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A Step-by-Step Guide to Building a Complex Care Coordination Program in a Small Setting.

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A care support project improved care for children with medical complexity by using collaborative teams and shared plans. This approach enhanced communication and reduced hospital admissions.

Keywords:
care coordinationchildren with medical complexityhealth care deliverypopulation health

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Area of Science:

  • Pediatric healthcare
  • Complex care management
  • Healthcare systems engineering

Background:

  • Children with medical complexity (CMC) represent a growing population.
  • Existing pediatric care models face challenges in managing CMC.
  • Effective care coordination is crucial for this population.

Purpose of the Study:

  • To describe a care support project for children with medical complexity.
  • To outline the structure and function of care support teams.
  • To evaluate the impact of shared care plans on patient outcomes and healthcare utilization.

Main Methods:

  • Implementation of a care support project focused on children with medical complexity.
  • Formation of multidisciplinary care support teams with defined roles.
  • Development and utilization of shared plans of care for providers and families.
  • Collaborative efforts to improve provider communication, set SMART goals, and track tasks.

Main Results:

  • Improved communication among healthcare providers.
  • Successful creation and implementation of Specific, Measurable, Assignable, Realistic, and Timely (SMART) goals.
  • Enhanced task tracking and care coordination.
  • Enabled patients to remain in their local medical homes.
  • Reduced hospital admissions and emergency room overutilization.

Conclusions:

  • Care support teams and shared plans of care are effective for managing children with medical complexity.
  • This model supports community physicians and facilitates local care access.
  • The project demonstrated a reduction in acute care utilization, indicating improved efficiency and patient outcomes.