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Continuous, Comprehensive, Coordinated Care Publications Fact Sheets
What is Care Coordination? This fact sheet provides the AAP definition of care coordination and the medical home along with examples of the process.

Care Coordination
Developed by the Utah Collaborative Medical Home
Project. This document provides the definition, the process, questions and answers, keys to family involvement, assessments, plans of care/ implementation /evaluation, resources, advocacy and funding.

Policy Statements

Periodicals/Articles

  • Broyles, R. S, Tyson, J. E., Heyne, E., Heyne, R.J., Hickman, J. F., Swint, M., Adams, S, West, L.A., Porneroy, N., Hicks, P., Ahn, C. Comprehensive Follow-Up Care and Life Threatening Illness Among High-Risk Infants. JAMA. 2000;284:2070-2076

  • Bradford, R. Promoting inter-agency collaboration in child services. Child: Care, Health and Development. 1993;355-367.

  • Christakis, D. A., Wright, J., Zimmerman, F. Bassett, A Connell, F. Continuity of Care Is Associated With High-Quality Care by Parental Report Pediatrics. 2002;109(4):1-6

  • Christakis, D. A, Mel, L. Koepsell,T. Zimmerman, F., Connell,F. Association of Lower Continuity of Care with Greater Risk of Emergency Department Use and Hospitalization in Children Pediatrics. 2001;103(3):524-529

  • Christakis, D. A., Wright, J., Koepsell, T., Emerson, S., Connell, F. Is Greater Continuity of Care Associated With Less Emergency Department Utilization? Pediatrics 1999;103:738-742

  • Desch LW, Nickel RE. The Physician’s Guide to Caring for Children with Disabilities and Chronic Conditions. Baltimore, MD: Pal H. Brookes Publishing Co; 2000; (800/638-3775) In press

  • Evans ME. Huz S. McNulty T. Bank SM. Child, Family, and System Outcomes if Intensive Case Management in New York State. Psychiatric Quarterly. 1996; 67(4):273-86

  • Feeney, D., Kaufman, J. Caring for Children with Special Health Care Needs. Caring Magazine. Dec 1994;12-16

  • Hack, C. Paradigms of Care for Children with Special Health Care Needs. Pediatric Annals. 1997;26(11), 674-678

  • Hartman AF. Parent-to-Parent Support: a Critical Component of Health Care Services for Families. Issues in Comprehensive Pediatric Nursing. 1992;15:55-67

  • Johnson, C., Blasco, P. Community Resources for Children with Special Needs. Pediatric Annals. 1997;26(11):679-686

  • Kretz SE. Pantos BS. Cost Savings and Clinical Improvement through Disease Management. Journal of Case Management. 1996;5(4):173-81

  • Liptak, G. Consultation with the Specialist: Home Care for Children Who Have Chronic Conditions. (Pediatrics in Review. 1997;18:271-273.) PDF Adobe PDF

  • Liptak, G., Burns, C., Davidosn, P.,McAnarney, E. Effects of Providing Comprehensive Ambulatory Services to Children With Chronic Conditions. Archives of Pediatrics and Adolescent Medicine. 1998;152:1003-8
    ABSTRACT | FULL TEXT
  • Perrin, J., Ireys, H. The Organization of Services for Chronically Ill Children and Their Families. Pediatric Clinics of North America. 1984. 31(1): 235-257.

  • Porter S, Haynie M, Biecle T, Caldwell T, Palfrey J. Children and Youth Assisted by Medical Technology in Education Settings: Guidelines for Care. 2nd ed. Baltimore, MD: Paul H. Brookes Publishing Co; 1997; (800/638-3775).

  • Presler, B. Care Coordination for Children with Special Health Care Needs. Orthopaedic Nursing. 1998;March/April Supplement:45-51

  • Smith, K. , Layne, M., Garell, D (1994). The Impact of Care Coordination on Children With Special Health Care Needs. Children’s Health Care. 23(4):251-266

  • Stille, CJ; Antonelli, RC. Coordination of Care for Children with Special Health Care Needs Current Opinion in Pediatrics. December 2004;16(6):700-705

  • Wertz, E. Children with Special Health Care Needs. Emergency Care for Children. Albany, NY: Delmar Thomson Learning; 2001;.97-150

  • Wertz, E. Children with Special Health Care Needs Assisted by Technology. Emergency Care for Children. Albany, NY. Delmar Thomson Learning; 2001;151-175

  • Wertz, E. Interacting with Parents and Caregivers. Emergency Care for Children. Albany, NY: Delmar Thomson Learning; 2001;243-253

  • Zuckerman B, Stevens G, Inkelas M, et al. Prevalence and correlates of high-quality basic pediatric preventive care. Pediatrics. 2004;114(6): 1522-1529

Reports/Documents

Innovative Approaches for Improving Referral, Consultation, and Shared Management in Primary and Specialty Pediatric Care
Washington, DC -- A new report from the Federal Expert Work Group on Pediatric Subspecialty Capacity and the MCH Policy Research Center profiles promising approaches to strengthen collaboration between primary and specialty pediatric care. The report, Promising Approaches for Improving the Interface between Primary and Specialty Pediatric Care, describes 10 real-world strategies to address referral, consultation, and shared management that can improve the availability of pediatric subspecialty care and enhance health outcomes for children.

The Federal Expert Work Group on Pediatric Subspecialty Capacity was formed by the Maternal and Child Health Bureau in response to growing evidence that access to pediatric subspecialty care in many parts of the U.S. is worsening. The group has 3 main objectives: 1) define the scope of current and projected pediatric subspecialty capacity problems and their consequences; 2) identify promising approaches for improving shared management between pediatric subspecialists and medical homes, reimbursement, continuing education and training, and state/regional delivery system networks; and 3) develop recommendations and a tactical plan to improve access to subspecialty care.

MCHB and JSI Release Review of Care Coordination Activities of DSCSHN State Implementation Grantees
Several of the health insurance and financing implementation grantees funded by the Division of Services for Children with Special Healthcare Needs (DSCSHN) of the Maternal Child Health Bureau (MCHB), had expressed an interest in examining care coordination models. An initial recommendation to review care coordination activities among these grantees sparked an interest to expand this review to all state implementation grantees. While a previous study had focused on the role of Title V in care coordination, there had never been a review of the role of state implementation grantees in this critical aspect of developing a system of care for CYSHCN.

As part of their current contract with DSCSHN, John Snow, Inc. (JSI) was asked to develop a survey to capture the range of activities among the state implementation grantees. This report addresses all 6 of the Healthy People 2010 outcomes, through a survey of all MCHB State Implementation grantees. The survey focused on the care coordination activities of the grantees, such as methods of care coordination program development and implementation, methods of financing, and effectiveness of care coordination.

2006 Medicare Care Management Demonstration Project
This 3 year demonstration was mandated under Section 649 of the MMA to promote the use of health information technology and improve the quality of care for beneficiaries. Doctors in small to medium sized practices who meet clinical performance measure standards will receive a bonus payment for managing the care of eligible Medicare beneficiaries. The demonstration will be implemented in California, Arkansas, Massachusetts and Utah.

2001 Medicare Coordinated Care Demonstration
This project tests whether providing coordinated care services to Medicare beneficiaries with complex chronic conditions can yield better patient outcomes without increasing program costs. Medicare will test the cost-effectiveness of paying for case management and disease management services under the Medicare Coordinated Care Demonstration. These coordinated care interventions will supplement routine care for chronically ill beneficiaries.

Historically, a small proportion of Medicare fee-for-service beneficiaries has accounted for a disproportionate share of Medicare expenditures. These beneficiaries often suffer from one or more chronic illnesses and require repeated costly hospitalizations. They typically receive fragmented health care across multiple health care providers and multiple sites of care. Moreover, providers may not follow evidence-based guidelines, and patients may not know how to care best for themselves. As the population ages, the number of chronically ill beneficiaries is expected to grow dramatically, with serious implications for Medicare program costs.

The Medicare Coordinated Care Demonstration, authorized by the Balanced Budget Act of 1997, will target beneficiaries with chronic conditions that represent high costs to the Medicare program, such as asthma, diabetes, congestive heart failure and related cardiac conditions, hypertension, coronary artery disease, cardiovascular and cerebrovascular conditions, chronic lung disease, cancer and other chronic conditions.

Beneficiaries will receive comprehensive care planning, patient education, and ongoing monitoring between doctor visits to improve self-care, identify complications early, avoid costly hospitalizations, and better coordinate treatments and medications for multiple illnesses and conditions. In addition, some of the projects will offer participating beneficiaries additional benefits aimed at removing barriers to prompt medical care, such as coordinating with community-based services, transportation, assistance with medications, non-covered home visits, and medical equipment. Beneficiaries will not have out-of-pocket costs for the demonstration services.

Fifty-eight applicants submitted proposals by the October 11, 2000 application deadline. CMS announced the selection of 15 demonstration sites in January 2001.

The demonstration was implemented on a rolling basis starting April 1, 2002. All 15 demonstration sites are now in operation.

Hall MA, Peeples RA, Lord RW. Liability Implications of Physician-Directed Care Coordination. Ann Fam Med. 2005;3(2)115-121 Note: You will need to register with Medscape to access this FREE article.

Johnson K. No Place Like Home: State Home Visiting Policies and Programs. Published by The Commonwealth Fund. May 2001;(#452)

Percelay JM. and Committee on Hospital Care Physicians’ Roles in Coordinating Care of Hospitalized Children Pediatrics. 2003;111(3):707-709

Nyman R, Ireys H. Children with Special Health Care Needs: Building a Quality-of-Care Initiative. Washington, DC:2004; Mathematica Policy Research, Inc.

Coordinating Care for the Chronically Ill: How Do We Get There from Here?
Prepared by the National Academy for State Health Policy. The report explores key aspects and results of innovative chronic care programs in six states. This report also identifies key issues states must consider as they begin to implement chronic care programs and create important linkages between the medical and long term care/supportive services systems. Issues explored include creating a universal assessment tool, focusing programs on people with multiple chronic conditions, and creating successful physician involvement, among others.

 Last Updated August 21, 2008

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