Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems

Abstract

Understanding a care coordination framework, its functions, and its effects on children and families is critical for patients and families themselves, as well as for pediatricians, pediatric medical subspecialists/ surgical specialists, and anyone providing services to children and families. Care coordination is an essential element of a transformed American health care delivery system that emphasizes optimal quality and cost outcomes, addresses family-centered care, and calls for partnership across various settings and communities. High-quality, cost-effective health care requires that the delivery system include elements for the provision of services supporting the coordination of care across settings and professionals. This requirement of supporting coordination of care is generally true for health systems providing care for all children and youth but especially for those with special health care needs. At the foundation of an efficient and effective system of care delivery is the patient-/family-centered medical home. From its inception, the medical home has had care coordination as a core element. In general, optimal outcomes for children and youth, especially those with special health care needs, require interfacing among multiple care systems and individuals, including the following: medical, social, and behavioral professionals; the educational system; payers; medical equipment providers; home care agencies; advocacy groups; needed supportive therapies/services; and families. Coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care, and improvement in the patient/family experience of care. Pediatrics 2014;133:e1451-e1460

Care Coordination Over Time in Medical Homes for Children With Special Health Care Needs

“…This is consistent with recommendations from the American Academy of Pediatrics' policy statement on care coordination. 8 Previous studies examined care coordination at 1 point in time, capturing the range of activities, volume, and cost to practices, 21 but not how care coordination changes as a practice's medical home model matures. We found that creation and installation of tools and practices for proactive activities typically followed some study or consideration of recurring issues faced by care coordinators and planning, including some trial and error, by medical home teams.…”

“…2 The scope and definition of "care coordination" have evolved, [3][4][5][6][7] and the 2014 American Academy of Pediatrics policy statement offers a framework, emphasizing patient-and familycenteredness, working in teams across medical and other settings, and enhancing families' capabilities. 8 This was part of a larger study to examine change toward the medical home model. 9 We used a positive deviance approach 10,11 and mixed methods 12,13 to examine successful practices that had participated in a national medical home learning collaborative in 2003 to identify factors or processes that contributed to implementation that could then be translated to other practices.…”

Future Directions for the Implementation and Dissemination of Statewide Developmental-Behavioral Pediatric Integrated Health Care

“…Measurably, 100% of families referred have made appointments for follow-up within 48 hr, with most behavioral health appointments being arranged before departing the clinic. Evidence for the importance of care coordination in promoting follow-through is accumulating rapidly (Silverstein et al, 2015;Turchi et al, 2014), and it is emphasized as a central aspect of the Collaborative's system development. In addition, measurement of concrete behaviors related to this construct are tracked through program evaluation efforts, including engagement, treatment adherence, early dropout rate, and appointment efficiency.…”

A patient-centered, coordinated care approach delivered by community and pediatric primary care providers to promote responsive parenting: pragmatic randomized clinical trial rationale and protocol

“…Both of these frameworks focus on strengthening integration of health services and systems (e.g., public health, clinical, and community) to break down siloes and to engage and empower patients and their families to optimize health outcomes. The AAP has called for the integration and coordination of care between clinical health care and community settings, such as WIC, that is centered on the comprehensive needs of the patient and family leading to a reduction in fragmented, inconsistent care [27]. …”