Care Delivery Management

Care Delivery Management promotes clinical care that is consistent with patient and family preference and scientific evidence. Many children and youth require more than the usual well child, preventive, and acute illness interventions. This page provides examples of resources and tools available to enhance the management of care delivery. Please note that this page provides additional resources as to what is provided in the Care Delivery Management section of the Building Your Medical Home toolkit.

Preparing the Office

Provider and Staff Knowledge of Medical Home
It is important for providers and office staff to understand their role in improving the delivery of care. The following medical home assessment questionnaires, created by a practice team in South Carolina, assess medical homeness as it relates to each of the AAP medical home policy elements. Versions are available for both the office staff and the health care professional.

Creating a Medical Home Team
Medical home improvement results occur as a product of teamwork. Teamwork involves a set of skilled cross-disciplinary interactions that are learned, practiced and refined to provide better care delivery management, promote safety, and enhance outcomes. Highly functioning teams are made up of those on the “front lines of care.” They engage family partners, have the capacity to test changes quickly, and possess the resilience to deal with the complexities of primary care. Teams require the benefit of support from their administrative leaders.

One strategy in building an effective practice team is to start the workday with a team ‘huddle’ to organize schedules, gather lab results, etc. Fostering “team thinking” in this way can help your practice organize and address patient and scheduling issues proactively on a daily basis. For more information on creating a team and how a team can affect quality improvement in the practice, please visit theBuilding Your Medical Home toolkit.

Team Huddles
The use of team huddles allows medical home care teams to have frequent but short meetings so that they can stay informed, review work, make and coordinate plans, and provide the best possible care to patients and their families.

Office Visits
To create efficiency and plan for patient visits of appropriate length, it is important for a practice to solicit the specific needs of the patient and family and use everyone’s time wisely. 

Other Resources

  • Access to Medical Care for Individuals with Mobility Disabilities
    US Department of Health and Human Services and the US Department of Justice
    This guide aims to assist health care providers with better serving persons with disabilities. It provides guidance for health care providers on how to provide equal access to medical care, anoverview of general requirements, commonly asked questions, and illustrated examples of accessible facilities, examination rooms, and medical equipment.

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Care Coordination

What Is Care Coordination?
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. The Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems policy statement, (Pediatrics, May 2014) written by the AAP Council on Children with Disabilities (COCWD) and the Medical Home Implementation Project Advisory Committee, specifically outlines the essential partnerships that are critical to this framework. The integration of primary care services with others in the medical care spectrum is part of a comprehensive approach for tackling the needs of patients and their families. Implementation of this framework aims for lower health care costs, less fragmented care and an improved experience for children and families. The policy provides practical application of care coordination integration in practices and communities and is intended to be broadly focused, realizing that every community has different needs, assets, and service gaps based on location, population, and cultural factors. An accompanying AAP News article, Beyond the Medical Home: Coordinating Care for Children provides more information about the policy statement.

To further augment and facilitate the application of the recommendations within this policy statement, the online Pediatric Care Coordination Curriculum provides content which can be adapted to the needs of any entity (eg, a single practice, a network of practices, parent and family organizations, or a state wide organization such as Title V). By design, the majority of the content is universally relevant but optimal use of the curriculum results when it is adapted to reflect local needs, assets and cultures. Access to this online resource is free.   

Examples of Care Coordination

  • A plan of care is developed by the physician, child or youth, and family and is shared with other providers, agencies, and organizations involved with the care of the patient.
  • The medical home shares information among the child or youth, family, and consultant and provides specific reason for referral.
  • Families are linked to family support groups, parent-to-parent groups, and other family resources.
  • When a child or youth is referred for a consultation or additional care, the medical home assists the child, youth, and family in communicating clinical issues.
  • The medical home physician evaluates and interprets the consultant’s recommendations for the child or youth and family and, in consultation with them and subspecialists, implements recommendations that are indicated and appropriate.

Competencies of Professionals Providing Pediatric Care Coordination

  • Family-centered, culturally effective behaviors supporting family professional partnerships.
  • Interpersonal communication proficiencies.
  • Care planning which promotes shared decision making and patient/family self-management.
  • The integration and use of health knowledge and resource information.
  • Team-based patient and family assessments and quality improvement capabilities.
  • Goal/outcome oriented efforts and attitude.
  • Role development skills are dynamically in step with the health care environment/ culture and the needs of families and health care teams.
  • Continuous learning and sharing of health, network, and community-based systems knowledge.
  • Resourcefulness in information technology operations.

Sample Job Descriptions

  • Practice Based Care Coordination Job Description doc
    Social work, case management, public benefits, and resource expertise. Tasks primarily social, not medical.
  • Parent Consultant Job Description doc
    Will be a parent of a CYSHCN, preferably with experience and / or comfort working in a medical setting.
  • Special Needs Consultation and Care Coordination Program Job Description doc
    Pediatric Nurse Case Manager
    General Summary: Utilizing the case management process, this position is responsible for providing care coordination services to a group of complex, special needs pediatric patients and their families across the continuum of care. The case manager assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the family and other members of the health care team

Billing & Coding
The American Medical Association added codes 99487-99489 to the CPT 2013 Professional Edition for care coordination that patients with complicated, ongoing health issues receive within a medical home, accountable care organization or similar delivery model. The codes were created so providers could bill for time spent connecting patients to community services, transitioning them from inpatient to other settings and preventing readmissions. For more information, visit the Payment & Finance page and refer to the Medical Home Coding Fact Sheet. For a listing of publications regarding care coordination, visit the Medical Home Literature page.

Medical Home Interview Videos New
Developed by the National Center for Medical Home Implementation

Care Coordination Resources

  • Family Centered Care Coordination Form PDF
    Building Your Medical Home toolkit
  • Care Coordination Accountability Measures for Primary Care Practice PDF
    Agency for Healthcare Research and Quality (AHRQ)
    This report presents selected measures from the Care Coordination Measures Atlas that are well-suited for primary care practice. The selected measures are divided into two sets: Care Coordination Accountability Measures (from the patient/family perspective) and Companion Measures (from the health care professional and system perspectives; ie, self-assessment). Pediatric measures featured in this report include the following:
    • Care Coordination Accountability Measures
      • Primary Care Assessment Tool—Child Edition (PCAT-CE)
      • Alternative: Family-Centered Care Self-Assessment Tool—Family Version
    • Companion Measures for Health Care Professionals
      • Family-Centered Care Self-Assessment Tool— Provider Version
      • Primary Care Assessment Tool - Provider Version (PCAT-PE)
      • Care Coordination Measurement Tool (CCMT)
    • Companion Measures for System Representatives
      • Medical Home Index (MHI-LV)
      • Primary Care Assessment Tool—Facility Edition (PCAT-FE)
  • Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework (May 2009; Antonelli & McAllister)
    The Commonwealth Fund
    This report proposes a framework for pediatric care coordination. It includes a definition of care coordination; outlines its principal characteristics, competencies, and functions; and sets forth a detailed process for its delivery. It also describes a model to implement care coordination across all health care settings and related disciplines
  • Measuring and Improving Care Coordination: Lessons from ABCD III
    National Academy for State Health Policy
    Through the Assuring Better Child Health and Development (ABCD) III initiative, Arkansas, Illinois, Minnesota, Oklahoma and Oregon piloted and evaluated strategies to improve care coordination among primary care providers and community service providers serving young Medicaid-eligible children. This report describes their evaluation methods, summarizes the results, and highlights lessons learned about evaluating care coordination.
  • Core Value, Community Connections: Care Coordination in the Medical Home
    Patient-Centered Primary Care Collaborative (PCPCC)
    This publication focuses on the theory and the practice of care coordination in the medical home.
  • How a Case Manager Can Help You Coordinate Care
    This article published in PhysBizTech discusses how case managers are being utilized as care coordinators in primary care practices to provide deeper connections with patient populations, which will help them achieve better healthcare outcomes.
  • Implementing a Care Coordination Program for Children with Special Health Care Needs: Partnering with Families and Providers
    In this study at the Children’s Hospital of Philadelphia (CHOP), health care professionals hosted focus groups with families to better understand the challenges they face and how the role of the care coordinator can best be designed to support them. Based on the focus group feedback, the researchers developed a training program and created new tools for care coordinators, such as Care Binders, Community Resources for Families Database, and a Care Coordination Network. The successful spread of education and knowledge from the care coordinators to families allowed new patients and families to receive coordinated, continuous care.
  • Renewed Emphasis on Team-based, Coordinated Care Places the Professional Case Manager Center Stage PDF
    Commission for Case Manager Certification
    This new issue brief and webinar recording provide guidance on care coordination, offering tools, resources, and insight into how case managers are breaking new ground in the advanced primary care setting as clinical partners in the new coordinated, team-based care setting. The issue brief identifies six functions of care coordination and explores the role of care coordination in new team-based care models as the nexus for communication, smooth care transitions and accountability. The webinar, Care Coordination: Tools and Resources for the Professional Case Manager, expands on the role case managers will play in the medical home, accountable care organizations, and advanced primary care-based delivery models. The webinar also introduces case managers to tools and resources for measuring the value of care coordination, as well as its role in prevention, patient safety, and in team-based care models.
  • The Care Coordination Toolkit PDF
    Cincinnati Children's Hospital Center for Infants and Children with Special Needs
    This toolkit outlines billing for the care coordination through a review of individual codes, proper documentation, and an easy to follow billing slip. 
  • Letters of Medical Necessity
    Medical Home Portal

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Care Plans

Every patient can benefit from a care plan (or medical summary) that includes all pertinent current and historic, medical, and social aspects of a child and family's needs. It also includes key interventions, each partner in care, and contact information.  A provider and family may decide together to also create an action plan, which lists imminent next health care steps while detailing who is responsible for each referral, test, evaluation or other follow up. If needed, emergency plans provide explicit instructions for prepared actions to be taken by the family, other caregivers or teachers, and all health care professionals.

Care plan oversight codes are intended to report care plan oversight services of children with chronic medical conditions provided by primary care physicians who coordinate the medical care management with other medical and non-medical service providers and family. For more information about these codes, and other medical home CPT codes, please visit the Payment & Finance page.

Care Plan Templates

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Co-managing Care

The medical home is responsible for coordinating timely medical information exchange for high quality care and communication. Effective co-management between specialists and the medical home requires a clear definition of roles and responsibilities, including those for patients and families. One way to formalize these responsibilities and create an understanding is to establish co-management agreements between the primary care team and specialists as well as individualized co-management plans for specific patients. The focus of this co-management may shift between primary and specialty care with the needs of the patients and the preferences of families.

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Partnering with the Community

Families often look to their physicians for guidance and support, mainly in the form of collaborative problem solving and resource management. It is important to be aware of, refer, and even partner with community organizations that offer ancillary services of benefit to patients and families.

Please visit the Resources & Linkages page for key organizations and tools to consider in creating community partnerships; additional contacts and agencies are listed on the State Pages.

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Promising Practices

Medical Home Interview Videos New
Developed by the National Center for Medical Home Implementation


AHRQ Health Care Quality: Frontline Innovators on Changing Care, Improving Health
Agency for Health Research and Quality (AHRQ)
This site features video profiles of six healthcare professionals sharing stories that illustrate the key elements of their innovations and the impact on the lives of individuals. Two videos that illustrate innovations in pediatric care that utilize elements of medical home are:


Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs
Institute for Healthcare Improvement (IHI)
This white paper outlines methods and opportunities to better coordinate care for people with multiple health and social needs, including how organizations have allocated resources to better meet the range of needs in this population. There is special emphasis on the experience of care coordination with populations of people experiencing homelessness.


Implementing a Care Coordination Program for Children with Special Health Care Needs: Partnering with Families and Providers
In this study at the Children’s Hospital of Philadelphia (CHOP), health care professionals hosted focus groups with families to better understand the challenges they face and how the role of the care coordinator can best be designed to support them. Based on the focus group feedback, the researchers developed a training program and created new tools for care coordinators, such as Care Binders, Community Resources for Families Database, and a Care Coordination Network. The successful spread of education and knowledge from the care coordinators to families allowed new patients and families to receive coordinated, continuous care.


Making Connections: Medicaid, CHIP, and Title V Working Together on State Medical Home Initiatives
National Academy for State Health Policy (NASHP)
Several of the most promising state medical home initiatives have involved interagency collaboration. This report details productive practices and policy considerations for collaborative medical home building in four areas: laying foundations for partnership; working together to engage patients and families; engaging health care providers and practices; and building strong systems of care.


Medical Home Care Approach Improves Efficiency and Care at Clinic for Low-Income Families PDF
Implementing a medical home practice model in a health clinic allows physicians and staff to provide comprehensive care to more patients, and to offer preventive programs and services. This can improve patients' compliance with their doctors' recommendations and reduce emergency room visits and hospital admissions, according to research conducted at a Connecticut clinic presented at the AAP National Conference and Exhibition in San Francisco on October 4, 2010.


New Jersey Blues Plan Houses Employees at Practices
American Medical News (2011)
Horizon Blue Cross Blue Shield of New Jersey is paying for a staff person to work full time at each medical office participating in a patient centered medical home pilot program. That person helps document care for quality-based pay and contacts patients about care.


Oklahoma's Web Portal: Fostering Care Coordination between Primary Care and Community Service Provider PDF
National Academy for State Health Policy (NASHP), 2012
This brief focuses on the Web-based referral and tracking system that Oklahoma has built into its pre-existing Preventive Services Reminder System. Oklahoma designed this Web portal to improve care coordination for children with or at risk for developmental delays and is considering ways to adapt the Web portal for other services and populations.


Practice Supports: Using Care Managers, Quality Improvement Coaches to Transform Medicaid Primary Care
Center for Health Care Strategies

This technical assistance brief describes how states are using two types of practice-based supports—care managers and quality improvement coaches—to help Medicaid primary care practices provide higher-quality, more patient-centered, and cost-effective care. The brief draws from the experiences of pilot programs in six states to describe models for deploying practice supports to primary care practices, different approaches for hiring and paying for these individuals, how Medicaid programs are using practice supports within a managed care delivery system, and early lessons that Medicaid is learning about these practice supports.


Presentation—The Medical Home and Out-of-Home Child Care
To better equip health care professionals with resources to educate colleagues and early education and child care professionals on various topics, Healthy Child Care America—an AAP program—highlights presentations in PowerPoint format in their e-Newsletters. The September 2010 issue focused on medical home and how child care programs, child care health consultants, pediatricians, and states can advance this approach to care.


Putting Patients First Might Really Save—Medical Practices Use New Approach in Delivering Care
A recent article in The Columbus Dispatch tells the story of practice transformation through a patient's eyes, depicting the positive changes experienced in the patient’s care. Central Ohio Medicine, part of Central Ohio Primary Care group, is one of nine area practices that have become medical homes. The effort is coordinated by Access HealthColumbus, a health policy group, which will collect and analyze quality and cost data.

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Rural Communities

Only about ten percent of physicians practice in rural America despite the fact that nearly one-fourth of the population lives in these areas. 1

This section provides a variety of resources and tools available to assist pediatric care providers in rural and frontier communities provide a medical home to children and youth.

  • Rural Assistance Center (RAC)
    The Health Resources and Services Administration (HRSA) Office of Rural Health Policy (ORHP)-funded RAC is a one-stop resource for rural health and human services. RAC helps rural communities access available programs, funding, and research that can enable them to provide quality health and human services to rural residents.
  • Rural Health IT Adoption Toolbox
    This HRSA resource addresses the needs of rural providers in the planning and implementation of health information technology. Resources compiled for this toolbox are from both public and private sector entities, including government agencies, academic institutions, and research organizations. 
  • Telehealth Resources
    Telehealth care is an increasing component of pediatric practice, especially in rural communities.
  • Compendium of Rural Best Practices and Models—Communities along the border, including practices in the clinical setting
    This compendium is representative of NRHA's Border Heatlh Initiative's activities to encourage the development of quality health care sevices for rural populations along the US-Mexcico border. Pages 9 and 22 of the Compendium provide pediatric examples.
  • AAP Rural Special Interest Group (RH SIG)
    The purpose of the AAP RH SIG is to identify, prioritize, and promote educational and training opportunities related to rural child health.
  • State Rural Health Associations (SRHA)
    Each SRHA focuses on improving the health of rural Americans living in their state, and serves as a conduit for rural communities to communicate needs and successes at a regional and national level.
  • State Offices of Rural Health (SORH)
    The general purpose of each SORH is to help their individual rural communities build health care delivery systems.
    • Grants Technical Assistance Workshops
      Every year, the ORHP, Community Based Division conducts several workshops in partnership with the SORH to educate rural health providers about upcoming community-based grant funding opportunities from HRSA, encourage community organizations to apply, and increase organizations' capacities in obtaining future grant funds.
  • National Survey of Children’s Health (NSCH) The Health and Well-Being of Children in Rural Areas: A Portrait of the Nation in 2007
    Health Resources and Services Administration (HRSA)
    According to this report, children in rural areas are more likely to face different challenges to their health and have less access to care when compared with children in urban areas. The report examines the overall health of rural children in the United States from birth to 17 years and finds greater prevalence of certain physical, emotional, behavioral and developmental conditions in rural areas.

1 Rural Healthy People 2010—"Healthy People 2010: A Companion Document for Rural Areas," is a project funded with grant support from the federal Office of Rural Health Policy.

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A medical home ensures continuity of care and successful transition for youth from pediatric to adult health care. By age 14, the youth, family, and medical home team should begin discussing the creation of an individualized written health care transition plan including  what services need to be provided, who will provide them, when they will be provided, and how they will be financed.

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For more information and resources about transitions, please visit the Transitions page.

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