School of Public Health

The Public as a Solution to Care Coordination

December 2016

Amy Carlsen, RN, from the Washington State Medical Homes Project says care coordination is one of the biggest barriers to medical home transformation.

Healthcare delivery through a medical home can improve quality and clinical outcomes, but making that transformation takes more than time and resources. It requires providers to change the way they practice.1

The seven goals of a pediatric medical home pose multiple, intertwined barriers for providers who already deal with competing priorities. Accessible, continuous and family-centered care requires a clinic to establish new processes that can accommodate same-day appointments, appointments outside the 9 to 5 work week, longer appointments for patients with special needs, and doctor to patient callbacks within 24 hours. Culturally effective care means additional staff training, the availability of interpreters, and the translation of written materials into multiple languages.

Comprehensive, compassionate, and coordinated care requires providers to shift to a team-based mentality and clinics to invest in enhanced healthcare information technology.  Providers must maintain more descriptive patient records, store data, use evidence-based decision support tools, and share all this information with outside providers.2

“Care coordination is one of the biggest challenges of the medical home,” said Amy Carlsen, a nurse who works on care coordination with the Washington State Medical Home Partnerships Project.

Carlsen explained that there are many different care coordination models, but there is no standardized system that connects them all. Many times families are left to “coordinate the coordinators.”


Care coordination is a fundamental component of the medical home, it is what facilitates integration of the fragmented health system.

Unlike a case manager who focuses solely on medical issues, a care coordinator gets to know the families of patients in context and connects them with resources appropriate to their life circumstances. The care coordinator manages communication between the primary care provider, the school, specialists, early interventionists and anyone else who might contribute to the patient’s well-being. 1, 3

But there is no current revenue stream for care coordination.

When a pediatrician recommends a cardiologist for a patient with an irregular heartbeat and then spends time with the child’s parent and the front office staff to determine the best specialist, the doctor’s time is not reimbursed. There are no active numeric codes that translates this effort into a billable service.

“It’s a business and an art to really do this well,” explained Maria Nardella, director of Washington state's Children with Special Healthcare Needs (CSHCN) Program. “It’s very challenging for private practices to provide excellent services and pull down enough revenue.” In addition to the diagnosis and treatment of illness, providers find themselves focused on financial administration and billable productivity. “This is not what they learn to do in medical school. It is frustrating for some medical providers who just want to help kids be healthy,” Nardella added.


Meredith Pyle, Washington State CHSCN Program Supervisor, wants families to demand high-quality pediatric care.

Clinics who successfully transform to medical homes dedicate staff time to the effort and typically add new staff as “patient care coordinators.” Some colleges and universities now offer courses in care coordination. For example, the University of Alaska in Anchorage and the Alaska Department of Health and Social Services designed a 10-week distance learning course on the principles of pediatric care coordination. In Washington, Whatcom Community College offers a 15-credit certificate for Care Navigation & Coordination.

But maybe the public should be more involved in the transformation of the healthcare system. “We should inform the public about the term and concept of the medical home,” said Carlsen. “We need to teach families what a medical home looks like and how to find a provider who can support their family and advocate for what they need.”

Meredith Pyle, who supervises Washington's CSHN Program, said: “We want families to be educated, informed and empowered about medical homes. We want families to know what high-quality pediatric care looks like to be able to ask for and demand it. Because if the consumers demand it, hopefully the industry will find a way to provide it.“

The Alaska Center for Pediatrics invites patients and their families to evaluate their medical home.

This is what happened at Alaska Center for Pediatrics. After the National Center for Quality Assurance officially recognized the clinic as a medical home, the clinic updated their website and patient information materials to reflect their new status. Staff made sure that patients understood what a medical home was and how the clinic’s delivery of healthcare had changed. When they surveyed parents at the end of the year to find out how they were doing, they were pleasantly surprised. “I saw the trust that our families have in our relationships,” said Jamie Reyes, the clinic’s patient care coordinator. “In those survey remarks, parents used the word ‘team’ a lot.”

But they also noticed something else. Not all the reviews were positive. “Their standards are really high now,” said practice administrator Leigh Anne Woodard. “It was interesting to see how patient’s expectation have been raised and how that will help us to continue to improve.”

The transformation from a traditional practice to a medical home is a slow and deliberate process. This reformation of a siloed health system ideally culminates in a patient-provider partnership. But perhaps the partnership can begin with the evolution and not the outcome. 


  1. Tschudy M, Raphael J, Nehal U, O’Connor K, et al.Barriers to Care Coordination and Medical Home Implementation Aug 2016, e20153458; DOI: 10.1542/peds.2015-3458 .
  2. Connexion HealthCare. Patient-Centered Medical Home: Overview and Barriers to Theory.Apr 2013.
  3. Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Pediatrics May 2014, 133 (5) e1451-e1460; DOI: 10.1542/peds.2014-0318 .