Care Coordination Using a Shared Plan of Care Approach: From Model to Practice.

Introduction: Children and youth with special health care needs (CYSHCN) need, but do not have, adequate care coordination (CC); CC leads to better pediatric care, improved family/professional experience of care, and enhanced population health. Current CC initiatives are promising but lack adherence to emerging definitions/standards. A Lucile Packard Report provides guidelines for using a Shared Plan of Care (SPoC) as a CC approach; studied implementation is needed.

Effects of a Care Coordination Intervention with Children with Neurodevelopmental Disabilities and Their Families.

Unlabelled: : Care coordination is integral to improving the health of children and families. Using a Shared Plan of Care (SPoC) as a care coordination activity is recommended, but related research on outcomes in pediatric populations with complex medical conditions is scarce.

Objective: This study explores family outcomes associated with implementation of a care coordination/SPoC intervention with a population of children with neurodevelopmental disabilities and their families.

Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?

Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration.

Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis.

Pediatric to adult transition: a quality improvement model for primary care.

Purpose: To examine the relationship between quality improvement activities with pediatric and adult primary care practices and improvements in transition from pediatric to adult care.

Methods: This was a time-series comparative study of changes in pediatric and adult practices involving five large pediatric and adult academic health centers in the District of Columbia. Using the Health Care Transition Index (pediatric and adult versions), we examined improvements in specific indicators of transition performance, including development of an office transition policy, provider knowledge and skills related to transition, identification of transitioning youth, transition preparation of youth, transition planning, and transfer of care.

Medical home transformation in pediatric primary care--what drives change?

Purpose: The aim of this study was to characterize essential factors to the medical home transformation of high-performing pediatric primary care practices 6 to 7 years after their participation in a national medical home learning collaborative.

Methods: We evaluated the 12 primary care practice teams having the highest Medical Home Index (MHI) scores after participation in a national medical home learning collaborative with current MHI scores, a clinician staff questionnaire (assessing adaptive reserve), and semistructured interviews. We reviewed factors that emerged from interviews and analyzed domains and subdomains for their agreement with MHI and adaptive reserve domains and subthemes using a process of triangulation.

Current status of transition preparation among youth with special needs in the United States.

Objective: To examine current US performance on transition from pediatric to adult health care and discuss strategies for improvement.

Methods: The 2009-2010 National Survey of Children with Special Health Care Needs is a nationally representative sample with 17 114 parent respondents who have youth with special health care needs (YSHCN) ages 12 and 18. They are asked about transition to an adult provider, changing health care needs, increasing responsibility for health care needs, and maintaining insurance coverage.

Improved outcomes associated with medical home implementation in pediatric primary care.

Objective: The medical home model with its emphasis on planned care, care coordination, family-centered approaches, and quality provides an attractive concept construct for primary care redesign. Studies of medical home components have shown increased quality and reduced costs, but the medical home model as a whole has not been studied systematically. This study tested the hypothesis that increased medical homeness in primary care practice is associated with decreased utilization of health services and increased patient satisfaction.

Improvement in the family-centered medical home enhances outcomes for children and youth with special healthcare needs.

Family-centered, coordinated, comprehensive, and culturally competent care for children and youth with special healthcare needs is a national priority. Access to a primary care medical home is a US Maternal and Child Health Bureau performance measure. Most primary care practices lack methods by which to partner with families and improve care.

Practice-based care coordination: a medical home essential.

Families who raise children and youth with special health care needs deserve a medical home. They expect a team approach to health care, with coordination across multiple services and settings. Children, youth, and families benefit from the organization of critical information into written care summaries and action plans.

Building medical homes: improvement strategies in primary care for children with special health care needs.

Families and professionals agree that children and adolescents need access to community-based medical homes. This is especially true for children with special health care needs (CSHCN). Most primary care practices are designed for children's routine preventive and acute care needs.

The Medical Home Index: development and validation of a new practice-level measure of implementation of the Medical Home model.

Objective: The Medical Home is a clinical practice concept that sets new standards for pediatric primary care. This study describes the development and validation of a tool to measure the Medical Home.

Methodology: The Medical Home Index (MHI) consists of 25 themes arranged among 6 domains of primary care office activity.