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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
- 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. .
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
March 23, 2007
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