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" resource.

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 home-ness 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.


Versions are available for both practice staff and clinicians.

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.

For more information on creating a team and how a team can affect quality improvement in the practice, please visit the "Building Your Medical Home" resource.

Additional team-based care resources:

Team Huddles
One strategy in building an effective practice team is to start the workday with a team huddle to organize schedules, gather lab results, etc. This 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. 

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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
  • Calls for partnership across various settings and communities.

The 2014 Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems policy statement, written by the AAP Council on Children with Disabilities and the Medical Home Implementation Project Advisory Committee, specifically outlines the essential partnerships that are critical to this framework. Implementation of this framework aims for lower health care costs, less fragmented care and an improved experience for children and families.

An accompanying AAP News article, " Beyond the Medical Home: Coordinating Care for Children" provides more information.

To further 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 such as:

  • Single practice
  • Network of practices
  • Parent and family organizations
  • 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.   

For more information regarding care coordination, visit the Medical Home Literature page.

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

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.

Care Coordination Resources:

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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
  • 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.

Co-Managing Care Resources:

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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

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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.

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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Transitions

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 are needed
  • Who will provide services
  • When services will be provided
  • How services will be financed

Video: How Does a Medical Home Support Transitioning from Pediatric to Adult Care?
Video: Why Is It Important for Primary Care Providers to Help Families Prepare to Transition from Pediatric to Adult Care?

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

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