Sustainable Care Coordination for CYSHCN and CMC: Experiences and Recommendations from the HRSA Funded National Care Coordination Academy

Full Description: In 2018, HRSA/ MCHB funded a Collaborative Improvement and Innovation (CoIIN) Network focused on children with medical complexity (CMC). Its purpose was to develop and test innovative care delivery and payment models for CMC; improve their quality of life and the well-being of their families; and increase cost-effectiveness of their care. To meet the demand for a resource to guide implementation of care coordination (CC) for CMC, the National Care Coordination Academy (NCCA) was launched in 2020. NCCA aimed to guide its participants in identifying needs and resources for CC for CMC and CYSHCN, offering approaches to mitigate challenges to access and equity resulting from COVID19. Teams are diverse and include family partners; Title V; providers; and Medicaid. 16 teams were accepted into NCCA. Teams not in the initial CMC CoIIN joined the NCCA, enhancing diversity inclusive of rural/ Native American Tribal; urban; clinic-based; and Integrated Care for Kids Innovation awardees.
NCCA employed model of interprofessional education, highlighting critical concepts of family engagement; impact of social determinants of health; training in CC; and outcome measurement. A Sustainability Affinity Group was created to guide identification of opportunities to scale early tests of change, highlighting multistakeholder approaches to financial sustainability. Each team’s journey addressed:
With whom are you communicating your proposal? System providers; Medicaid; Legislators; families; community orgs.
What’s the message being communicated? Population served; quality; utilization.
What data is used to support the effort? Patients served and their complexity; services provided; patient/family experience; utilization; outcomes; payment modeling.
How are you communicating? Written products for decision makers; presentations to key officials including policymakers not deeply knowledgeable of the needs of CYSHCN and CMC.
Teams focused on 3 elements of CC sustainability: care model design; outcomes; and business case. Accomplishments of each team included use of CC measures; assessment of family engagement; family reported experience of care integration; and assessment of utilization of care for CMC and CYSHCN to inform business case.
Lessons learned:
Each team is at different level of progress with respect to CC implementation, measurement, and sustainability. Essential to “meet teams where they are”, encouraging teams to learn from each other on their journey
• Emphasize family engagement, partnership
• Select outcome measures important to all stakeholders
• Emphasize Equity in every aspect of design, implementation, and performance measurement
• Seek common ground– alignment of priorities of families of CMC and CYSHCN; Title V; Medicaid; engage providers across disciplines. CC is a “Team Sport”!
NCCA is demonstrating the feasibility and impact of MCH programs working with families, providers, and Medicaid to advance equity, value, and sustainability.

Abbreviated Description: To meet the demand for a resource to guide implementation of care coordination (CC), the National Care Coordination Academy (NCCA) was launched in 2020. It aims to guide teams in identifying needs and resources for CC for children with complex needs and CYSHCN. Team rosters include family partners; Title V; providers; and Medicaid. 14 teams began the NCCA, bringing broad diversity inclusive of rural/ Native American Tribal; urban; clinic-based; and Integrated Care for Kids Innovation awardees.
Teams focused on 3 elements of CC sustainability: care model design; outcomes; and business case. Progress included use of CC measures; assessment of family engagement; family reported experience of care integration; and assessment of utilization of care for CMC/ CYSHCN to inform business case.