Care Coordination

Overview

Patient-centered medical home (PCMH) is the foundation of efficient and effective healthcare delivery. One of the most pivotal concepts PCMH delivery is care coordination.

The American Academy of Pediatrics defines care coordination as “. . . a process that facilitates linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health.” (Pediatrics 104:4) The provision of comprehensive care coordination in the PCMH is particularly important for children and youth with special healthcare needs where multiple systems, including medical, educational, community service, and ancillary services, interface to provide a whole-child orientation to care. In the ideal setting, the PCMH ushers children through every aspect of care delivery, including navigating health and community resources. Such a comprehensive approach to medical care provision increases effectiveness and decreases costs. As a result, the Institute of Medicine has identified care coordination as one of the 20 national priorities for action to medical care and called for curricula to support care coordination. As a result, the Tennessee Chapter of the American Academy of Pediatrics has developed a video curriculum and web-based resources to prepare Tennessee Healthcare Providers to launch care coordination resources in their practices.

The videos review the general science behind care coordination, risk screening and chronic disease registry formation, disease management, quality improvement, and team-based care. The literature base for these presentations is provided under literature links. These are followed by presentations from various Tennessee-specific stakeholders in child health and community service. Video presentations are augmented by links to county specific resource directories for provider daily use. If you have a patient with a resource need that is not referenced, please contact the Medical Home Implementation Program Care Coordination Director, Becky Brumley, at becky.brumley@tnaap.org.

Videos

Slides for each presentation are also available for download. Click the link below each video to download the slides for that particular presentation.

Literature & Forms

Tools

Articles and Forms

Helpful Literature

Surveys & Measurements

Community Resources

Tennessee Chapter American Academy of Pediatrics