Enhanced Care Coordination

Children with medical complexity (CMC) require intensive care and support from multiple health care providers and community resources. Their families often report fragmented care due to a lack of active coordination between these services. This fragmented care may encompass duplicative or unnecessary services, unmet needs, excessive wait times, and missing information needed to make the correct medical decisions. The fragmentation is reflected on a family’s care map.

Care coordination is crucial for optimal health and health care for CMC. All services need to be proactively managed and delivered in an efficient and effective manner. The CARE Award identified and tested several change concepts with potential for significantly improving care coordination, including dynamic care teams (DCT), access plans and care plans with shared goals. By implementing a care coordination system, children’s hospitals are positioned to reduce avoidable utilization, and improve the patient and family experience. However, new payment models, along with a sustainability plan, are needed to transform the delivery system.

The Importance of Care Coordination

This short, self-paced course describes how coordinating a broad range of services puts families at the center of care and improves outcomes for CMC.

Launch Module

Reflections on Care Coordination

CMC require the coordination of a myriad of supportive services from across the continuum to achieve maximum health and wellness. This white paper shares strategies to improve coordination of care for CMC and their families employed by practice sites as a part of the CARE Award.

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The Essential Role of Care Coordination

Hear project champions from several CARE Award hospitals explain how care coordination is an essential part of improving care management for children with medical complexity.

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Related resources

White Paper

Impacting the Health Care Spend for Children with Complex Conditions

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Care Program Improves Family Health-Related Quality of Life

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Success Stories

Methods for Advancing Care Coordination

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CARE Webinar Series

Optimal Care Design

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