“Real” Care Coordination as a Pathway to Family-Centered · PDF...
Transcript of “Real” Care Coordination as a Pathway to Family-Centered · PDF...
“Real” Care Coordination, a Pathway to Family-Centered Care
Jeanne W. McAllister, Associate Research Professor Pediatrics IUSM Children’s Health Alliance of Wisconsin Conference; November 15, 2016
Today’s Priorities: Studied Implementation of Care Coordination (CC)
1) Describe (“real”) care coordination, how it meets the bio psychosocial needs of children/families w/ special needs
2) Outline key steps necessary/beneficial for studied implementation of care coordination best practices
3) Relate CC approaches to 2 vignettes / shared plans of care;
Identify key child/youth, family, and clinician goals & applied strategies; progress against goals; and lessons learned.
4) Relate CC (& care/case management) to the Triple Aim
Family of a child with a chronic health care condition:
“If you can bring us real care coordination,
you will have saved our family”.
Ever go to hear a favorite author speak? One perspective
Impact • Family • Professionals • System
“REAL” Care Coordination
Fidelity to
Best Practice Model:
Is it/Does it…?
Family-Centered
Assessment driven
Continuous
Team-based
Bio psychosocial needs
Skill Building
Recommendations – Family-Centered Care Coordination/Shared Plan of Care (SPOC)
Achieving a SPOC w/CYSHCN & Families
Principles 1) Patients & families are central
and engaged
2) Teams are enabled/supported to help create/use SPOC
3) Health care and community professionals efforts are integrated
4) Cross system family-centered care coordination is sustained
McAllister J. Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs:
A White Paper and Implementation Guide. Lucille Packard Foundation for Children's Healthcare;2014
Ten Steps to Achieving a Shared Plan of Care (SPOC) 1. Identify who will benefit from a shared plan of care (SPOC) 2. Discuss with families and colleagues the value of developing and using
a comprehensive and integrated shared plan of care. 3. Select, use and review a multi-faceted assessment with each child, youth
and family 4. Set shared personal family as well as clinician goals 5. Identify other needed partners (e.g. subspecialists, and community
providers) and link them into the planning process 6. Develop the plan of care “Medical Summary” section 7. Establish the plan of care “Negotiated Actions” (goals and strategies)
portion 8. Ensure that the SPOC is available, accessible, and retrievable (permissible
partners) 9. Provide tracking, monitoring and oversight for the SPOC 10. Systematically use the SPOC model process with a group of patients and
families
Ten Steps to Achieving a Shared Plan of Care; Source: Lucile Packard Foundation for Children’s Health; Achieving a Shared Plan of Care with Children with Special Health Care Needs and their Families www.http://www.lpfch.org/sites/default/files/field/publications/achieving a_shared_plan_of_care_full.pdf
RCCP team took following steps to move toward REAL care coordination
Win institutional support to implement and study a best practice model of CC
Assemble, cultivate and activate an interdisciplinary family-centered CC team
Apply improvement science to all processes and tools
Provide SPOC related support to all “care neighborhood” partners
DREAM - Integrate model CC elements into the local context of ongoing healthcare delivery
Team
Using Care Coordination Pilot, Team, Efforts as a continuous Learning Organization/Opportunity
SPOCS; Jan 2015-July 2016; n=235
• Target Population CSHCN
2-10 years old w/neurodevelopmental diagnosis followed in Riley Hospital (NDBS) sub specialty programs
• SPOC captures child/family; medical summary and goals with progress against goals
• SPOC tool as standard of care and educational instrument for “care neighborhood”
Jan 2015-Present
Shared Plan of Care (SPOC) In Place Standard of Care (AMCHP) 18 Months
0
50
100
150
200
250
Jan-15 April July October Jan-16 April July
HOW?
Structure &
Flexibility
“They moved my bowl.”
1. Family Outreach &
Engagement
Referral, criteria met, accept
Communicate family/inform and
consent
Registry entry/documentati
on
Referral and Primary Care
Communication
2.Family/Team Readiness &
Pre-Visit Work
Pre-visit Contact
Family : CC
Trust/rapport Assessments &
Measures
Medical summary & goal information
Relationship building
3. Population care and
Teamwork
Huddles data review,
questions
Prepare to meet basic needs for
visit
Consult experts, research needs
Population - review clinical &
system challenges
4Planned Care Visits/SPOC
Co-Production
Develop rapport/“what matters”; visit
structure
Integrate bio-psychosocial &
medical
Frame goals/negotiated
actions (SPOC) Complexity level
Strategies to meet goals, draft SPOC
5.Ongoing CC & Community
Transfer
Share/use plan of care, address
accountabilities
Communicate w/primary care &
other partners
Follow-up, track, monitor & measure
3-6 months of CC, readiness for local
“locus of CC” transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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1. Family Outreach &
Engagement
Referral, criteria met, accept
Communicate family/inform and
consent
Registry entry/documentati
on
Referral and Primary Care
Communication
2.Family/Team Readiness &
Pre-Visit Work
3. Population care and
Teamwork
4Planned Care Visits/SPOC
Co-Production
5.Ongoing CC & Community
Transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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1. Family Outreach &
Engagement
2.Family/Team Readiness &
Pre-Visit Work
Pre-visit Contact
Family : CC
Trust/rapport Assessments &
Measures
Medical summary & goal information
Relationship building
3. Population care and
Teamwork
4Planned Care Visits/SPOC
Co-Production
5.Ongoing CC & Community
Transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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1. Family Outreach &
Engagement
2.Family/Team Readiness &
Pre-Visit Work
3. Population care and
Teamwork
Huddles data review,
questions
Prepare to meet basic needs for visit
Consult experts, research needs
Population - review clinical &
system challenges
4Planned Care Visits/SPOC
Co-Production
5.Ongoing CC & Community
Transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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A
1. Family Outreach &
Engagement
2.Family/Team Readiness &
Pre-Visit Work
3. Population care and
Teamwork
4Planned Care Visits/SPOC
Co-Production
Develop rapport/“what matters”; visit
structure
Integrate bio-psychosocial &
medical
Frame goals/negotiated
actions (SPOC) Complexity level
Strategies to meet goals, draft SPOC
5.Ongoing CC & Community
Transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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1. Family Outreach &
Engagement
2.Family/Team Readiness &
Pre-Visit Work
3. Population care and
Teamwork
4Planned Care Visits/SPOC
Co-Production
5.Ongoing CC & Community
Transfer
Share/use plan of care, address
accountabilities
Communicate w/primary care &
other partners
Follow-up, track, monitor & measure
3-6 months of CC, readiness for local
“locus of CC” transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to meet the bio-psychosocial needs of children and youth, while enhancing person & family care-giving skills and capabilities.
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Shared Plan of Care:
Evolution Frame & form
About Me 20%
Medical Summary
40%
Negotiated Actions
40%
STEPS
• Identify/agree
• Outreach/Assess
• Understand and Prioritize “
Goals”
• Strategize Approaches
• Use SPOC
• Communicate & collaborate
• Build Skills
- Family
- Team
VIGNETTE #1 “BV”
• About Me • Medical Summary • Negotiated Actions Outcomes:
About Me
Medical Summary
Negotiated Actions
1.
Family Outreach &
Engagement
2.
Family/Team Readiness &
Pre-Visit Work
3.
Population care and
Teamwork
4.
Visits/SPOC Co-
Production
5.
Ongoing CC &
Community Transfer
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VIGNETTE #1 “About Me” (1-3) Pre Visit Contact & Preparation for visit • BV is a 3 yr.. boy attached to loving parents (Burmese
refugees) and baby sister who is on the brink of language and mobility (he comes with an ASD diagnosis, meets age criteria and is referred by a Riley specialist)
• Limited English, no transportation, dependent upon father (who has no paid time off) to navigate American health care system
• Pre visit - Medicaid cab, interpreter, known clinician as part of team
J– Family from Burma; speak Hakha Chin and require very specific interpretation
J has - Global Developmental Delay; gross motor delay; & expressive language delay
“Planned Care Visit” (4) Mother, father, BV, baby sister, Chin interpreter, care coordinator and clinician MEDICAL SUMMARY – Pre-Populated, completed in real time NEGOTIATED ACTIONS “Critical Conversation” – 1) Obtain outpatient habilitation therapy within limits of family’s schedule & transportation needs 2) Better understanding BV’s needs & Rxs 3) Support to navigate evaluations/treatments 4) Establish adequate health care financing Ongoing Care Coordination (5) Team and family work to integrate care, communication and financial needs (ISDH/CSHCS, BDDS, Children’s Hospital, etc.) Shared Plan of Care translated into Chin for all permissible partners
BV Outcomes
1. Accessed options for therapeutic interventions that meet the families location, transportation and schedule needs
2. Achieved recommended subspecialty consults (e.g. neurology, genetics)
3. Family skills - learned to initiate contact with language line to maintain communication with the care team
4. Locus of care coordination transitioned/reemphasized with PCP/nurse team at FQHC medical home
- Learning Partnership
- Accessing interventions / resources previously unknown - Holding planned care visits w/ additional patients/families
1.
Family Outreach &
Engagement
2.
Family/Team Readiness &
Pre-Visit Work
3.
Population care and
Teamwork
4.
Visits/SPOC Co-Production
5.
Ongoing CC & Community
Transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Vignette 2 “Patrick O.”
Patrick O – About Me
Enjoys
Loving 8 yo, often in good mood
Likes to play by self, enjoys Sponge Bob and Angry Birds
Sings, calendar time at school
Self care - partial skills
Some speech; little back/forth
Other Insights
Little eye contact
Avoid touching, changing routine
Dislikes messy play, teeth brushing
Walks, uses wheelchair for waning stamina
Family system complex; flexibility limited
PDSA: Clinician Observation: Repetitive play, will let you join and take a turn
Planned Care Visit / SPOC
MEDICAL SUMMARY
Multiple medical needs: autism, mitochondrial disorder, cardiac involvement,
14 Specialties involved
NEGOTIATED ACTIONS
Therapies, in line with needs and payment
Navigate home health options/fit with child care needs
Therapeutic adaptive recreational opportunities
Other clinician – integration, waiver, behavioral supports/visual aids, safety, PCP collaboration
Outcomes
Goals
Completed
In Progress
On hold
Dropped
Implications for Care of Population Family Goals - Coding Categories /Guidelines
1. Getting the Right Interventions and Treatments
2. Paying for HealthCare and Related Needs
3. Quality of Family Life
4. Meeting Basic Needs
5. Getting an Appropriate Education
6. Understanding Diagnosis & Treatments
7. Access and Communication Across Complex Systems of Care
Implications for Care (235 Families; 1,378 Goals)
Monthly Measures (CC)
Top Care Coordination Interventions
Promoting:
Development/use of Shared Plan of Care
System cohesion/alignment of approach
Access and linkages to care & resources
Top Care Coordination Interventions
Preventing:
Delay of treatments & interventions
System fragmentation/redundancy
Excessive family burden (financial, worry)
Family Feedback
“No one asked these questions prior”
“I have never had a visit like this before”
“I have felt so alone in this, care coordination has opened my mind; I now know how to use the many special services available to our son” (Father).
Team Feedback
“I have spent a lifetime learning evidence-based strategies for children and families; the constraints of our payment system prevent me from ensuring that families access best practices and optimal services.
“I am selfish, I really like seeing my patients get care coordination, I want them to get help accessing services that I can just recommend
“Learning family goals & using them to drive CC is better, I cannot go back to working the way I did before” (CC)
Family Experience of CC Survey-Early Data Significant shifts (statistically valid)
Care coordinator
Confidence
Problem solving
Family life in control
Understand child
Able to ask for help
Understand disorder
Know service needs
Understand service system
Hours spent CC lowered
Satisfied w/communication
Worry reduced
--Close to significance--
Therapies (ABA, play)
Respect family Rx choices
Progress Against Goals
Completed
In progress
On hold
Dropped
At “exit” goals are evaluated
75% indicating either achieved or in progress
(“In Progress”)
Life is simpler with a map!
1. Family Outreach &
Engagement
Referral, criteria met, accept
Communicate family/inform and
consent
Registry entry/documentati
on
Referral and Primary Care
Communication
2.Family/Team Readiness &
Pre-Visit Work
Pre-visit Contact
Family : CC
Trust/rapport Assessments &
Measures
Medical summary & goal information
Relationship building
3. Population care and
Teamwork
Huddles data review,
questions
Prepare to meet basic needs for
visit
Consult experts, research needs
Population - review clinical &
system challenges
4Planned Care Visits/SPOC
Co-Production
Develop rapport/“what matters”; visit
structure
Integrate bio-psychosocial &
medical
Frame goals/negotiated
actions (SPOC) Complexity level
Strategies to meet goals, draft SPOC
5.Ongoing CC & Community
Transfer
Share/use plan of care, address
accountabilities
Communicate w/primary care &
other partners
Follow-up, track, monitor & measure
3-6 months of CC, readiness for local
“locus of CC” transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to: meet the bio-psychosocial needs of children and youth, while enhancing person & family care-giving skills and capabilities.
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1. Family Outreach &
Engagement
Referral, criteria met, accept
Communicate family/inform and
consent
Registry entry & documentation
Referral and Primary Care
Communication
2.Family/Team Readiness &
Pre-Visit Work
Pre-visit Contact
Family : CC
Trust/rapport Assessments &
Measures
Medical summary & goal information
Relationship building
3. Population care and
Teamwork
Huddles data review,
questions
Prepare to meet basic needs for
visit
Consult experts, research needs
Population - review clinical &
system challenges
4Planned Care Visits/SPOC
Co-Production
Develop rapport/“what matters”; visit
structure
Integrate bio-psychosocial &
medical
Frame goals/negotiated
actions (SPOC) Complexity level
Strategies to meet goals, draft SPOC
5.Ongoing CC & Community
Transfer
Share/use plan of care, address
accountabilities
Communicate w/primary care &
other partners
Follow-up, track, monitor & measure
3-6 months of CC, readiness for local
“locus of CC” transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to: meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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1. Family Outreach &
Engagement
Referral, criteria met, accept
Communicate family/inform and
consent
Registry entry/documentati
on
Referral and Primary Care
Communication
2.Family/Team Readiness &
Pre-Visit Work
Pre-visit Contact
Family : CC
Trust/rapport Assessments &
Measures
Medical summary & goal information
Relationship building
3. Population care and
Teamwork
Huddles data review,
questions
Prepare to meet basic needs for
visit
Consult experts, research needs
Population - review clinical &
system challenges
4Planned Care Visits/SPOC
Co-Production
Develop rapport/“what matters”; visit
structure
Integrate bio-psychosocial &
medical
Frame goals/negotiated
actions (SPOC) Complexity level
Strategies to meet goals, draft SPOC
5.Ongoing CC & Community
Transfer
Share/use plan of care, address
accountabilities
Communicate w/primary care &
other partners
Follow-up, track, monitor & measure
3-6 months of CC, readiness for local
“locus of CC” transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to: meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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1. Family Outreach &
Engagement
Referral, criteria met, accept
Communicate family/inform and
consent
Registry entry/documentati
on
Referral and Primary Care
Communication
2.Family/Team Readiness &
Pre-Visit Work
Pre-visit Contact
Family : CC
Trust/rapport Assessments &
Measures
Medical summary & goal information
Relationship building
3. Population care and
Teamwork
Huddles data review,
questions
Prepare to meet basic needs for
visit
Consult experts, research needs
Population - review clinical &
system challenges
4Planned Care Visits/SPOC
Co-Production
Develop rapport/“what matters”; visit
structure
Integrate bio-psychosocial &
medical
Frame goals/negotiated
actions (SPOC) Complexity level
Strategies to meet goals, draft SPOC
5.Ongoing CC & Community
Transfer
Share/use plan of care, address
accountabilities
Communicate w/primary care &
other partners
Follow-up, track, monitor & measure
3-6 months of CC, readiness for local
“locus of CC” transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to: meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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1. Family Outreach &
Engagement
Referral, criteria met, accept
Communicate family/inform and
consent
Registry entry/documentati
on
Referral and Primary Care
Communication
2.Family/Team Readiness &
Pre-Visit Work
Pre-visit Contact
Family : CC
Trust/rapport Assessments &
Measures
Medical summary & goal information
Relationship building
3. Population care and
Teamwork
Huddles data review,
questions
Prepare to meet basic needs for
visit
Consult experts, research needs
Population - review clinical &
system challenges
4Planned Care Visits/SPOC
Co-Production
Develop rapport/“what matters”; visit
structure
Integrate bio-psychosocial &
medical
Frame goals/negotiated
actions (SPOC) Complexity level
Strategies to meet goals, draft SPOC
5.Ongoing CC & Community
Transfer
Share/use plan of care, address
accountabilities
Communicate w/primary care &
other partners
Follow-up, track, monitor & measure
3-6 months of CC, readiness for local
“locus of CC” transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to: meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities.
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Shared Plan of Care: Evolution
8 X 8 X
Frame and form
Components
About Me 20%
Medical Summary
40%
Negotiated Actions
40%
SPOC EVOLUTION
1. Family Outreach &
Engagement
Referral, criteria met, accept
Communicate family/inform and
consent
Registry entry/documentati
on
Referral and Primary Care
Communication
2.Family/Team Readiness &
Pre-Visit Work
Pre-visit Contact
Family : CC
Trust/rapport Assessments &
Measures
Medical summary & goal information
Relationship building
3. Population care and
Teamwork
Huddles data review,
questions
Prepare to meet basic needs for
visit
Consult experts, research needs
Population - review clinical &
system challenges
4Planned Care Visits/SPOC
Co-Production
Develop rapport/“what matters”; visit
structure
Integrate bio-psychosocial &
medical
Frame goals/negotiated
actions (SPOC) Complexity level
Strategies to meet goals, draft SPOC
5.Ongoing CC & Community
Transfer
Share/use plan of care, address
accountabilities
Communicate w/primary care &
other partners
Follow-up, track, monitor & measure
3-6 months of CC, readiness for local
“locus of CC” transfer
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based
activity designed to: meet the bio-psychosocial needs of children and youth, while enhancing
person & family care-giving skills and capabilities. .
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1. Family Outreach &
Engagement
BROCHURE
REFERRAL FORM
REGISTRY
2.Family/Team Readiness &
Pre-Visit Work
WHAT I NEED
EXPERIENCE OF CC SURVEY
SPOC EXAMPLE
3. Population care and
Teamwork
TEAM MEETINGS
HUDDLES
STRUCTURES & PROCESSES
ROLES
4Planned Care Visits/SPOC
Co-Production
VISUAL TO FRAME TIME
GOAL EXAMPLES
SPOC INTERATIONS
COMMON LANGUAGE
5.Ongoing CC & Community
Transfer
SPOC
LETTERS
EXITS / RE-ENROLL
TEMPLATES (REPETITION)
RCCP: Testing and Refining the Shared Plan of Care (SPOC) as an Approach to Family-Centered Care Coordination (CC)
TOOLS CREATED IN REAL TIME AS PART OF STUDIED IMPLEMENTATION AND QUALITY IMPROVEMENT
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Lessons Learned in Studied Implementation
Individual needs, styles
Care and feeding of a team
Expectations with accurate understanding of CC
Testing and improving
(vs. “please do x, y and z”)
Patient care and data
People & Process & Tools
Declaring a Definition and Model
Care Coordination
Care Management
…Somewhat a Matter of Linguistics ?
Who is CC for?
Is it defined, how?
Evaluation of implementation?
Getting to Real Care Coordination
Care Coordination is a patient & family-centered, assessment driven, continuous, team-based activity designed to: meet the bio-psychosocial needs of children and youth, while enhancing person family care-giving skills and capabilities.
Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
Case Management Society of America
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
Centers for Healthcare Strategies Inc., 2007).
Focus - Care Coordination
Care Coordination, using a Shared Plan of Care
approach, holds the potential to:
Improve child health outcomes,
Reduce family burden, increase skills, and
Lower system costs (over the child’s life course).
In other words, address the triple aim (Berwick)
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“Turn Key” Care Coordination?
Care Coordination Elevator Speech?
Care coordination “elevator speech”?
“With care coordination…you
have to take the stairs!
(1-2 steps at a time)
People
Process Tools
+ Implement-
ation
+ Learning
Real Care Coordination
References
① Association of Maternal and Child Health Programs, Standards for Systems of Care for Children and Youth with Special Health Care Needs, Antonelli, R.J., McAllister, J., & Popp, P. (2009). Making care coordination a critical component of the pediatric health care system: A multidisciplinary framework. New York, New York: The Commonwealth Fund. Standards
② American Academy of Pediatrics Council on Children with Disabilities and Medical Home Advisory Committee. (2014). Patient and family centered care coordination: A framework for integrating care for children and youth across multiple systems. Pediatrics, 133(5), e1451-e1460. Definition
③ Antonelli, R.J., McAllister, J., & Popp, P. (2009). Making care coordination a critical component of the pediatric health care system: A multidisciplinary framework. New York, New York: The Commonwealth Fund. Framework
④ McAllister, J.W. (2014). Achieving a shared plan of care with children and youth with special healthcare needs: White paper and implementation guide. Lucile Packard Foundation for Children’s Health. Retrieved from http://lpfch-cshcn.org/publications/research-reports/achieving-a-shared-plan-of-care-with-children-and-youth-with-special-health-care-needs/ Model
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