Connecticut Children's Medical Center, Center for Care Coordination

Background Information

​Type of Practice: Children's Hospital

Location: Hartford, Connecticut

Population Served: Children with special health care needs, including those with behavioral health needs, vulnerable children, and those at risk for developmental delays and disorders

Pediatric Medical Home Implementation Strategies

• ​Identify the target population for your project's care coordination services. Learn about your target populations and utilize these data to build relationships with community providers and agencies to link children and families to appropriate resources and services.
• Recruit and hire staff who understand the target population for your project. Connecticut Children's Center for Care Coordination serves children with a wide variety of special health care needs, as well as serving those who are at risk for developing delays and disorders, so staff with varying levels of clinical and non-clinical expertise are needed. These include the following:
  • Pediatric nurses who primarily support families of children with chronic and complex medical conditions.
  • Clinical social workers who support families of children with behavioral health conditions. These professionals typically have a Master of Social Work degree and/or are Licensed Clinical Social Workers.
  • Community care coordinators who support families of children who are impacted by social determinants of health. These professionals typically have a Bachelor of Science degree in family studies or social work.
• Train all care coordination staff to utilize the Strengthening Families Protective Factors framework with families to build resilience, support social connection, and enhance the provision of family-centered care coordination services.
• Stratify the patient population by levels of medical and social complexity and assign each family and child to the appropriate staff member for care coordination services.
• Enhance the accessibility of care coordination services by allowing Center staff to meet and/or communicate with families through any method that works best for families, including the following:
  • Meeting with families over the phone
  • Emailing families
  • Conducting home visits with families and children
  • Meeting with families at schools and provider appointments
• Collaborate closely with families to create a detailed care plan and connect families and children to both medical and non-medical services. These care coordination activities may include the following:
  • Collaborate with families and schools to assist with creating Individual Education Programs
  • Assist families in obtaining legal support to advocate for educational needs
  • Assist families with financial support to ensure adequate coverage for health care services and non-medical services
  • Connecting families to diagnosis specific organizations at the community, state, and/or national level(s)
  • Connecting families of children with special needs with each other for peer support
  • Collaborating with families and physicians to facilitate successful transition from pediatric to adult health care
• Collaborate closely with primary care providers and referring providers to ensure the patient's care plan is shared and communicated with all appropriate stakeholders.
• Utilize various technology platforms such as electronic medical records and the state's Department of Public Health Title V database to ensure care plans are shared and accessible.

Challenges

• While Connecticut Children's Center for Care Coordination focuses on providing family-centered care coordination resources, the center encountered challenges in engaging families throughout the development and oversight of the project. The center has tried to engage families through advisory groups, focus groups, surveys, newsletters, and other outreach, with limited success. Many families of children with special health care needs do not have time and capacity to participate in such initiatives. The Center is currently revising its family engagement strategy based on past experiences and feedback from families.
• Another challenge identified by the Center has been appropriately managing expectations for patients, families, and providers. Often, families require access to resources that the Center cannot control or supply, such as affordable housing. Additionally, providers' expectations regarding care coordination needs (for example, referral to early intervention) may not always align with family's immediate needs (for example, connection with WIC or SNAP benefits). The Center always focuses on providing family-centered care by meeting families where they are in terms of needs and capacity.

More Information

• For more information, contact Susan Roman, RN, MPH, Connecticut Children's Center for Care Coordination Program Director.
• Expanding Care Coordination to Promote Children's Health, Development and Well-being
• Strengthening Families Protective Factors Framework
• Connecticut Medical Home Program
• Statewide Replication of the Connecticut Children's Center for Care Coordination