Children’s Health Foundation pediatricians are using their learnings from the CHF Pediatric Care Management Improvement Collaborative and other regional and national research to guide their approaches to addressing the varied medical and overall care needs of children, especially those with chronic or complex medical and psychosocial conditions.

In pediatrics, chronic medical conditions are just one factor contributing to the child/family’s need for an effective pediatric medical home care team. Other important factors include the child’s physical, social and mental functioning; as well as the family’s resources, structure and dynamics. Pediatrician members of the Children’s Health Foundation recognize the importance of these multi-faceted considerations when delivering top quality pediatric care. Currently, the following factors have surfaced as key considerations in understanding the pediatric medical home needs of children and families:

  • Medical Complexity (based on number and severity of chronic conditions)
  • Family Factors affecting the support needed for optimal self-management of the child’s medical condition and overall health
  • Patient Functioning Factors affecting the support needed for optimal self-management of the child’s medical condition and overall health

Pediatrician members of the Children’s Health Foundation are working in 2013 to better understand the multi-faceted needs of children and families and to enhance their delivery of personalized, patient-centered pediatric care.

See a Project Storyboard Summarizing 2013 Work by Children’s Health Foundation pediatricians on Needs-Driven Pediatric Population Segmentation Informing Child & Family Centered Care Management.

Children’s Health Foundation pediatricians are using their learnings from the CHF Pediatric Care Management Improvement Collaborative and other regional and national research to guide their approaches to addressing the varied medical and overall care needs of children, especially those with chronic or complex medical and psychosocial conditions.

In pediatrics, chronic medical conditions are just one factor contributing to the child/family’s need for an effective pediatric medical home care team. Other important factors include the child’s physical, social and mental functioning; as well as the family’s resources, structure and dynamics. Pediatrician members of the Children’s Health Foundation recognize the importance of these multi-faceted considerations when delivering top quality pediatric care. Currently, the following factors have surfaced as key considerations in understanding the pediatric medical home needs of children and families:

  • Medical Complexity (based on number and severity of chronic conditions)
  • Family Factors affecting the support needed for optimal self-management of the child’s medical condition and overall health
  • Patient Functioning Factors affecting the support needed for optimal self-management of the child’s medical condition and overall health

Pediatrician members of the Children’s Health Foundation are working in 2013 to better understand the multi-faceted needs of children and families and to enhance their delivery of personalized, patient-centered pediatric care.

Pediatrician members of the Children’s Health Foundation benefit from understanding their pediatric populations at a level that supports their ability to proactively target their care delivery approaches to meet the needs of their patients and while also optimizing their operations and addressing policy and payment requirements.

By stratifying the pediatric population in a consistent manner across the CHF network of 100 pediatricians, population level data becomes more meaningful and offers the possibility of influencing payment models to better align with the services provided by the pediatric medical home.

At the individual pediatric practice level, the data informs operational decisions to align services and resources to the needs and wishes of children and families served which helps optimize practice operations.

At the patient level, an enhanced and broadened understanding of patient needs enables better patient care, family satisfaction and provider satisfaction, along with the chance to positively affect costs of care delivery.

Much of current research and subsequent health policy advocates care coordination as a critical element in the delivery of patient-centered primary care medical home. It is clear that the ability to provide comprehensive, coordinated care that emphasizes prevention, stabilizes cost growth, and reduces the current fragmentation, duplication and gaps in care experienced by patients is key to achieving the triple aim of better health, better health care and lower costs in pediatric health care.

In pediatrics, there are few tools and models that have been broadly adopted. The development and implementation work to be completed by the collaboration of CHF’s pediatric practices will offer leading ideas and tools and assist practices in practical implementation of care coordination activities within the office-based setting.

CHF has developed a pediatric chronic condition population model which illustrates the distribution of the pediatric population based on complexity of care needs.

Figure 1: Pediatric Chronic Conditions Population Model®

Somewhat different than most of the adult population, children may move more frequently between tiers throughout their development. And their tier placement is heavily influenced by psycho-social changes in their family life. Implementation of proactive, targeted care management across a population this broad and fluid is challenging for pediatric practices.

Improving office-based pediatric care management will ultimately benefit all children served by pediatricians of the Foundation, yet targeted care management actions will focus on children and youth in tiers 1-3 which includes newborns and children with one or more chronic health condition such as asthma, diabetes, ADHD, mental health disorders, obesity, and others.

A key approach of the Foundation’s Pediatric Care Management Improvement initiative includes facilitation of a learning collaborative. This will provide an educational forum to share research collected by the Foundation through a multi-disciplinary team of pediatric care experts in our community which included extensive literature review, interview of over twenty care managers in various settings and survey of parents of children with special health care needs. The Collaborative will also serve as a learning and development forum for pediatric practices to explore, test, adapt, implement and spread office-based care management methods, tools and strategies which improve the delivery of proactive, targeted care management and disease-based care coordination.

Pediatric practice members of the Children’s Health Foundation have the opportunity to participate in the Population Management program and/or utilize tools and resources developed by the Foundation.

Participants in the Children’s Health Foundation Population Management program should meet the following criteria:

  • Licensed pediatrician or pediatric provider (MD, DO, PNP) member of the Children’s Health Foundation, or practice staff of a pediatric provider member of the Children’s Health Foundation
  • Interested in collaborating with other pediatric practices around understanding and assessing child and family support needs for optimal self-management of their medical condition and overall health.
  • Willing to identify and flag children/youth with special health care needs
  • Willing to designate a pediatrician or nurse as a “champion” and a clinical staff person(s) as a care coordination/management “implementation specialist” who will be instrumental in considering and testing changes and helping spread adoption throughout your practice.

For more information on the CHF’s quality programs or membership, please contact us at This email address is being protected from spambots. You need JavaScript enabled to view it. or 503-222-5703.