Care Coordination Using a Shared Plan of Care Approach: From Model to Practice

Area of Science:

• Pediatric Healthcare
• Care Coordination
• Health Services Research

Background:

• Children and youth with special health care needs (CYSHCN) often lack adequate care coordination (CC), despite its benefits for pediatric care and population health.
• Current CC initiatives show promise but need better adherence to emerging standards.
• A Shared Plan of Care (SPoC) is a recommended CC approach requiring further implementation study.

Purpose of the Study:

• To illuminate family-centered, interdisciplinary, team-based care coordination and SPoC components.
• To underscore the importance of family participation and engagement in CC.
• To reveal implementation processes and lessons learned from a CC program.

Main Methods:

• A five-phase workflow was used to implement CC in a children's hospital ambulatory care setting for children (ages 2-10) with neurodevelopmental disabilities.
• The workflow included family outreach, pre-visit work, population-based teamwork, SPoC co-production during visits, and ongoing coordination.
• Family surveys and SPoC goals informed the program evaluation.

Main Results:

• The Riley Care Coordination Program (RCCP) successfully enrolled 268 children with neurodevelopmental disabilities over 6 months, demonstrating feasibility.
• Co-produced SPoCs facilitated goal achievement for families and care neighborhood partners.
• Plan-do-study-act improvement cycles led to program enhancements.

Conclusions:

• Prioritizing family goals in CC led to improved interventions, treatments, confidence, and navigation skills for children and families.
• The RCCP achieved enhanced CC through care neighborhood learning partnerships, moving beyond episodic care.
• Investing in quality CC aligned with national standards shows significant promise.