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.
Provider and Staff Knowledge of Medical Home
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
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:
What Is Care Coordination?
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:
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
Competencies of Professionals Providing Pediatric Care Coordination
Sample Job Descriptions
Billing & Coding
Care Coordination Resources:
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:
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.
Co-Managing Care Resources:
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.
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.
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:
Video: How Does a Medical Home Support Transitioning from Pediatric to Adult Care?
For more information and resources about transitions, please visit the Transitions page.