title: Care coordination over time in medical homes for children with special health care needs.
abstract: OBJECTIVE
  To explore how care coordination changes conceptually and practically in primary care practices when implementing the medical home and to identify reasons for different types of changes.
  
  
  METHODS
  Six years after a 2003-2004 national learning collaborative to implement the medical home model for children with special health care needs, we examined care coordination in 12 pediatric practices with the highest postintervention Medical Home Index scores, indicating high level of adoption of the model. Data included interviews of 48 clinicians, care coordinators, and parents and medical record reviews of 60 patients with special health care needs receiving care in these practices.
  
  
  RESULTS
  Initially, care coordination activities were prompted by patients' acute problems, and over time activities, tools, and policies were implemented to avert many such problems and expand the scope of services offered to patients. Example activities were making previsit calls with families, writing care plans, developing relationships with community agencies, and tracking referrals. Although some activities were common across practices, the persons involved and efforts toward different activities varied with practice context. Drivers included motivation and creativity of medical home teams, organizational changes, funding to expand care coordinator positions, protected time for such activities, and adoption of electronic record systems.
  
  
  CONCLUSIONS
  In high-performing medical homes, care coordination activities changed from being mostly reactive to patients' episodic needs to being more systematically proactive and comprehensive. This shift was promoted by factors external and internal to the practice. Ensuring these factors in medical home implementation may accelerate adoption of proactive care coordination activities.
authors.affiliation: Division of General Pediatrics/MGH Center for Child and Adolescent Health Research & Policy, MassGeneral Hospital for Children, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; jvancleave@partners.org.
authors.forename: Jeanne
authors.initials: J
authors.lastname: Van Cleave
authors.affiliation: Division of General Pediatrics/MGH Center for Child and Adolescent Health Research & Policy, MassGeneral Hospital for Children, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;
authors.forename: Alexy Arauz
authors.initials: AA
authors.lastname: Boudreau
authors.affiliation: Children's Health Services Research, Indiana University Medical School, Indianapolis, Indiana; Center for Medical Home Improvement, Crotched Mountain Foundation, Greenfield, New Hampshire; and.
authors.forename: Jeanne
authors.initials: J
authors.lastname: McAllister
authors.affiliation: Center for Medical Home Improvement, Crotched Mountain Foundation, Greenfield, New Hampshire; and.
authors.forename: W Carl
authors.initials: WC
authors.lastname: Cooley
authors.affiliation: Internal Medicine/Pediatrics Residency Program, University of Pennsylvania/Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Andrea
authors.initials: A
authors.lastname: Maxwell
authors.affiliation: Division of General Pediatrics/MGH Center for Child and Adolescent Health Research & Policy, MassGeneral Hospital for Children, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;
authors.forename: Karen
authors.initials: K
authors.lastname: Kuhlthau
mesh_terms: D002648:Child; D002662:Child Health Services / Q000458:organization & administration*; D006801:Humans; D018802:Patient-Centered Care / Q000458:organization & administration*; D012189:Retrospective Studies; D013997:Time Factors