Yogman Pediatric Associates is a small pediatric practice that has leveraged existing technology, resources, and partnerships to implement behavioral health care coordination as a means to enhance the care provided to patients/families in their practice based on the tenets of the medical home model. By utilizing grant funding, Yogman Pediatric Associates hired a licensed independent clinical social worker and parent partner to support care coordination activities and measured same by modifying and utilizing the Care Coordination Measurement Tool for children with behavioral health needs.

Updated: July 2018

​Implementation Insights:
  • Designate and integrate care coordination duties to team members and into practice culture.
  • Leverage existing technology and resources to track and enhance implementation of care coordination activities.
  • Utilize daily formal and informal team huddles to enhance team-based and culturally competent care.

 Background Information

      • Type of Practice: Small pediatric practice affiliated with Mount Auburn Hospital
      • Location: Cambridge, Massachusetts
      • Population Served: Children, particularly those with behavioral health needs

 Pediatric Medical Home Implementation Strategies

      • Receive various grants at the state and local levels to financially support developing a patient-centered medical home, hiring a care coordinator, and parent partner.
      • Hire a licensed independent clinical social worker (LICSW) to work in the office and provide behavioral health care coordination   and behavioral health consultation and treatment for children and families.
      • Collaborate with the National Center for Care Coordination Technical Assistance to modify the Care Coordination Measurement Tool to measure the effectiveness of behavioral health care coordination.
      • Integrate the LICSW in the office, allowing for facilitation of warm hand-offs.
      • Hire a parent partner of a child with behavioral health needs to work under the supervision of the LICSW and conduct culturally competent outreach and behavioral care coordination duties.
      • Utilize billing codes for care coordination.
      • Develop a parent advisory group including mothers, fathers, and community members to provide expertise, feedback, improvements, and support to the practice.
      • Embed care plans into the electronic medical record for ease of coordinating care with families of children with complex behavioral health needs.
      • Created registries within the electronic medical record system to track behavioral health diagnoses of patients.
      • Conduct surveys to track provider and patient satisfaction.
      • Utilize daily team huddles and informal huddles during the day to support and enhance team-based care.


      • The practice struggles with financial support for sustainability of the LICSW position. Upon completion of the grant funding, the LICSW and parent partner care coordinator positions were combined and reduced to a part-time position with Yogman Pediatric Associates.
      • To sustain the LICSW in the practice, the LICSW is contracted with other pediatric practices in the region and currently only spends half of her time at Yogman Pediatric Associates.