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.
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.
Heath Care Professional Provider Survey 
Health Care Office Staff Survey
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 the Building Your Medical Home toolkit.
Huddles: Increased Efficiency in Mere Minutes a Day 
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TransforMED, 2207
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.
Additional pre-visit templates can be found on AAP’s Practice Management Online (PMO), available to AAP members:
What Is Care Coordination?
Pediatric care coordination is a family-centered, relationship-based, interdisciplinary activity necessary to ensure optimal behavioral, developmental, health, and wellness outcomes for children and youth while enhancing the care giving capabilities of families. Care coordination is a process that facilitates connecting children and their families with appropriate services and resources in a coordinated effort to achieve good health. However, care coordination for children with special health care needs often is complicated because there is no single point of entry into the multiple systems of care, and complex criteria frequently determine the availability of funding and services among public and private payers. For more information on children and youth with special health care needs, click here.
In their important role of providing a medical home for all children, primary care physicians have a vital role in the process of care coordination, especially in building a partnership with the child/youth, family, and practice team. A designated staff member, someone who functions in or develops the role of a “practice-based care coordinator” is invaluable. The care coordinator can help to ensure the success of the family and practice partnership. A framework to define, describe, and evaluate care coordination is also helpful. Billing for the care coordination requires an understanding of the individual codes, proper documentation, and an easy to follow billing slip. For more information, visit the Payment & Finance page. For a listing of publications regarding care coordination, visit the 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.
Available Resources
- The Care Coordination Toolkit
Developed by the 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.
- Colorado Patient Navigator Training
This program offers a full curriculum designed to build patient navigator skills and knowledge. Courses and workshops relate to issues navigators deal with every day and are taught by patient navigation experts. A variety of formats make it easy to incorporate training into a busy schedule including face-to-face workshops, online courses, and self-paced online tutorials. A patient navigator is a member of the healthcare team who helps patients "navigate" the healthcare system and get timely care. Navigators work with patients to identify their barriers to healthcare and connect them to the resources they may need such as financial assistance, counseling, language translation or transportation. Courses are for patient navigators, social workers, parish nurses, CNAs, and other community health care workers. They are intended for health workers who want a basic understanding of issues and practices related to advanced chronic disease. Those relatively new to assisting patients and families will benefit most.
- The Patient-Centered Medical Home (PCMH): Integrating Comprehensive Medication Management to Optimize Patient Outcomes
This report was developed by the Patient Centered Primary Care Collaborative (PCPCC) Medication Management Task Force under the Center for Public Payer Implementation (CPPI), whose charge is to promote the PCMH concept in all facets of the public payer system. The Center believes that critical to the success of the PCMH is the ability to maximize the appropriate use of medications to prevent and control disease.
- PowerPoint Presentations From the AAP Health Child Care America Program
To better equip health care professionals with the resources to educate colleagues and early education and child care professionals, Healthy Child Care America features a new PowerPoint presentation in each issue of its e-Newsletter. Each presentation is on a different topic and can be customized to meet your needs. These resources are available to help you educate others on the definition and benefits of health consultation, and how pediatricians can be health consultants too. In addition, they have developed a general presentation on the AAP and Healthy Child Care America program.
- Practice Based Care Coordination
- Social work, case management, public benefits, and resource expertise
- Tasks primarily social, not medical
- Parent Consultant
- 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
- 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
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
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.
More practice tools can be accessed by AAP members via Practice Management Online (PMO), which is available as a member benefit to all AAP members. These tools include:
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.
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.
For more information and resources about transitions, please click here.
