• ​Policy

• Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems
  This American Academy of Pediatrics policy statement provides a definition and framework for implementing care coordination.
• Definition
  
• Pediatric care coordination is a patient-and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational and financial needs to achieve optimal health and wellness outcomes. (Definition adapted from: American Academy of Pediatrics Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems. Pediatrics. 2014; 133(5): e1451- 1460).

Originally published in the Commonwealth Fund report titled, "Developing Care Coordination as a Critical Component of a High Performance Pediatric Health Care System: Forging a Multidisciplinary Framework for Pediatric Care Coordination," this table is a guiding framework for care coordination competencies and functions.

Reproduced with permission from Antonelli R, McAllister J, Popp J. Developing Care Coordination as a Critical Component of a High Performance Pediatric Health Care System: Forging a Multidisciplinary Framework for Pediatric Care Coordination. Washington, DC: The Commonwealth Fund; 2009.  

• ​Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families Achieving Optimal Health Outcomes, 2nd Edition

• This curriculum was created through a subcontract with Boston Children's Hospital and the National Center for Medical Home Implementation (NCMHI), with support from the Maternal and Child Health Bureau in the Health Resources and Services Administration. The curriculum is designed to build capacity among diverse stakeholders (AAP Chapters, Maternal and Child Health Title V/Children and Youth with Special Health Care Needs programs, pediatricians, families, and others) through the following activities:
• Effective implementation of key components of care coordination
• Collaborative communication within inter-professional care teams
• Investment in technology solutions
• Download full curriculum
• Download individual curriculum modules
• Getting Started: Introduction to the Curriculum and "At-A-Glance" Overview
• Module 1: High-Value Integrated Care Outcomes Depend on Care Coordination
• Slides
• Facilitator Guide
• Appendix
• Module 2: Developing and Sustaining Strong Family/Professional Partnerships
• Slides
• Facilitator Guide
• Module 3: Social Determinants of Health
• Slides
• Facilitator Guide
• Module 4: Measurement Matters: Creating an Effective and Sustainable Integrated Care Model
• Slides
• Facilitator Guide
• Module 5: Using Technology to Improve Care Planning and Coordination
• Slides
• Facilitator Guide
• Evaluation Module: Sample Tools to Evaluate Your Care Coordination Training

• Pediatric Care Coordination Curriculum, First Edition  
• The original (first edition) version of the Pediatric Care Coordination Curriculum was created by Boston Children's Hospital with support from the Maternal and Child Health Bureau in the Health Resources and Services Administration. The curriculum demonstrates the principles, key concepts, and activities necessary to successfully provide care coordination to patients and families.                       
  
• Health Care Coordination in Schools: An Instructional Curriculum for School Nurses
  The National Center for Medical Home Implementation partnered with the California State University, Sacramento, to edit the PCCC specifically for school nurses. The full curriculum is now available for download below.
• Module 1: How School Nurses Can Implement Care Coordination
• Overview and presentation documents
• In-person handouts
• Pre-session readings
• Download all documents in Module 1 (Zip file)
• Module 2: How School Nurses and Care Coordination Supports Students with ADHD
• Overview and presentation documents
• In-session handouts
• Download all documents in Module 2 (Zip file)
• Module 3: Health-related Social Service Needs: Strategies to Assess and Address Shared Planning in the Family-centered Health Care Home
• Overview and presentation documents
• Download all documents in the Instructional Curriculum for School Nurses      

• Sources of Care Coordination Measurement
  
• National Committee for Quality Assurance Care Coordination Measures  
• National Quality Forum Care Coordination Measures*
• Center of Excellence on Quality of Care Measures for Children with Complex Needs- Family Experience with Coordination of Care
  
• Boston Children's Hospital Integrated Care Program

• Care Coordination Measurement Tool
  This tool enables assessment of value in health delivery models by measuring the activities of care coordination, necessary resources to implement those activities, and resulting outcomes.
• ​Care Coordination Measurem​ent Tool (2009)
• Updated Care Coordination Measurement Tool (2017)
• 2017 Care Coordination Measurement Tool Adaptation and Implementation Guide

• Pediatric Integrated Care Survey 
  This family-reported survey instrument measures family experiences of care integration. This tool can be used to inform quality improvement and interventions to improve care integration. To request this survey instrument in Spanish, contact the National Center for Care Coordination Technical Assistance.
• User Manual
• Core Instrument
• Supplementary Questions
• Module 1: Transition to Adult Care
• Module 2: Care Plan
• Module 3: Integrator Version
• Module 4: Burden
• Module 5: School and Services through Individualized Education Plans

*Note: Many of these measures are linked to specific conditions. While this measures set is important, the National Center for Care Coordination Technical Assistance supports implementation and measurement of care coordination across all settings and conditions. 

•  Publications
• Validation of a Parent-Reported Experience Measure of Integrated Care  
• Utilizing a Modified Care Coordination Measurement Tool to Capture Value for a Pediatric Outpatient Parenteral and Prolonged Oral Antibiotic Therapy Program  
• The Care Coordination Conundrum and Children and Youth with Special Health Care Needs
• Archived Webinars and Podcasts
• Multidisciplinary Care Coordination Training for Children with Medical Complexity: The Arizona Experience Podcast
• Measuring Family Experience of Care to Improve Care Delivery Webinar
• Coordinating Care for Kids—School Nurses Linking with the Medical Home Webinar
• Pediatric Care Coordination: Beyond Policy, Practice, and Implementation Webinar
• Care Coordinator Job Descriptions
  Job titles and roles vary across intitutions and settings based on resources and community needs. As such, the National Center for Care Coordination Technical Assistance (NCCCTA) does not develop specific job descriptions, as these should be determined based on the unique resources and needs of each team. Functions of care coordination that should be completed by a team member are included in the American Academy of Pediatrics policy statement, "Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems." Sample care coordinator job descriptions that may be used as a reference are available through the National Resource Center for Patient/Family-Centered Medical Hom here.
• Care Planning Tools
• Care Mapping
• Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs
• National Institute for Children's Health Quality Care Plan Template
• National Center for Medical Home Implementation Care Plan Templates
• Massachusetts Child Health Quality Coalition Care Coordination Strengths and Needs Assessments

• National Center for Care Coordination Technical Assistance
  The National Center for Care Coordination Technical Assistance (NCCCTA) is a partnership between the National Resource Center for Patient/Family-Centered Medical Home and Boston Children's Hospital Integrated Care Program. The mission of the NCCCTA is to support the promotion, implementation and evaluation of care coordination activities and measures in child health across the United States.
• The following technical assistance and support is available to individuals interested in implementing care coordination:
• One hour of introductory technical assistance regarding the Pediatric Care Coordination Curriculum, Care Coordination Measurement Tool and the Pediatric Integrated Care Survey.
  
• Two additional hours of technical assistance in the adaptation, implementation and evaluation of the aforementioned tools.
• Assistance and support through email, as necessary.
  
• Contact us for technical assistance and support.
• View a graphical summary of a 2015 environmental scan, performed by the NCCCTA, that looked at care coordination activities across the United States. If you would like to receive a more comprehensive report, contact the National Center for Care Coordination Technical Assistance.
  
• View a comprehensive poster describing the National Center for Care Coordination Technical Assistance.
  
• To learn more about these care coordination tools, visit the Boston Children's Hospital Integrated Care Web site.
• To join the NCCCTA Community of Learners Listserv ®, email the National Center for Care Coordination Technical Assistance. This listserv® is intended for anyone who is focused on pediatric care coordination capacity building and measurement. Valuable tools, measures, resources and publications are shared. Members are encouraged to pose questions for discussion and information about work that they are conducting.
  

• Overview
• The "Practical Application of Care Coordination" initiative is a collection of real life examples of care coordination implementation. The initiative aligns with the mission of the National Center for Care Coordination Technical Assistance (NCCCTA) to create a community that is focused on care coordination capacity building and measurement.
  
• In 2017, the NCCCTA merged its "Care Coordination in the Community" initiative with the National Center for Medical Home Implementation "Promising Practices" initiative. Examples of identified projects are included below.
  

• If you are interested in having your project or initiative published on this Web page (the project or initiative does not need to be fully implemented in order to be published on this Web page) please email the National Center for Care Coordination Technical Assistance. 

•  Examples of Care Coordination in the Community
  
• Tennessee Chapter of the American Academy of Pediatrics
• Help Me Grow
• Keeping Families Healthy
• Family Voices of Wisconsin
• Yogman Pediatric Associates
• Doernbecher Children's Hospital
• Phoenix Children's Hospital