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.