CHF has defined key competencies and outlined effective approaches of pediatric office-based care management to assist our member practices with implementing the components which will help them deliver better care, become more organized and efficient with managing patients and improve their medical home preparedness.

CHF is hosting a Pediatric Care Management Improvement Collaborative in order to facilitate the development and spread of the above competencies supporting proactive, targeted office-based pediatric care management. This includes monthly facilitated learning sessions . Work in 2012 has included development, sharing and implementation of the following:

  • Identification of children with special health care needs
  • Prioritizing (tiering) children
  • Ability to view, organize and manage patient information for care management
  • Managing information in the EMR
  • Exploring other patient data tools (CHA developed an excel-based “registry” tool)
  • Delivery of care management competencies and collaborative care
  • Population monitoring and visit coordination
  • Understanding team-based approaches and tactics
  • Assessing practice and provider readiness for patient-centered models
  • Educating and communicating “transformation” at the practice
  • Five key areas to consider regarding transformation of primary care
  • Exploring care plan options for key Affordable Care Act (ACA) diagnoses
  • Sharing of PCPCH suitable care plans for general, ADHD, obesity and asthma
  • Development of a quarterly “Take Care” newsletter to support PCPCH
  • Discussion of communication messaging to providers, staff and patients/families
  • Connectivity to specialty and hospital care managers
  • Networking with care managers in other pediatric care settings
  • Awareness of and linkages to community programs and resources

Testing of approaches and tools is underway at many CHF pediatric practices and there has been valuable learning to help accelerate and improve effectiveness of efforts. The collaborative workgroup continues to meet monthly to further explore practical approaches to enhance the delivery of proactive, targeted care management.