This page includes a collection of tools and resources for all individuals, including pediatric clinicians, state agencies (Medicaid, Title V), family advocates, family/professional partnership groups, and other pediatric medical home stakeholders interested in care coordination.
Information about the National Center for Care Coordination Technical Assistance (NCCCTA) can be found under the "Technical Assistance and Support" heading. The NCCCTA is housed in the Integrated Care Program at Boston Children’s Hospital and supported through a partnership with the National Center for Medical Home Implementation.
The National Resource Center for Patient/Family-Centered Medical Home is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totalling $4,100,000 with no funding from nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
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- 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).
- Policy
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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:
- Patient- and family-centered
- Proactive, planned, and comprehensive
- Promotes self-care skills and independence
- Emphasizes cross-organizational relationships
Care Coordination Competencies:
- Develops partnerships
- Communicates proficiently
- Uses assessments for intervention
- Is facile in care planning skills
- Integreates all resource knowledge
- Possesses goal/outcome orientation
- Takes an adaptable and flexible approach
- Desires continuoua learning
- Applies team-building skills
- Is adept with information technology
Care Coordination Functions:
- Provides separate visits and care coordination interactions
- Manages continuous communications
- Completes/analyzes assessments
- Develops care plans with families
- manages/tracks tests, referrals, and outcomes
- Coaches patients/families
- Integrates critical care information
- Supports/facilitates care transitions
- Facilitates team meetings
- 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.
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- 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 care 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
- Module 2: Developing and Sustaining Strong Family/Professional Partnerships
- Module 3: Social Determinants of Health
- Module 4: Measurement Matters: Creating an Effective and Sustainable Integrated Care Model
- Module 5: Using Technology to Improve Care Planning and Coordination
- Evaluation Module: Sample Tools to Evaluate Your Care Coordination Training
- Telehealth Case Studies
- 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:
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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
- Module 2: How School Nurses and Care Coordination Supports Students with ADHD
- Module 3: Health-related Social Service Needs: Strategies to Assess and Address Shared Planning in the Family-centered Health Care Home
- Download all documents in the Instructional Curriculum for School Nurses
- Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families Achieving Optimal Health Outcomes, 2nd Edition
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- 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. - 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.
- Care Coordination Measurement Tool
*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.
- Sources of Care Coordination Measurement
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- 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 Coordinator Job Descriptions
Job titles and roles vary across intitutions and settings based on resources and community needs. As such, the National Center for Care Coordination Technical Assistance (NCCCTA) does not develop specific job descriptions, as these should be determined based on the unique resources and needs of each team. Functions of care coordination that should be completed by a team member are included in the American Academy of Pediatrics policy statement, "Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems." Sample care coordinator job descriptions that may be used as a reference are available through the National Resource Center for Patient/Family-Centered Medical Home here. - 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
- Publications
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- National Center for Care Coordination Technical Assistance
The National Center for Care Coordination Technical Assistance (NCCCTA) is a partnership between the National Resource Center for Patient/Family-Centered Medical Home and Boston Children's Hospital Integrated Care Program. The mission of the NCCCTA is to support the promotion, implementation and evaluation of care coordination activities and measures in child health across the United States. - The following technical assistance and support is available to individuals interested in implementing care coordination:
- One hour of introductory technical assistance regarding the Pediatric Care Coordination Curriculum, Care Coordination Measurement Tool and the Pediatric Integrated Care Survey.
- Two additional hours of technical assistance in the adaptation, implementation and evaluation of the aforementioned tools.
- Assistance and support through email, as necessary.
- Contact us for technical assistance and support.
- View a graphical summary of a 2015 environmental scan, performed by the NCCCTA, that looked at care coordination activities across the United States. If you would like to receive a more comprehensive report, contact the National Center for Care Coordination Technical Assistance.
- View a comprehensive poster describing the National Center for Care Coordination Technical Assistance.
- To learn more about these care coordination tools, visit the Boston Children's Hospital Integrated Care Website.
- To join the NCCCTA Community of Learners Listserv ®, email the National Center for Care Coordination Technical Assistance. This listserv® is intended for anyone who is focused on pediatric care coordination capacity building and measurement. Valuable tools, measures, resources and publications are shared. Members are encouraged to pose questions for discussion and information about work that they are conducting.
- National Center for Care Coordination Technical Assistance
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- Overview
- The "Practical Application of Care Coordination" initiative is a collection of real life examples of care coordination implementation. The initiative aligns with the mission of the National Center for Care Coordination Technical Assistance (NCCCTA) to create a community that is focused on care coordination capacity building and measurement.
- In 2017, the NCCCTA merged its "Care Coordination in the Community" initiative with the National Center for Medical Home Implementation "Promising Practices" initiative. Examples of identified projects are included below.
- If you are interested in having your project or initiative published on this Web page (the project or initiative does not need to be fully implemented in order to be published on this Web page) please email the National Center for Care Coordination Technical Assistance.
- Examples of Care Coordination in the Community
- Overview
Last Updated
06/21/2022
Source
American Academy of Pediatrics