Published online August 31, 2007
PEDIATRICS Vol. 120 No. 3 September 2007, pp. e723-e733 (doi:10.1542/10.1542/peds.2006-1684)
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SPECIAL ARTICLE

Practice-Based Care Coordination: A Medical Home Essential

Jeanne W. McAllister, BSN, MS, MHAa,b, Elizabeth Presler, ARNP, PhDc and W. Carl Cooley, MD, FAAPa,b

a Center for Medical Home Improvement, Crotched Mountain Foundation and Rehabilitation Center, Greenfield, New Hampshire
b Department of Pediatrics, Dartmouth Medical School, Hanover, New Hampshire
c Care Coordination Unit, Shriners Hospitals for Children, Lexington, Kentucky

Families who raise children and youth with special health care needs deserve a medical home. They expect a team approach to health care, with coordination across multiple services and settings. Children, youth, and families benefit from the organization of critical information into written care summaries and action plans. If primary care pediatricians, family physicians, and internists are to achieve optimal health care quality and improvement of existing health care delivery, care coordination will be an essential contributing process to their team approach. Several national health policy recommendations identify care coordination as a cross-cutting intervention to fill the gap between what exists and what is needed in health care today. A practice-based care-coordination model, including a definition and vision for care, a framework of structures and processes, and a position description with specific competencies, is needed. Improvement methodology provides an effective means for health care teams to implement and evaluate practice-based care coordination within their medical home. The improvement approach and model must be flexibly applied to have utility across diverse health care organizations. A medical home team approach, with fully developed practice-based care-coordination services, will enhance health and cost outcomes for children, youth, and families and heighten the professional satisfaction of those delivering health care.

Key Words: children with special health care needs • care coordination • access to health care • quality of life • medical home • quality improvement • primary care

Abbreviations: CYSHCN—children and youth with special health care needs • CSHCN—children with special health care needs • CMHI—Center for Medical Home Improvement

Accepted Jan 31, 2007.


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