• Conference/Meeting
  • March 4-9, 2018

2018 Quality and Safety in Children's Health Conference

  • Concurrent
  • March 6, 2018
  • 11:15 AM - 11:45 AM

Implementing Primary-specialty Care Coordination Partnerships for Children with Medical Complexity

Rhonda Cady, PhD, RN, Clinical Scientist - Health Services, Gillette Children's Specialty Healthcare

Summary: This session details a pilot model of primary-care, specialty-care partnership care coordination implemented for rural or limited-English proficient medically complex children. Despite implementation challenges, evaluation indicates increased family satisfaction with cross-system communication, appointment coordination and receiving important care information. Significant decrease in specialty-care utilization could reflect improved coordination and self-management ability. 

Description: Children with medical complexity (CMC) require primary and specialty care management of health needs. Care coordination is a fundamental medical home function, yet CMC, families and providers encounter communication and collaboration barriers. Rural and limited-English proficient families face additional challenges including frequent trips to distant specialty centers, and difficulty understanding and implementing multiple provider recommendations. Gillette Children’s Specialty Healthcare, a tertiary pediatric sub-specialty system, conducted a three-year pilot with four primary care clinics (PCC) and enrolled 40 CMC (10 per PCC). Project goals include enhanced communication and coordination between families, primary and specialty providers, and community resources. A shared plan of care is central to partnership. 

Learning Objectives:

• Examine factors increasing care coordination usefulness for rural and limited-English proficient children with medical complexity.
• Discuss child, parent and staff evaluation findings for the partnership care coordination model.

Session Recordings

Implementing Primary-specialty Care Coordination Partnerships for Children with Medical Complexity

Quick Reference

  • What the team measured as part of the Triple Aim. Time: 9:00
  • Description of team successes. Time: 17:46