TABLE 2

Examples of Proactive Care Coordination Activities and Rationale

Proactive Care Coordination Activity or ProcessRationale With Supporting Quote(s)
Previsit phone calls with families to obtain updates, assess needs, and set visit agendas“Because what happens when we don’t have that [previsit phone call], for example, a provider walks into a visit, realizes we don’t have records. You know, the nurse might be spending time calling, the provider may be spending time.” (Care coordinator)
“She [the physician] is ready with all that information, so her time is well spent, my time is well spent, and we really do address a lot of different things for [my child].” (Parent)
Written care plans or health summaries“This care plan, this is for their use, for bringing to specialists’ visits so that they don’t have to be so much of a historian when they’re there.” (Care coordinator)
“We got roomed [at the Emergency Department], the nurse came in with the care plan, she said, “Give me 5 minutes, I’m reading through your care plan right now,” so she knew everything that she needed to know when we got there, and then by the time the doctor—we saw the doctor, too. He had also read through our care plan and said, “Well, you know,” he kind of ticked off several things right off the top, ’cause he could see from the care plan that certain things did or didn’t need to be addressed.” (Parent)
Identifying charts of medically complex patients and scheduling longer visits“Nobody likes to look at their schedule and see the [patient] name that you know is going to take you out. But now you look and you see you have 20 minutes, or 30, and we have a couple that take 40, but if that’s what it takes, that’s what it takes.” (Physician)
Brief daily huddles between care coordinators, nurses, and physicians about patients scheduled for visits that day“So we sit down at the beginning of every session, and we click on every single patient who’s scheduled and review what’s going to happen. ‘It’s a well visit. What are the vaccines she needs? Let’s look at this. Hey, this isn’t documented.’” (Care coordinator)
Organizing family-oriented materials for common problems or scenarios (eg, transition to adult settings, special education services)“We fight pretty hard to get them what they need either in their IEP [Individualized Education Plan] or 504. Because you know, if we’re not advocating for them, parents … they get overwhelmed. They throw their hands up. We do a lot of … we do a lot of resource providing for education. I have a packet that I put together for what your rights are for the IEP or 504.” (Care coordinator)
“We do have a transition packet that’s been put together for pediatrics—questions to ask starting at 14, as kids go from junior high to senior high. To start talking about those needs, to get the patients as involved as possible and aware of their care.” (Parent, speaking about her role as a “parent partner” to the practice)
Creating processes to streamline communication with specialists, schools, community agencies“I developed a form because we weren’t getting … from Early Intervention, we couldn’t get them to understand … we were ordering ten thousand different ways when we wanted a medical eval for a developmental issue, and we wouldn’t get it.” (Care coordinator)
“There’s good communication. … There was definite interaction [between the specialist and the primary care pediatrician]. I know that from when, at one point they were worried about his heart again. There was some medication, lifting up his heartbeat or something. I remember the cardiologist coming in and saying, “I just spoke with Dr. C [the primary care pediatrician].” (Parent)
Establishing a system for tracking referral completion“My sister works in a doctor’s office, and she said, for referrals, ‘We fax a sheet of paper over, and the patient calls, and it’s done.’ And for us, we normally set up the appointment for the parent, give them the information, follow up, make sure they went, get the report to the doctor, follow up with the parent.” (Care coordinator)