Oregon Health & Science’s Doernbecher Children’s Hospital is a top academic teaching pediatric hospital in the United States. The Pediatric Outpatient Parenteral Antibiotic Therapy (OPAT) program is a subspecialty practice which serves pediatric patients who are discharged and sent home with IV or oral antibiotics to complete treatment of their serious infection. In the pediatric setting, the OPAT program uses care coordination to enhance care for children and youth and collaborates closely with the patient’s primary care and / or subspecialty medical home. The OPAT program utilized the Care Coordination Measurement Tool (CCMT) to justify value of the program to hospital administration,  including prevented hospital readmissions and reduction of emergency room visits.

Implementation Insights*

  • Communication is key. Check in regularly with families, other care providers and home health staff via telephone to stay up to date on patient care and health status.
  • Utilize the CCMT to measure how staff time and other resources are being used on care coordination activities. Identify strengths, weaknesses, opportunities, and needed resources to optimize patient-centered care, as well as roles and level of licensure required to provide that care.
  • Adapt by aligning non-billable care coordination activities to additionally hired staff or to other existing hospital services, if possible.

​*These implementation insights resulted from utilization of the CCMT. 

Updated: July 2018


 Background Information

  • Type of Practice: Pediatric infectious disease outpatient program
  • Location: Portland, Oregon
  • Population Served: The program serves children in Oregon and surrounding states. Due to the hospital's status as an academic tertiary care and referral center, the program sees medically and socially complex patients.

 Pediatric Medical Home Implementation Strategies

  • Review charts retrospectively to ascertain potential errors and avoidable poor outcomes that occurred without the OPAT program. For example, we measured outcomes such as readmissions and emergency room visits, as well as loss of patient/families to follow up during treatment for infection.
  • Collaborate with the National Center for Care Coordination Technical Assistance to modify the Care Coordination Measurement Tool to measure and track non-billable hours spent on care coordination. Examine outcomes for patients who received care coordination services.
  • Present results to hospital administration to demonstrate value of the OPAT program and to advocate for system changes that reduce errors and avoid poor outcomes.


  • ​Many patients served through the OPAT program have medical and social complexity. Complexities require additional non-billable care coordination services.
  • The Pediatric OPAT program experienced challenges due to initial small staff size, which resulted in clinical providers' time being inappropriately used for care coordination and administrative office functions.
  • Care coordination for non-English speaking families utilizing interpreter services was particularly difficult and may impede family-centered care.

 Strategies to Overcome Challenges

  • ​Engage families in the inpatient setting prior to discharge through warm hand offs, meet and greets with OPAT staff, and by teaching families or caregivers about the child's OPAT plan of care.
  • Ensure phone communication check ins with families, providers, and others in the patient's medical home is clear, concise, and delivered in a timely manner.
  • Deliver multidisciplinary care through joint visits with other medical providers to enhance the patient-family experience and develop shared care plans regarding infection treatment.
  • Embed portions of the CCMT into the electronic medical record to track care coordination activities and reduce duplication of efforts.
  • Hire additional staff and utilize existing hospital services, if possible, to assist with vital, yet time consuming, care coordination activities. We engaged hospital case managers and social workers to assist with assessments prior to discharge, and with hospital-to-home care planning. We delegated work like obtaining lab results, faxing, phone check ins with families, and scheduling appointments to new or existing staff members.
  • Utilize the CCMT to ensure appropriate division of labor so our team could operate at the top of their licenses and function as best as possible.