pediatric care coordination is a patient-and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational and financial needs to achieve optimal health and wellness outcomes. (Definition adapted from: American Academy of Pediatrics Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems. Pediatrics. 2014; 133(5): e1451- 1460).

Originally published in the Commonwealth Fund report titled, "Developing Care Coordination as a Critical Component of a High Performance Pediatric Health Care System: Forging a Multidisciplinary Framework for Pediatric Care Coordination," this table is a guiding framework for care coordination competencies and functions.

Defining Characteristics of Care Coordination:

1. Patient- and family-centered
2. Proactive, planned, and comprehensive
3. Promotes self-care skills and independence
4. Emphasizes cross-organizational relationships

Care Coordination Competencies:

1. Develops partnerships
2. Communicates proficiently 
3. Uses assessments for intervention
4. Is facile in care planning skills
5. Integreates all resource knowledge
6. Possesses goal/outcome orientation
7. Takes an adaptable and flexible approach 
8. Desires continuoua learning
9. Applies team-building skills
10. Is adept with information technology

Care Coordination Functions:

1. Provides separate visits and care coordination interactions
2. Manages continuous communications
3. Completes/analyzes assessments
4. Develops care plans with families
5. manages/tracks tests, referrals, and outcomes
6. Coaches patients/families
7. Integrates critical care information
8. Supports/facilitates care transitions
9. Facilitates team meetings
10. Uses health information technology

Reproduced with permission from Antonelli R, McAllister J, Popp J. Developing Care Coordination as a Critical Component of a High Performance Pediatric Health Care System: Forging a Multidisciplinary Framework for Pediatric Care Coordination. Washington, DC: The Commonwealth Fund; 2009.

• ​Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families Achieving Optimal Health Outcomes, 2nd Edition
  • This curriculum was created through a subcontract with Boston Children's Hospital and the National Center for Medical Home Implementation (NCMHI), with support from the Maternal and Child Health Bureau in the Health Resources and Services Administration. The curriculum is designed to build capacity among diverse stakeholders (AAP Chapters, Maternal and Child Health Title V/Children and Youth with Special Health Care Needs programs, pediatricians, families, and others) through the following activities:
    • Effective implementation of key components of c​are coordination
    • Collaborative communication within inter-professional care teams
    • Investment in technology solutions
  • Download individual curriculum modules
    • Getting Started: Introduction to the Curriculum and "At-A-Glance" Overview
    • Module 1: High-Value Integrated Care Outcomes Depend on Care Coordination
      • Slides
      • Facilitator Guide
      • Appendix
    • Module 2: Developing and Sustaining Strong Family/Professional Partnerships
      • Slides
      • Facilitator Guide
    • Module 3: Social Determinants of Health
      • Slides
      • Facilitator Guide
    • Module 4: Measurement Matters: Creating an Effective and Susta​inable Integrated Care Model
      • Slides
      • Facilitator Guide
    • Module 5: Using Technology to Improve Care Planning and Coordination
      • Slides
      • Facilitator Guide
    • Evaluation Module: Sample Tools to Evaluate Your Care Coordination Training​​​
    • Telehealth Case Studies​
      • ​Care Planning and Coordinating Transitions from Inpatient to Outpatient Settings
      • ​​Using Telehealth to Coordinate Care for Youth with Complex Needs Transitioning from Pediatric to Adult Care

• The original (first edition) version of the Pediatric Care Coordination Curriculum was created by Boston Children's Hospital with support from the Maternal and Child Health Bureau in the Health Resources and Services Administration. The curriculum demonstrates the principles, key concepts, and activities necessary to successfully provide care coordination to patients and families.  

  Contact the NRC-PFCMH for the first edition of the curriculum.

• Health Care Coordination in Schools: An Instructional Curriculum for School Nurses
  The National Center for Medical Home Implementation partnered with the California State University, Sacramento, to edit the PCCC specifically for school nurses. The full curriculum is now available for download below.
  • Module 1: How School Nurses Can Implement Care Coordination
    • Overview and presentation documents
    • In-person handouts
    • Pre-session readings
  • Module 2: How School Nurses and Care Coordination Supports Students with ADHD
    • Overview and presentation documents
    • In-session handouts
  • Module 3: Health-related Social Service Needs: Strategies to Assess and Address Shared Planning in the Family-centered Health Care Home
    • Overview and presentation documents
  • Download all documents in the Instructional Curriculum for School Nurses

• ​​​​​​​Sources of Care Coordination Measurement
  • National Committee for Quality Assurance Care Coordination Measures
  • National Quality Forum Care Coordination Measures*
  • Center of Excellence on Quality of Care Measures for Children with Complex Needs- Family Experience with Coordination of Care
  • Boston Children's Hospital Integrated Care Program
    • Care Coordination Measurement Tool
      This tool enables assessment of value in health delivery models by measuring the activities of care coordination, necessary resources to implement those activities, and resulting outcomes.
      • ​Care Coordination Measurem​ent Tool 
      • Updated Care Coordination Measurement Tool 
      • 2017 Care Coordination Measurement Tool Adaptation and Implementation Guide
    • ​Pediatric Integrated Care Survey
      This family-reported survey instrument measures family experiences of care integration. This tool can be used to inform quality improvement and interventions to improve care integration. To request this survey instrument in Spanish, contact the National Center for Care Coordination Technical Assistance.
      • User Manual
      • Core Instrument
      • Supplementary Questions
      • Module 1: Transition to Adult Care
      • Module 2: Care Plan
      • Module 3: Integrator Version
      • Module 4: Burden
      • Module 5: School and Services through Individualized Education Plans

*Note: Many of these measures are linked to specific conditions. While this measures set is important, the National Center for Care Coordination Technical Assistance supports implementation and measurement of care coordination across all settings and conditions.

• Publications
  • Validation of a Parent-Reported Experience Measure of Integrated Care
  • Utilizing a Modified Care Coordination Measurement Tool to Capture Value for a Pediatric Outpatient Parenteral and Prolonged Oral Antibiotic Therapy Program
  • The Care Coordination Conundrum and Children and Youth with Special Health Care Needs
• Archived Webinars and Podcasts
  • Multidisciplinary Care Coordination Training for Children with Medical Complexity: The Arizona Experience Podcast
  • Measuring Family Experience of Care to Improve Care Delivery Webinar
  • Coordinating Care for Kids—School Nurses Linking with the Medical Home Webinar
  • Pediatric Care Coordination: Beyond Policy, Practice, and Implementation Webinar
• ​​​Care Planning Tools
  • Care Mapping
  • Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs
  • National Institute for Children's Health Quality Care Plan Template
  • National Resource Center for Patient/Family-Centered Medical Home Care Plan Templates
  • Massachusetts Child Health Quality Coalition Care Coordination Strengths and Needs Assessments