Improving Care Coordination, Case Management, and Linkages to

Critical Characteristics of High Performing Pediatric Care Coordination
The foundational characteristics and attributes of excellent pediatric care coordination include the following:
1. Patient and Family-centered
• Links patients and families to an accessible, community-based primary care Medical Home
2 Pro-active, Planned, and Comprehensive
• Supports anticipatory, proactive, continuous and longitudinal care
• Builds upon family strengths and is guided by a comprehensive, standardized assessment of needs
• Supports and relies upon team care
• Facilitates the care planning process including consultation, referral, testing, goals (jointly developed and
shared), monitoring and follow-up
• Plans for the transition of youth from pediatric to adult systems of care
3. Promotes Self Care Skills and Independence
• Care coordination ensures the provision of patient/family education to build self-management skills
• Care coordination seeks to equip families with the necessary skills to navigate a complex health care system
4. Emphasizes Cross Organizational Relationships
• Care coordination builds strategic relationships across a community which support integration of care and
patient/youth/family self-management skills
• Care coordination assures effective communication and collaboration back and forth along the continuum
of care
Antonelli RC, McAllister JW, and Popp J. Developing Care Coordination as a Critical Component of a High Performance Pediatric Health Care System:
Forging a Multidisciplinary Framework for Pediatric Care Coordination. (In press) The Commonwealth Fund, forthcoming 2009.
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concept in 10 states (three practices per state) and by building capacity for state Title V programs, which promote,
sustain and spread improvements after the project period is completed. Because the medical home model
dealt with care coordination and linkages between services and supports, these programs demonstrate how
to use existing agencies and infrastructure to disseminate the medical home model and support linkages. One
national study assessed the feasibility of implementing a bundle of Bright Futures 74 recommendations and evaluated
a modified learning collaborative’s effectiveness in improving preventive and developmental care. The results
demonstrated significant changes across a learning collaborative. 75
Several states provide outstanding examples of state-level child health quality improvement. Vermont and Utah
are among those with focused efforts.
The Vermont Child Health Improvement Program (VCHIP)—a program of the University of Vermont Department
of Pediatrics, in collaboration with the Vermont Department of Health and the Vermont chapter of the American
Academy of Pediatrics—has demonstrated the broad effectiveness of a statewide quality improvement outreach
project. VCHIP engaged most pediatric providers in the state. The program’s mission is to optimize the health of
Vermont’s children by initiating and supporting measurement-based efforts to enhance private and public child
health practice. 76 One VCHIP project demonstrates how an effective statewide pediatric quality improvement outreach
program can improve preventive services for children 5 years old. 77 VCHIP has designed and shared a model
for “improvement partnerships” that consist of public and private collaboratives that use measurement-based
efforts and a systems approach to improve the quality of children’s health care. Improvement partnerships can ad-
Improving Care Coordination, Case Management, and Linkages to Service for Young Children: Opportunities for States
National Academy for State Health Policy