Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Pediatric to Adult Transfer Assistance, Planning for Transition, PROVIDER/PRACTICE

Intervention Description: The purpose of the study was to evaluate an adult health care program model for emerging adults with type 1 diabetes transitioning from pediatric to adult care.

Intervention Results: From baseline to 6 months, mean A1C decreased by 0.7% (8 mmol/mol), and BGMF increased by 1 check per day. Eighty-eight percent of participants attended ≥2 visits in 6 months, and the program was rated highly by participants and providers (pediatric and adult).

Conclusion: This study highlights the promise of an adult health care program model for pediatric to adult diabetes transition.

Study Design: Pre, post, and retrospective cohort

Setting: Clinic-based (Pediatric to Adult Diabetes Transition Clinic at academic institution (UPenn))

Population of Focus: Emerging adults with type 1 diabetes

Data Source: Transfer summaries and electronic medical records, including pre- and post- program assessments

Sample Size: N=72

Age Range: 18-25 years

Intervention Components (click on component to see a list of all articles that use that intervention): Social Supports, Care Coordination, Prenatal Care Access,

Intervention Description: The study proposed an intervention framework based on the themes and ideas generated from the qualitative analysis of participant perspectives. The proposed intervention design included three overarching thematic domains: (1) social support in the form of accompaniment and reassurance, (2) improved care delivery with greater consistency, communication, and individualization of outpatient prenatal care, and (3) improved access to outpatient prenatal care, convenient appointment availability, and uninterrupted insurance coverage during pregnancy , . The proposed intervention features included integrating CHWs into care teams and existing childbirth education, connecting pregnant individuals with social services resources, group prenatal care support, health information exchange, prenatal passport cards or applications, visit checklists, advanced access scheduling, enhanced care team visibility, drop-in pregnancy support center, insurance screening and enrollment, and CHW support for navigation and continuity . The intervention design aimed to improve trust and impact of prenatal care, advance equitably improved outcomes, and address unmet needs in those at risk for poor pregnancy outcome

Intervention Results: The study identified unique unmet needs and ideas for improving prenatal care among pregnant women with different patterns of unscheduled care utilization. Participants expressed a desire for social support interventions that address unmet psychosocial needs, care coordination, accompaniment, and navigation for at-risk pregnant women, while also addressing broader needs such as insurance eligibility, navigation to community-based resources, and access to timely prenatal care . The proposed intervention framework aimed to address these needs and improve prenatal care delivery for low-SES, Medicaid-insured, predominantly Black, pregnant women . The study also identified limitations, including a small sample size and potential social desirability bias . Overall, the study offers the opportunity to leverage qualitative narratives, tailor and adapt intervention design to meet the specific needs of a hard-to-engage population, and reduce inequitable, preventable maternal morbidity and mortality .

Conclusion: The study concluded that the use of a qualitative study design generated person-centered intervention elements that can improve trust and impact of prenatal care. The findings focused on the differential needs and ideas of pregnant women with unique patterns of utilization of unscheduled care, demonstrating a need for embedding targeted social support alongside clinical care to advance equitably improved outcomes. The study suggested that targeted interventions incorporating user ideas and addressing unique unmet needs of specific subgroups may improve perinatal outcomes. The proposed intervention elements may help maternity care systems improve health care delivery for Black, low-SES pregnant women by specifically focusing on community health worker (CHW) integration to address unmet psychosocial needs, care coordination, accompaniment, and navigation for at-risk pregnant women, while also addressing broader needs such as insurance eligibility, navigation to community-based resources, and access to timely prenatal care , .

Study Design: The study utilized a participatory action, qualitative research design to explore the perspectives and experiences of pregnant women regarding their prenatal care, barriers to care, and unscheduled care utilization in an obstetric triage unit. The qualitative analysis involved conducting in-depth, semi-structured interviews with pregnant women at the point of unscheduled hospital-based obstetric care, prompting participants regarding perspectives on group prenatal care and community health worker (CHW) interventions, and asking open-ended questions regarding ideas for improving care 2, 2. The qualitative data obtained from these interviews were then analyzed using grounded theory to identify major themes and develop an intervention framework aligned with participant perspectives

Setting: The setting for the study was an academic hospital outpatient setting, where pregnant women enrolled in a prenatal clinic were interviewed at the point of unscheduled hospital-based obstetric care in a triage unit . This setting allowed the researchers to gather insights from pregnant women who had experienced unscheduled care and to explore their perspectives on group prenatal care and community health worker (CHW) interventions, as well as their ideas for improving care

Population of Focus: The target audience for the study included pregnant women, particularly those from low socioeconomic status (SES) and Medicaid-insured, predominantly Black, pregnant women. The study aimed to capture the perspectives and experiences of this specific demographic group regarding their prenatal care, unscheduled care utilization, and ideas for improving care delivery

Sample Size: The study enrolled a total of 40 participants, who were categorized into two groups: Group 1 (n = 20) and Group 2 (n = 20) . These groups were defined based on the degree of utilization of unscheduled care during pregnancy, allowing for a comparative qualitative analysis of participant ideas for improving prenatal care. The sample size of 40 participants provided a substantial basis for capturing diverse perspectives and experiences related to prenatal care and unscheduled care utilization.

Age Range: The study did not explicitly mention the age range of the participants. However, it provided the mean age of the participants in Group 1 as 25.5 years and in Group 2 as 25.0 years . This suggests that the participants were generally in their mid-20s, but without specific details on the age range.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement, Care Coordination,

Intervention Description: The intervention is a previsit screening checklist that is completed by the patient prior to the medical encounter and covers areas such as nutrition, reproductive health, and social and nursing services. The checklist is then reviewed by the clinical assistant, who coordinates with other team members to provide same-day access to requested services. The intervention aligns with a discernable strategy of promoting teamwork during a medical visit through delegation of tasks among care team members and providing same-day access to existing medical services. The use of a previsit screening checklist is intended to help care teams anticipate patient needs for services and proactively coordinate access to requested services at the time of the visit. The article describes a study that analyzes a multicomponent intervention, which includes the previsit screening checklist, as well as previsit huddles, PDSA (Plan-Do-Study-Act) cycles focusing on workflow, regular care team meetings, and patients' and parents' advisory boards.

Intervention Results: The study reported several key results: 1. The majority of patients were receptive to the previsit screening checklist. 2. 85% of the requested services were provided at the time of the medical visit. 3. Nonclinician staff felt more involved in patient care. 4. Providers' satisfaction increased. Additionally, the study found that female patients accounted for the majority of the service requests, with reproductive health services being the most commonly requested type of service. These results suggest that the previsit screening checklist intervention improved teamwork and access to preventive services for adolescent and young adult patients in the medical home serving low-income populations.

Conclusion: The study concluded that the implementation of a previsit screening checklist in a primary care setting can optimize teamwork, increase patient access to preventive services, and support patient engagement in decision making. The checklist intervention was found to be easily incorporated into the clinic workflow, promoting a culture of teamwork and enhancing health care delivery. Despite some challenges, the study demonstrated that the use of the previsit screening checklist was associated with improved access to preventive services for adolescents and young adults in the primary care setting.

Study Design: The study utilized a quality improvement project design to evaluate the implementation of a previsit screening checklist in a primary care setting. The project involved a multidisciplinary team and incorporated input from advisory boards and key informants. The intervention was evaluated through a combination of quantitative and qualitative approaches, including iterative Plan-Do-Study-Act (PDSA) cycles to assess the needs and acceptance of the checklist prior to and during the intervention. The study design focused on process evaluation and outcome measures to assess the impact of the intervention on patient access to preventive services and teamwork within the clinic

Setting: The study was conducted in a primary care pediatrics and adolescents practice located in a low-income urban neighborhood of Boston. The practice is owned by a children's hospital and serves children, adolescents, and young adults through age 25 years. The majority of patients are first- or second-generation immigrants of Latino descent, and most are of low-income families, with an income level below the poverty line, and about 74% qualify for Medicaid .

Population of Focus: The target audience of the study was adolescent and young adult patients (ages 13-25) who received care at a primary care pediatrics and adolescents practice located in a low-income urban neighborhood of Boston. The majority of patients were first- or second-generation immigrants of Latino descent, and most were of low-income families, with an income level below the poverty line, and about 74% qualified for Medicaid

Sample Size: The sample size in the study consisted of 291 patients who completed the previsit screening checklist during an adolescent well visit. Additionally, 222 of these patients requested services based on the checklist. The study provided a breakdown of the sample characteristics, including age, gender, race, primary language, and type of insurance for the patients who completed the checklist

Age Range: The age range of the patients included in the study is 13 to 25 years old.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Pediatric to Adult Transfer Assistance, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This quality-improvement initiative was designed to implement a structured intervention that supports the planned transfer of care to adult primary care.

Intervention Results: Over 3 years, our PN reached out to 96% of patients (n = 226) eligible to transfer care and offered transfer assistance in person or in writing. Among those surveyed, 92% (n = 93) reported awareness of our practice transition policy, and 83% (n = 64) rated their confidence to transfer care at 3 or higher on a 5-point scale.

Conclusion: AYAs are aware of our practice transition policy, yet they welcome in-person transfer assistance. This intervention seems to improve their confidence to transfer care. However, despite PN outreach efforts, many remain empaneled in our practice and thus lack the self-care skills necessary to complete the transfer independently. Future transition interventions should address AYA's self-management skills toward transition readiness.

Intervention Components (click on component to see a list of all articles that use that intervention): Family-Based Interventions, Care Coordination, Medicaid,

Intervention Description: N/A

Intervention Results: Children who were not white, living in non-English households, with less family income or education, or who were uninsured had lower rates of access to a medical home and its components. A medical home was associated with beneficial child outcomes for all six of the outcomes and the family-centered care component was associated with better results in five outcomes. ED visits were less likely for children who received care coordination (aOR 0.81, CI 0.70-0.94).

Conclusion: Our study highlights the role of key components of the medical home and the importance of access to family-centered health care that provides needed coordination for children. Health care reforms should consider disparities in access to a medical home and specific components and the contributions of each component to provide quality primary care for all children.

Study Design: We analyzed data from the 2016-2017 National Survey of Children's Health (NSCH) to assess five key medical home components - usual source of care, personal doctor/nurse, family-centered care, referral access, and coordinated care - and their associations with child outcomes. Health outcomes included emergency department (ED) visits, unmet health care needs, preventive medical visits, preventive dental visits, health status, and oral health status. We used multivariate regression controlling for child characteristics including age, sex, primary household language, race/ethnicity, income, parental education, health insurance coverage, and special healthcare needs.

Setting: NSCH survey; United States

Population of Focus: Practitioners in children's health

Sample Size: 61572

Age Range: 0-17

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Patient Navigation, Midwifery,

Intervention Description: The intervention described in the article is the Early Care Model for initiation of perinatal care. This model is a midwifery-led, patient-centered approach designed to reduce barriers to early initiation of perinatal care for pregnant individuals. The key components of the intervention include: Timely access to care as soon as pregnancy is confirmed or suspected. One-hour telehealth visits for early pregnancy assessment and support. Comprehensive assessment of clinical and social needs during the initial prenatal visit. Tailored perinatal care recommendations and referrals based on individual health history and preferences. Promotion of midwifery care and education about all care options. Use of virtual language interpretation services for increased accessibility. Focus on antiracist and antibias approaches to provide equitable care , . These components collectively aim to provide early and comprehensive care to pregnant individuals, address systemic barriers to care engagement, and promote improved outcomes and decreased disparities in perinatal health

Intervention Results: Instead, it focuses on describing the key strengths and components of the Early Care Model for initiation of perinatal care, as well as the potential impact of the model on health equity and perinatal outcomes. The article emphasizes the importance of early access to prenatal care, the benefits of the model's approach to care initiation, and the strategies for overcoming barriers to implementation, such as billing and reimbursement challenges in the United States healthcare system

Conclusion: The conclusion drawn from the article on the Early Care Model for initiation of perinatal care highlights the potential of this model to significantly impact health equity in perinatal care. The model is seen as a promising approach to reducing disparities, improving outcomes, and increasing access to early and comprehensive perinatal care for pregnant individuals. However, the article also acknowledges the real barriers to implementation, particularly related to billing and reimbursement systems in the United States healthcare system. To address these barriers and make the Early Care Model more accessible and actionable, the article presents recommendations for stakeholders, including health plans, legislators, and regulators. These recommendations focus on adjusting reimbursement to reflect the benefits of the model, expanding Medicaid coverage for pregnant individuals, and advocating for policy changes to support the adoption of innovative care delivery models like the Early Care Model . Overall, the article underscores the importance of addressing systemic challenges in healthcare delivery to promote equitable care, improve perinatal outcomes, and enhance access to quality care for pregnant individuals.

Study Design: the article outlines the key components and strategies of the model, focusing on its innovative approach to providing early and comprehensive perinatal care to pregnant individuals. The model is presented as a new care delivery approach aimed at reducing barriers to early initiation of perinatal care and improving health outcomes for pregnant people and their fetuses

Setting: it does mention that the model was developed and implemented by Quilted Health, a healthcare organization based in Washington state . The model is designed to be adaptable to the needs of specific communities and care settings

Population of Focus: The target audience for the Early Care Model for initiation of perinatal care includes pregnant individuals seeking prenatal care services. The model is designed to reduce barriers to early initiation of perinatal care and improve outcomes for pregnant people and their fetuses 2. Additionally, stakeholders involved in the implementation of the model, such as health plans, legislators, regulators, and perinatal care providers, are also key audiences for the recommendations and strategies outlined in the article

Sample Size: The focus of the article is more on the model itself, its strategies, and the potential impact on health equity in perinatal care

Age Range: However, the model is designed to provide early access to prenatal care for pregnant individuals, which typically includes adults of reproductive age. The focus is on improving perinatal outcomes and reducing disparities in care for pregnant individuals, regardless of their specific age range

Intervention Components (click on component to see a list of all articles that use that intervention): Assessment (Provider), Access, Care Coordination, Targeting Interventions to Focused Groups

Intervention Description: N/A

Intervention Results: Fifty-three percent (n = 107) of the children received care within a medical home. Low socioeconomic status (young caregiver: risk ratio [RR] = 0.73; 95% CI 0.55, 0.97; low education: RR= 0.69; 95% CI 0.49, 0.98) and delayed language (RR = 0.63; 95% CI 0.42, 0.95) were associated with a lower likelihood of receiving care within a medical home. Degree of prematurity and neonatal clinic follow-up participation were unrelated to receipt of care within a medical home.

Conclusion: Receipt of care within a medical home was lacking for nearly one-half of preterm toddlers, especially those with lower socioeconomic status and poorer developmental status. Discharge from a neonatal intensive care unit may be an optimal time to facilitate access to a primary care medical home and establish continuity of care.

Study Design: Participants were 202 caregivers of children born at <35 weeks of gestation. At 10-16 months of corrected age, caregivers completed the National Survey of Children's Health (2011/2012) medical home module and a sociodemographic profile. Care within a medical home comprised having a personal doctor/nurse, a usual place for care, effective care coordination, family-centered care, and getting referrals when needed. Gestational age and neonatal follow-up clinic attendance were abstracted from the medical record. The Bayley Scales of Infant and Toddler Development, Third Edition assessed developmental status. Log-binomial regression examined factors related to receiving care within a medical home.

Setting: NSCH Survey; United States

Population of Focus: Caregivers of children born pre-term

Sample Size: 202

Age Range: Caregivers vary in age. Babies born before 35 weeks.

Intervention Components (click on component to see a list of all articles that use that intervention): , Care Coordination, Telehealth/Virtual Care

Intervention Description: Medical advances have improved survival of critically ill children, increasing the number that have substantial ongoing care needs. The first aim of this study was to compare healthcare utilization of children with complex chronic conditions across an extensive geographic area managed by a predominantly telehealth-based team (FamiLy InteGrated Healthcare Transitions-FLIGHT) compared to matched historical controls. The second aim was to identify risk factors for healthcare utilization within the FLIGHT population. We performed a retrospective cohort study of all patients enrolled in the care management team. First, we compared them to age- and technology-based matched historic controls across medical resource-utilization outcomes. Second, we used univariable and multivariable linear regression models to identify risk factors for resource utilization within the FLIGHT population.

Intervention Results: Sixty-four FLIGHT patients were included, with 34 able to be matched with historic controls. FLIGHT patients had significantly fewer hospital days per year (13.6 vs. 30.3 days, p = 0.02) and shorter admissions (6.0 vs. 17.3 days, p = 0.02) compared to controls. Within the telehealth managed population, increased number of technologies was associated with more admissions per year (coefficient 0.90, CI 0.05 - 1.75) and hospital days per year (16.83, CI 1.76 - 31.90), although increased number of complex chronic conditions was not associated with an increase in utilization.

Conclusion: A telehealth-based care coordination team was able to significantly decrease some metrics of healthcare utilization in a complex pediatric population. Future study is warranted into utilization of telemedicine for care coordination programs caring for children with medical complexity.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Transition Assistance, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: Our aim was to assess the effect of a communication technology enhanced transition coordinator intervention compared with usual care on clinic attendance among transitioning youth with type 1 diabetes.

Intervention Results: There were no baseline differences in age, sex, HbA1c and number of follow-up visits, emergency department visits and diabetic ketoacidosis admissions in the 1 year prior to transition between the usual care (n = 101) and intervention (n = 102) groups. In the year following transfer, 47.1% in the usual care group vs 11.9% in the intervention group did not attend any outpatient diabetes appointments (p < 0.01). There were no differences in glycaemic control or diabetic ketoacidosis post transfer.

Conclusion: Our intervention was successful in improving clinic attendance among transitioning youth with type 1 diabetes. Importantly, this programme used simple, readily accessible communication technologies, which increases the sustainability and transferability of this strategy.

Intervention Components (click on component to see a list of all articles that use that intervention): Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination, PROVIDER/PRACTICE

Intervention Description: The Youth Transition Project (YTP) is a public-private partnership focused on Foster Care youth ages 16-21 transitioning from foster care or experiencing homelessness. The centerpiece of the project is a tiny-home village with comprehensive life skills, employment training, education and well-being supports provided by the broader community. The goal is that disconnected West Virginia youth are supported to reach their full potential as they transition into adulthood.

Intervention Results: Over an 18-month period, a total of 127 (59.1%) youth were transitioned and seen by an AMHS provider, 41 (19.1%) remained on a waitlist for services and 47 (21.8%) canceled services. The average time to transition was 110 days (SD = 100). Youth exhibited a wide range of diagnoses; 100% of the population was identified as having serious psychiatric problems. Findings demonstrate that the Youth Transition Project has been successful in promoting continuity of care by transitioning youth seamlessly from youth to adult services.

Conclusion: Inconsistencies in wait times and service delivery suggest that further model development is needed to enhance the long-term sustainability of the Youth Transition Project.

Study Design: Prospective cohort

Setting: Children and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS)

Population of Focus: Youth with mental health and/or addiction problems transitioning to Adult Mental Health and Addiction Services

Data Source: The Ontario Common Assessment of Need–Self (OCAN-Self)—a self-report indicator; youth tracking tools (modified from Singh et TRACK measures); The Global Appraisal of Individual Needs Short Screener (GAIN-SS)—a 27- item self-report measure used to screen for mental health and addictions problems; and the adult needs and strengths assessment for transition to adulthood (ANSA-T), completed by caregiver

Sample Size: 215 seen by the transition coordinator; 127 completed their transition and were seen by an AMHS provider; 41 youth had yet to transition and remained on a waitlist for AMHS

Age Range: 16-20 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Prenatal Care Access,

Intervention Description: provides a comprehensive approach to care for women of advanced maternal age. This approach includes preconception care, routine prenatal care, and surveillance for potential complications during pregnancy. The document emphasizes the importance of compassionate care and support for women in this age group as they navigate the journey of motherhood. The recommendations provided in the document are based on existing knowledge and expert consensus in the field of women's health care.

Intervention Results: The document emphasizes the importance of preconception care, routine prenatal care, and surveillance for potential complications during pregnancy. The approach is designed to optimize care for women of advanced maternal age and improve the likelihood of a normal pregnancy outcome. The document also highlights the importance of compassionate care and support for women in this age group as they navigate the journey of motherhood.

Conclusion: he PDF file provides a comprehensive approach to care for women of advanced maternal age, including preconception counseling, antepartum testing, and postpartum care. The authors emphasize the importance of addressing medical comorbidities, performing detailed anatomic surveys, and providing appropriate antepartum testing and growth assessments. They also discuss the risks and benefits of various screening and diagnostic tests for fetal aneuploidy. Overall, the PDF file highlights the need for individualized care and close monitoring of women of advanced maternal age to ensure safe and healthy outcomes for both mother and baby.

Study Design: as it appears to be a review article or clinical guideline rather than a research study with a defined sample size. Therefore, the document synthesizes existing knowledge and recommendations in the field of women's health care for women of advanced maternal age, drawing from relevant literature and expert consensus.

Setting: US The comprehensive approach to care for women of advanced maternal age is being implemented. However, the information and recommendations provided in the document can be applied in various healthcare settings, including hospitals, clinics, and private practices.

Population of Focus: The target audience for the comprehensive approach to care for women of advanced maternal age includes women's health care providers, such as midwives, nurse practitioners, clinical nurse specialists, and perinatal nurses. Additionally, this information may also be relevant to obstetricians, gynecologists, and other healthcare professionals involved in the care of women during preconception, prenatal, and peripartum stages.

Sample Size: na

Age Range: na

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Care Coordination, Public Insurance (Health Care Provider/Practice)

Intervention Description: The Coordinated Healthcare for Complex Kids (CHECK) model takes a broad approach to care coordination and health promotion by addressing social determinants of health, caregiver wellness, and mental health needs, in addition to chronic disease management, for children and youth with chronic health conditions. Community health workers deliver care coordination and assess individual and family needs, as well as patterns of health care utilization, to determine specific services offered to each family. The program is focused on lowering health care costs, especially regarding emergency department admissions, of pediatric patients with chronic health conditions.

Intervention Results: Overall Medicaid expenditures and utilization decreased considerably during the first year of the CHECK program for both participants and the usual care group. Notably, expenditures did not increase among CHECK participants, which has been noted in other care coordination programs. The rate of inpatient and ED utilization decreased for both groups. The mean (SD) inpatient utilization before enrollment in CHECK was 63.0 (344.4) per 1000 PYs for the intervention group and 69.3 (370.9) per 1000 PYs for the usual care group, which decreased to 43.5 (297.2) per 1000 PYs and 47.8 (304.9) per 1000 PYs, respectively, after the intervention.

Conclusion: Overall Medicaid expenditures and health care utilization (hospital and ED) decreased similarly for both CHECK participants and the usual care group.

Study Design: RCT

Setting: Community (Coordinated Healthcare for Complex Kids (CHECK) program; Illinois Medicaid)

Population of Focus: Children and young adults with chronic disease who receive public insurance

Data Source: Illinois Medicaid paid claims for CHECK participants using the Care Coordination Claims Data (CCCD) provided by the Illinois Department of Healthcare and Family Services

Sample Size: 6,245 children and young adults (3,119 in the control group and 3,126 in the intervention group)

Age Range: Children <1 and youth >18 (mean age was 11.3 years)

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Community-Based Group Education, Patient Navigation,

Intervention Description: In 2014, the University of Illinois Health and Health Sciences System initiated the Coordinated Healthcare for Complex Kids (CHECK) program. This comprehensive care coordination demonstration project aimed to provide services for children and young adults with chronic health conditions in Chicago insured by Medicaid. CHECK adopted a holistic approach, addressing social determinants of health, caregiver wellness, mental health, and chronic disease management. The program targeted individuals with diagnoses such as asthma, diabetes, sickle cell disease, seizure disorder, or prematurity, spanning from birth to age 25. Participants were enrolled in the traditional, fee-for-service state Medicaid program or a Medicaid managed care organization (MCO) in Illinois. CHECK offered various services, including care coordination by community health workers (CHWs), mental health services by professionals, and disease-specific health education. CHWs assessed individual and family needs, analyzing health care utilization patterns in the year before enrollment. The program operated from May 1, 2014, to April 30, 2017, with data collection conducted in May 2018, covering the 12 months before and after randomization. For further details, refer to Table 4: Intervention Descriptions in the Evidence Review.

Intervention Results: In this analysis of the Chicago-based CHECK program (a large care-coordination initiative for low-income children and youth with chronic health conditions), overall Medicaid expenditures and utilization decreased considerably during the first year of the CHECK program for both CHECK participants and the usual care group. Notably, expenditures did not increase among CHECK participants, which has been noted in other care coordination programs. The rate of inpatient and ED utilization decreased for both groups. The mean (SD) inpatient utilization before enrollment in CHECK was 63.0 (344.4) per 1000 PYs for the intervention group and 69.3 (370.9) per 1000 PYs for the usual care group, which decreased to 43.5 (297.2) per 1000 PYs and 47.8 (304.9) per 1000 PYs, respectively, after the intervention.

Conclusion: Medicaid expenditures and utilization patterns decreased similarly among participants who were enrolled in the CHECK program and those in the UC group. Among children and young adults with asthma and those considered medium and high risk, a comprehensive care coordination program indicated that it could decrease ED utilization.

Study Design: RCT

Setting: Community (Coordinated Healthcare for Complex Kids (CHECK) program; Illinois Medicaid)

Population of Focus: Children with chronic diseases

Sample Size: The study involved a total of 6,245 children and young adults, with 3,119 individuals in the control group and 3,126 individuals in the intervention group.

Age Range: The study included children younger than 1 year old and youth older than 18 years. The mean age of the participants was 11.3 years.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), Educational Material (Provider), Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Nurse/Nurse Practitioner, PROFESSIONAL_CAREGIVER, Patient Navigation (Assistance), Care Coordination, STATE, Multicomponent Approach

Intervention Description: The Healthy Beginnings system of care in Atlanta, GA connects children and their families to health insurance and a medical home model of care to support children’s health and development. The main components are care management + education and parent engagement + collaborative partnerships. A registered nurse, known as the health navigator, supports parents and helps them learn how to work with health care professionals on behalf of their children; they also connect parents to the Center for Working Families to ensure that they receive public benefits for which they are eligible.

Intervention Results: Healthy Beginnings coordinated care approach has ensured that participating children and families have health insurance (97%) and receive regular immunizations (92%), ongoing health care from a primary care physician and dental health provider, and regular developmental screenings (98%) and follow-up care. Healthy Beginnings has dramatically increased children’s access to health care and forms the basis for a cost-effective approach that can be replicated in other communities.

Conclusion: By building upon the partnerships formed through the foundation’s community change effort, Healthy Beginnings has dramatically increased neighborhood children’s access to health care and forms the basis for a cost-effective approach that can be replicated in other communities.

Study Design: Program evaluation

Setting: Community (Community-based organizations in Atlanta, Georgia)

Population of Focus: Low-income young children and families

Data Source: Questionnaire data

Sample Size: 279 children

Age Range: 0-10 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Enrollment Assistance, Patient Navigation,

Intervention Description: Healthy Beginnings seeks to prevent or reduce health disparities through a community-based, coordinated care approach based in a high quality early learning center. Healthy Beginnings is a system of care that connects children and their families to health insurance and a medical home to support children’s continuing health and development. The system also ensures that children have immunizations, periodic developmental screenings, and follow-up care, with frequent check-ups and assessments where indicated. It also provides families with health education both individually and through monthly workshops for groups of parents. The Healthy Beginnings partners worked together to develop a system of care that supports high-quality preventive health care for all children enrolled at Educare Atlanta. The system is integrated with the work of teachers and other staff at Educare Atlanta, as well as local health care providers, and it ensures that there is an ongoing relationship between parent and physician. The Healthy Beginnings main components are care management, education and parent engagement, and collaborative partnership. Healthy Beginnings employs one registered nurse, known as a health navigator, who supports parents and helps them learn how to work with health care professionals on behalf of their children; the health navigator also coordinates regular visits to pediatricians and other health care providers and resources.

Intervention Results: Results suggest that the Healthy Beginnings System of Care has been effectively implemented and has exceeded expectations in terms of achieving the goals of the State of Georgia Governor's Office for Children and Families. Data indicated overwhelmingly positive satisfaction with the system of care: 74% of respondents strongly agreed that they were satisfied. Very few respondents (fewer than 6%) reported that they were neutral, and none strongly disagreed that they were satisfied. In terms of short-term outcomes for participating children, Healthy Beginnings exceeded all of its performance requirements from the Governor's Office for Children and Families in 2013. For example, more than 90% of the children had health insurance and were up-to-date in their immunizations. Nearly all children visited a medical home at least annually, and 98% were current with developmental screenings, according to the Ages and Stages Questionnaires. By building upon the partnerships formed through the foundation’s community change effort, Healthy Beginnings has dramatically increased neighborhood children’s access to health care and forms the basis for cost-effective approach that can be replicated in other communities.

Conclusion: The Annie E. Casey Foundation has been investing in multiple human capital and housing and public open spaces redevelopment strategies in the neighborhoods of Neighborhood Planning Unit V in Atlanta for more than a decade. Although the Healthy Beginnings System of Care is still in its early stages, the foundation has found the concurrent focus on community change and health to be highly compatible with its family strengthening strategies—and a critical contributor to the well-being of the community’s children and families.

Study Design: Systems of care framework

Setting: Community (Community-based organizations in Atlanta, Georgia)

Population of Focus: Low-income young children and families

Sample Size: 279 children

Age Range: 0-10 years

Intervention Components (click on component to see a list of all articles that use that intervention): School-Based Family Intervention, Care Coordination, Collaboration with Local Agencies (State),

Intervention Description: Asthma imposes tremendous burden on children, families, and society. Successful management requires coordinated care among children, families, health providers, and schools. Building Bridges for Asthma Care Program, a school-centered program to coordinate care for successful asthma management, was developed, implemented, and evaluated. The program consists of five steps: (1) identify students with asthma; (2) assess asthma risk/control; (3) engage the family and student at risk; (4) provide case management and care coordination, including engagement of health-care providers; and (5) prepare for next school year. Implementation occurred in 28 schools from two large urban school districts in Colorado and Connecticut.

Intervention Results: Significant improvements were noted in the proportions of students with completed School Asthma Care Plans, a quick-relief inhaler at school, Home Asthma Action/Treatment Plans and inhaler technique (p < .01 for all variables).

Conclusion: Building Bridges for Asthma Care was successfully implemented extending asthma care to at-risk children with asthma through engagement of schools, health providers, and families.

Study Design: Program evaluation

Setting: Twenty-eight schools from two large urban school districts in Colorado and Connecticut

Population of Focus: Students with asthma in the participating schools; Families of the at-risk students; School nurses who led the program; Health-care providers engaged in the care coordination activities; Implementation teams in the two urban school districts of Colorado and Connecticut; Asthma champions within the school districts who provided guidance and support for program implementation at individual schools

Sample Size: 463 students

Age Range: Children 5 to 12 years old

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner,

Intervention Description: Assignment of a nurse practitioner–pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care.

Intervention Results: Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01).

Conclusion: The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions.

Study Design: The study design was a pragmatic randomized controlled trial (RCT) that compared the effectiveness of structured care coordination for children with medical complexity (CMC) to usual care. The study used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over two years.

Setting: The study was conducted in Ontario, Canada, across 12 complex care clinics. The clinics were selected based on their capacity to provide care to children with medical complexity (CMC) and their families.

Population of Focus: The target audience for the study includes healthcare professionals, policymakers, and researchers involved in the care of children with medical complexity (CMC) and their families. The findings of the study are relevant to professionals working in complex care clinics, as well as those involved in developing and implementing care coordination programs for CMC. Additionally, the study may be of interest to healthcare policymakers and researchers focused on improving the quality of care and reducing healthcare utilization for this population.

Sample Size: The study initially assessed 451 participants for eligibility, of whom 207 met the preestablished inclusion criteria for randomization. Ultimately, 139 participants (77 in the intervention group and 62 in the waitlist control group) were included in the primary analysis. Of these, 117 participants completed the 12-month follow-up, and 108 completed the 24-month follow-up.

Age Range: The median age of the participants at enrollment was 29 months, with an interquartile range (IQR) of 9-102 months. This indicates that the age range of the participants in the study was from as young as a few months to over 8 years old.

Intervention Components (click on component to see a list of all articles that use that intervention): , Care Coordination

Intervention Description: Wraparound care coordination for youth with serious emotional and behavioral challenges has been implemented in every state and in many child-serving contexts, but evidence from rigorous effectiveness studies is scarce. We conducted a 20-month longitudinal randomized control trial of a pilot Wraparound program for youth in foster care and involved in the juvenile justice system (n = 24), comparing outcomes with youth receiving community “treatment as usual” (TAU; n = 23).

Intervention Results: Youth in both groups experienced significantly improved outcomes, including fewer arrests and greater residential stability. Wraparound youth were less likely to be rearrested (odds ratio [OR] = 0.59, 95% confidence interval [CI] = [0.17, 2.04]), and survival analysis found they went longer before doing so than TAU youth. Wraparound youth were also more likely to be educationally on track than TAU youth by the end of the study (OR = 4.09, 95% CI = [1.89, 18.72]).

Conclusion: Although these findings were nonsignificant at p < .05 due to small sample sizes, effect sizes were medium to large, and no such trends were found for the TAU group. Implications for Wraparound’s implementation and effectiveness, as well as the strengths and limitations of conducting a randomized control trial in “real-world” systems, are discussed.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Care Coordination, Integration into Adult Care, Pediatric to Adult Transfer Assistance, Planning for Transition

Intervention Description: This is a longitudinal, observational cohort study in UK secondary care including 374 young people, aged 14–18.9 years at recruitment, with type 1 diabetes (n = 150), cerebral palsy (n = 106) or autism spectrum disorder with an associated mental health problem (n = 118). All were pre-transfer and without significant learning disability. We approached all young people attending five paediatric diabetes centres, all young people with autism spectrum disorder attending four mental health centres, and randomly selected young people from two population-based cerebral palsy registers. Participants received four home research visits, 1 year apart and 274 participants (73%) completed follow-up.

Intervention Results: Exposure to recommended features was 61% for ‘coordinated team’, 53% for ‘age-banded clinic’, 48% for ‘holistic life-skills training’, 42% for ‘promotion of health self-efficacy’, 40% for ‘meeting the adult team before transfer’, 34% for ‘appropriate parent involvement’ and less than 30% for ‘written transition plan’, ‘key worker’ and ‘transition manager for clinical team’. Three features were strongly associated with improved outcomes. (1) ‘Appropriate parent involvement’, example association with Wellbeing (b = 4.5, 95% CI 2.0–7.0, p = 0.001); (2) ‘Promotion of health self-efficacy’, example association with Satisfaction with Services (b = − 0.5, 95% CI – 0.9 to – 0.2, p = 0.006); (3) ‘Meeting the adult team before transfer’, example associations with Participation (arranging services and aids) (odds ratio 5.2, 95% CI 2.1–12.8, p < 0.001) and with Autonomy in Appointments (average 1.7 points higher, 95% CI 0.8–2.6, p < 0.001). There was slightly less recruitment of participants from areas with greater socioeconomic deprivation, though not with respect to family composition.

Conclusion: Three features of transitional care were associated with improved outcomes. Results are likely to be generalisable because participants had three very different conditions, attending services at many UK sites. Results are relevant for clinicians as well as for commissioners and managers of health services. The challenge of introducing these three features across child and adult healthcare services, and the effects of doing so, should be assessed.

Study Design: Longitudinal, observational cohort study

Setting: Community (Home)

Population of Focus: Young people from across England and Northern Ireland with one of three conditions: 1) type 1 diabetes mellitus, 2) autism spectrum disorder (ASD) and additional mental health problems, or 3) cerebral palsy (CP)

Data Source: Baseline demographic questionnaire; Scaled questionnaires—Mind the Gap, Warwick Edinburgh Mental Wellbeing Scale, Rotterdam Transition Profile, Autonomy in Appointments

Sample Size: 374 young people (150 for diabetes, 118 for ASD, and 106 for CP); 369 parents/ caregivers

Age Range: 14-18.9 years at recruitment

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Telemedicine Systems (Hospital),

Intervention Description: The intervention described in this study is a virtual wraparound care program called "vKids." The program provided comprehensive care coordination, education, parental support, acute care triage, and virtual visits to children with medical complexity (CMC) and their families. The program utilized a virtual team of pediatric physicians, pediatric nurse practitioners, pediatric nurses, and social workers to address the medical and social needs of patients and families. The program was designed to address the challenges faced by families of CMC, including geographic barriers, transportation challenges, and the lack of reimbursement for the level of support services and care coordination needed.

Intervention Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate.

Conclusion: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.

Study Design: The study utilized a retrospective cohort design to measure the pre-intervention and post-intervention utilization for inpatient, outpatient, and emergency department settings, as well as the cost of care and patient satisfaction for children with medical complexity (CMC). The economic framework was used to evaluate the outcomes of the virtual wraparound care program, and data for study participants were extracted from the HIDI dataset for all inpatient and outpatient visits across all hospitals in the state between October 1, 2017, and March 31, 2020.

Setting: The study was conducted in the United States, specifically in the states of Missouri, Tennessee, and North Carolina. The program was implemented in a virtual care setting, providing wraparound care to address the medical and social needs of patients and families using a virtual team of pediatric physicians, pediatric nurse practitioners, pediatric nurses, and social workers.

Population of Focus: The target audience for the study includes healthcare professionals, policymakers, and researchers interested in pediatric care, particularly for children with medical complexity (CMC). Additionally, the findings of the study may be relevant to healthcare administrators and organizations seeking to implement or improve virtual care programs for pediatric patients with complex medical needs. The study's focus on the economic evaluation and outcomes of a virtual wraparound care program makes it particularly relevant to those interested in innovative care models and their impact on healthcare utilization and patient satisfaction.

Sample Size: The study included a total of 80 children with medical complexity (CMC) for the economic evaluation, and 75 of these children had sufficient data for analysis. The sample size of 75 patients was used for the pre- and post-analysis of the program's impact on hospitalizations, emergency department visits, and overall charges.

Age Range: 0-19 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner, Collaboratives,

Intervention Description: The intervention described in the study is a longitudinal care coordination program for infants with medical complexity. The program provides care coordination to infants in the NICU through their first year at home, with a focus on family-facing activities. The program aims to support families in navigating the complex healthcare system, accessing community resources, and coordinating care across inpatient and outpatient settings. The care coordination program involves the involvement of care coordinators, outpatient providers, and program organizers to provide comprehensive support to families.

Intervention Results: Parent-reported benefits included frequent communication and personalized support that met families’ and patients’ evolving needs. Care coordinators, who were trained as nurses and social workers, developed longitudinal relationships with parents. This seemed to facilitate individualized support throughout the first year of life. Providers reported that smaller caseloads were central to the success of the program.

Conclusion: As is true for all descriptive program evaluations, this study offers observations about this program without drawing definitive conclusions about impact.

Study Design: The study design is a descriptive program evaluation using the Centers for Disease Control and Prevention Framework for Program Evaluation. The study used a sequential exploratory mixed-methods approach to evaluate parental experiences, provider perspectives, and care coordinator perspectives. The study also developed a logic model to describe program structure and stated goals.

Setting: The study was conducted at a level IV NICU at a freestanding academic children's hospital, Ann & Robert H. Lurie Children's Hospital of Chicago.

Population of Focus: The target audience for the study includes healthcare providers, particularly those involved in the care of infants with medical complexity, such as neonatologists, nurses, therapists, chaplains, child life specialists, primary care physicians, surgeons, physician assistants, and nurse coordinators. Additionally, the study is relevant to care coordinators, program organizers, and researchers interested in longitudinal care coordination for infants with medical complexity.

Sample Size: 5 parents were interviewed, and 23 parents completed a survey; 8 providers were interviewed, and 26 providers participated in focus groups; 2 care coordinators were interviewed.

Age Range: The age range of the study participants is from birth to the first year of life, as the program provides care coordination to infants in the NICU through their first year at home.

Intervention Components (click on component to see a list of all articles that use that intervention): Prenatal Care Access, Care Coordination, Quality Improvement/Practice-Wide Intervention,

Intervention Description: The intervention involved the implementation of a new model of prenatal care called PodCare. This model required changes to providers' schedules, including the extension of weekly resident physician didactic schedules to include one hour of Pod meetings. At these meetings, providers selected patients for discussion to ensure completeness of care and appropriate delivery planning. The model aimed to decrease the number of prenatal care visits while increasing continuity with providers and maintaining high-quality care .

Intervention Results: The results of the study showed that after the implementation of the PodCare model, the median number of prenatal care visits decreased from 13 to 10 (p < 0.00004) and the median number of providers seen decreased from 7 to 5 (p < 0.0000008). Additionally, more patients chose care with the low-risk physician team (42% compared to 26%). The model also performed well above national averages on measures of timeliness of care and percentage of deliveries receiving a postpartum visit. There were no significant differences in secondary outcomes such as mode of delivery, Group B strep testing, and diabetes screening

Conclusion: The study concluded that the PodCare model increased the value of individual prenatal care by decreasing the number of visits, increasing continuity, and providing care coordination. The model provides a robust experience in interdisciplinary care and may be successful at other academic institutions. The study also suggested that the PodCare model presents savings in opportunity cost given more available clinic visits for other obstetrical or gynecologic patients. The model also allows residents and associate providers to provide the bulk of care under the supervision of an attending physician, making it a cost-effective and resource-wise decision

Study Design: The study utilized a retrospective cohort design to compare the outcomes of prenatal care before and after the implementation of the PodCare model. Data were abstracted retrospectively from the electronic medical record for all patients initiating prenatal care in the one year before and after PodCare, and a washout period of six months on either side of the intervention was applied

Setting: The study was conducted in an academic setting at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, USA .

Population of Focus: The target audience of the study was healthcare providers and clinic staff who provide prenatal care to pregnant women. The study aimed to test the hypothesis that a new model of prenatal care, PodCare, would increase the value of traditional prenatal care by decreasing the number of visits while increasing continuity with providers and maintaining current high-quality care .

Sample Size: The study included 85 women in 2013 and 165 women in 2014 as study subjects . These women were included in the analysis to evaluate the impact of the PodCare model on prenatal care visits and provider interactions.

Age Range: The age range of the participants in the study was 18.8 to 42.6 years .

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Nurse/Nurse Practitioner, Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination, Quality Improvement/Practice-Wide Intervention

Intervention Description: This quantitative descriptive study used a survey questionnaire to investigate nurses' role and responsibilities in health care transition planning (HCTP) for youth and young adults with chronic illness and/or disability. The survey looked at respondents' role in health care transition planning (HCTP), inclusion of HCTP in job description, levels of HCTP knowledge, and ratings of importance of HCTP elements.

Intervention Results: Over 64% of respondents performed HCTP activities related to complex chronic illness management. Only 18% reported specialized training in HCTP. The highest-ranking items in regard to perceived importance were educating and supporting disease self-management and speaking with families about complex needs. Predictors of perceived importance were role, inclusion of transition planning in a job description, percentage of time in direct care, caring for those aged 14 years and older, and level of knowledge about HCTP.

Conclusion: The findings highlight key aspects of the pediatric nurse role in HCTP and identify specific elements that can be addressed to support future HCTP role development.

Study Design: Quantitative descriptive methodology

Setting: Hospitals/Clinics

Population of Focus: Pediatric nurses

Sample Size: 1814

Age Range: Adults

Intervention Components (click on component to see a list of all articles that use that intervention): Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination, PROVIDER/PRACTICE

Intervention Description: To identify (a) determinants of glycated haemoglobin (HbA1c) at 18 and 30 months following transition in young people with Type 1 diabetes mellitus (T1DM) to a youth-specific diabetes service; and to (b) evaluate the impact of the service on acute admissions with diabetic ketoacidosis (DKA) over a 14-year period.

Intervention Results: Data from 439 adolescents and young adults (Median age: 18) were analysed. The recommended standard of glycaemic control, HbA1c < 7.5% (58 mmol/mol), was achieved by 23% at baseline, 22% at 18-months, and 20% at 30-month. After adjusting for lag time (>3 months) and diabetes duration (>7 years), glycaemic control at first visit predicted subsequent glycaemic control at 18-month and 30-month follow-up. From 2001 to 2014, only 8.6% were lost to follow-up; admissions and readmissions for DKA reduced from 72% (32/47) to 4% (14/340) (p < 0.001). Furthermore, mean length of stay (LOS) significantly decreased from 6.56 to 2.36 days (p < 0.001).

Conclusion: Continuing engagement with the multidisciplinary transition service prevented deterioration in HbA1c following transition. Age-appropriate education and regular follow-up prevents DKA admissions and significantly reduced admission LOS.

Study Design: Pre-post and retrospective cohort

Setting: Clinic-based (Referral from pediatrics services to a multidisciplinary transition service)

Population of Focus: All youth with diabetes referred to the young adult diabetes service since 2001

Data Source: Administrative database

Sample Size: 439 adolescents and young adults

Age Range: Median age: 18 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner,

Intervention Description: This project implemented an innovative care coordination model, involving one-on-one supports from a trained care coordinator who liaised with the broader intersectoral care team to improve joint care planning, integration of services, and the experience of both families and care providers.

Intervention Results: Over 2 years, this project provided care coordination to 84 children and their families, with an age range from 2 to 17 years. The care coordination intervention demonstrated positive impacts for children, families, and care teams and contributed to clinical efficiencies. Children had fewer visits to the emergency department and less frequent acute care use. Improvement in access to services, joint care planning and communication across providers, and better linkage with school supports were demonstrated.Families reported that the program decreased their stress around coordinating care for their child.

Conclusion: This work demonstrated that intersectoral care coordination is attainable through innovative and collaborative practice for children with complex neurodevelopmental and medical needs.

Study Design: The study design is a single-group interventional study using a repeated-measures framework. The study evaluated the impact of a care coordination intervention on children with concurrent neurodevelopmental disorders and chronic health conditions. The study used previously established outcome measures and conducted surveys at 0, 6, and 12 months to evaluate the impact of care coordination activities. The study did not include a control group receiving standard of care during the same period, and randomizing patients to care coordination or standard care was deemed a barrier to referral and recruitment. Therefore, the study design has limitations, but it provides valuable insights into the effectiveness of a care coordination intervention for children with neurodevelopmental disorders and complex medical needs.

Setting: The article does not provide a specific setting for the study. However, it does mention that the participants were identified and referred from a variety of sources, including subspecialty clinics at a regional Canadian children’s hospital, community pediatricians, nurses, allied health professionals, and pediatric mental health services.

Population of Focus: The target audience for the study is healthcare providers, policymakers, and researchers who are interested in improving care coordination for children with neurodevelopmental disorders and complex medical needs.

Sample Size: The study provided care coordination to 84 children and their families over a period of two years.

Age Range: 2 to 17 years

Intervention Components (click on component to see a list of all articles that use that intervention): Multicomponent Approach, Care Coordination, Family-Based Interventions,

Intervention Description: The intervention in the study was the addition of a community health worker (CHW) to the HealthySteps (HS) care team. The HS model consists of different tiers of service, and the most intensive tier (tier 3) is called comprehensive services. It includes ongoing collaborative team–based well-child visits, care coordination, and systems navigation, which are provided to families determined to be most at risk according to screenings, clinical judgment, and caregiver concerns. Through this program, behavioral health treatment for concerns related to development, behavior, parent-child relationship, and parental mental health is also provided to families. When social determinants of health (SDOH) concerns are identified by pediatric primary care providers, HS Specialists work with families to address their needs. In this study, families were directed to meet with a separate health care worker, similar to a CHW, to receive referrals to address their SDOH needs. The study showed that the overall referral success rate for HS families participating in this study was 88%, and having an HS + CHW team resulted in a successful referral rate of 100% for food services and 89% for childcare services.

Intervention Results: Medical charts with documentation of HS comprehensive services between January and June 2018 were reviewed at 3 primary care clinics: 2 with an HS Specialist (HSS Only) and 1 with an HS Specialist and CHW (HSS + CHW). Eighty-six referrals were identified, 78 of which had documented outcomes. Outcomes were categorized as successful, unsuccessful, and not documented. The HSS + CHW group had a higher rate of successful referrals (96%) than the HSS Only group (74%). Statistical analysis (χ2 = 8.37, P = .004) revealed a significant association between the referral outcome and having a CHW on a primary care team with an HS Specialist.

Conclusion: Yes, the study reported statistically significant findings related to the success of referrals when comparing the HSS Only group with the HSS + CHW group. The referral success rate was 74% for the HSS Only group compared with 96% for the HSS + CHW group, and this difference was statistically significant (χ2 = 8.37, P = .004). Additionally, a logistic regression analysis showed that participation in HSS + CHW compared with HSS Only related to an increased likelihood of a successful referral. The logistic regression model was statistically significant (χ21 = 8.0, P < .001), explaining 19.0% of the variance in successful referrals and correctly classifying 88.5% of cases. These findings indicate that the inclusion of a community health worker on the HealthySteps care team was associated with a significantly higher likelihood of successful referrals to community resources.

Study Design: The study design was a retrospective chart review. Data for the study were collected through retrospective chart reviews of all 192 families who received HealthySteps (HS) comprehensive services over a 6-month period. The chart reviews were conducted to identify the documentation of referrals to community resources or community health workers (CHWs) by HS Specialists. The study also included descriptive analyses of the demographics of study participants and conducted comparisons between the HSS Only group and the HSS + CHW group to assess potential confounding variables.

Setting: The study took place in a large urban city and was conducted in three pediatric primary care practices. The city where the study was conducted had a significant percentage of individuals living below the poverty threshold, with many families facing numerous hardships simultaneously, such as limited access to health care and medical insurance.

Population of Focus: The target audience for the study is likely healthcare professionals, policymakers, and researchers interested in improving access to social determinants of health resources for families with young children living in low-income, underserved urban settings. The study provides insights into the effectiveness of a community health worker (CHW) within a primary care team with a HealthySteps (HS) Specialist in increasing successful connections to community resources for pediatric patients. The findings of the study may be useful for healthcare professionals and policymakers seeking to improve the health outcomes of children living in poverty by addressing social determinants of health.

Sample Size: The study included a total of 192 participants, with 96 participants in the combined HSS Only group and 96 participants in the HSS + CHW group. The demographic data from the two HSS Only sites were combined to form a single HSS Only group due to the small sample size at each site.

Age Range: The age group of the children in the study varied, with ages ranging from birth to 53 months in the combined HealthySteps Specialist (HSS) Only sample, and from birth to 48 months in the HealthySteps Specialist + community health workers (HSS + CHW) group. The study included children from birth to early childhood, encompassing a critical developmental period.

Intervention Components (click on component to see a list of all articles that use that intervention): Mobile Programs, Quality Improvement/Practice-Wide Intervention, Care Coordination,

Intervention Description: Children in two communities of a large city in the Midwestern United States have higher rates of asthma than other areas of the city. The communities have barriers to accessing care, including high rates of unemployment and being uninsured and undocumented. A mobile van provides no-cost asthma care to children at schools in these communities, but use of these services has decreased more than 50% over the past 5 years. School nurses have the potential to improve asthma outcomes by collaborating with health-care providers. The purpose of the program was to increase the number of appointments scheduled and attended on the asthma van at both schools. For this program, we (a) implemented an unaccompanied minor consent, (b) enhanced care coordination, and (c) improved a respiratory health survey tool.

Intervention Results: Results showed an increased number of appointments scheduled and attended on the asthma van.

Conclusion: The program was successful even though community-specific barriers existed.

Study Design: Pre-post intervention study

Setting: Two communities in a large city in the Midwestern United States

Population of Focus: Children in two communities in a large city in the Midwestern United States who have higher rates of asthma compared to other areas in the city

Sample Size: 718 students for Community A School and 267 students for Community B School

Age Range: Children aged 6-11 years old

Intervention Components (click on component to see a list of all articles that use that intervention): , Group Education, Care Coordination

Intervention Description: The study sample consisted of 228 children referred by pediatricians for outpatient child psychiatry evaluation within an urban safety-net hospital system in 2013 in a collaborative-practice model (CPM). In the pilot clinic, 32 youths were referred to the CPM intervention. Among the remaining seven clinics, 196 youths were referred to usual care (control group). Differences in treatment access and engagement between the intervention and control groups were assessed using propensity-score weighted logistic regression models.

Intervention Results: Holding all else constant, children receiving the CPM intervention had four times higher odds of accessing psychiatric evaluations than children in the usual care control group (adjusted odds ratio [AOR]=4.16, p<.01). The odds of engagement (i.e., participation in follow-up appointments) were seven times greater for youths in the CPM than youths in the control group (AOR=7.54, p<.01).

Conclusion: Access and engagement were significantly higher for children receiving CPM than for usual care participants. This suggests that integrated CPM warrants further investigation as an approach for improving the odds that children and families will receive needed mental health or substance use disorder treatment.

Intervention Components (click on component to see a list of all articles that use that intervention): Collaboration with Local Agencies (Health Care Provider/Practice), Patient Navigation, Care Coordination,

Intervention Description: The CPM brings inpatient child psychiatry consultation-liaison elements, such as team-based rounds, to an outpatient setting. Child psychiatry and family support specialist (FSS) staff were available weekly in the pediatrics clinic." Involved collaboration between psychiatry and pediatric providers.

Intervention Results: Holding all else constant, children receiving the CPM intervention had four times higher odds of accessing psychiatric evaluations than children in the usual care control group (adjusted odds ratio [AOR]=4.16, p<.01). The odds of engagement (i.e., participation in follow-up appointments) were seven times greater for youths in the CPM than youths in the control group (AOR=7.54, p<.01).

Conclusion: These findings serve as preliminary evidence suggesting that the CPM for integrated pediatric care should be further studied to isolate potential causal effects on the odds that children and families will receive needed mental health treatment. Additional areas for future investigation include heterogeneity of effect among subpopulations and across delivery systems; effectiveness of substituting other child mental health clinicians into the child psychiatrist role (given workforce capacity) or coordinating with other resources, such as telephone-based child psychiatry consults; and the unique effects of the FSS role on CPM outcomes

Study Design: Quasi-experimental pre-post study with nonrandomized intervention and control groups

Setting: Urban, safety-net hospital system pediatric clinics

Population of Focus: Children and adolescents ages 4-19 referred for psychiatric evaluation

Sample Size: 228 participants

Age Range: Ages 4-19 years old

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We assessed the effectiveness of a transition protocol that aimed to improve the transfer of adolescents to adult primary care. Chart reviews were conducted on 21- and 22-year-old patients seen 18 months before and after protocol implementation. Completion of an adult medicine appointment scheduled within 6 months from the last pediatric visit was the primary outcome of interest.

Intervention Results: In pre-implementation period, 20.9% of patients versus 39.3% in post-implementation period were transferred. Transfer was higher in patients who had a dedicated transition visit, had a transition order placed, and were tracked during the transfer process.

Conclusion: Implementing a transition protocol in pediatric clinics can improve the transition of adolescents aging out of pediatric care and may diminish gaps in medical care that can be associated with poor health outcomes.

Intervention Components (click on component to see a list of all articles that use that intervention): Multicomponent School-Based Program, Outreach (School Staff), Care Coordination,

Intervention Description: N/A

Intervention Results: Based on a sample of 64,710 children, 0.5% identified school-based providers as their primary source of health care. Children who were older, uninsured, or living in the Northeast were significantly more likely to report school-based providers as their usual source of care. Children whose usual source of care was a school-based provider were less likely to receive care meeting medical home criteria than children who usually received care at a doctor's office.

Conclusion: While SBHCs improve access to care, our findings indicate potential challenges with establishing a medical home for children who usually receive health care from a school-based provider.

Study Design: Using data from the 2016-2018 National Survey of Children's Health (NSCH), we analyzed children's usual source of care (school-based provider, doctor's office or clinic, other location, or none), and whether they received care meeting medical home criteria.

Setting: 2016-2018 National Survey of Children's Health; United States

Population of Focus: Children and adolescents, particularly those that use SBHCs

Sample Size: 64710

Age Range: 0-17

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Continuity of Care (Caseload),

Intervention Description: We identified strategies used by Community Health Centers (CHCs) to assist patients with insurance applications, and assessed patients’ receptivity to these efforts.

Intervention Results: Patients’ understanding of eligibility status, reapplication schedules, and how to apply, were major barriers to insurance enrollment. Clinic staff addressed these barriers by reminding patients when applications were due, assisting with applications as needed, and tracking submitted applications to ensure approval. Families trusted clinic staff with insurance enrollment support, and appreciated it.

Conclusion: CHCs are effective at helping patients with public health insurance. Access to insurance expiration data, tools enabling enrollment activities, and compensation are needed to support enrollment services in CHCs.

Study Design: Observational cross-sectional comparative study

Setting: Community (4 Community Health Centers in urban and rural settings, in Oregon)

Population of Focus: Low-income families

Sample Size: 26 clinic staff, 18 adult family members

Age Range: Clinic staff, parents with at least 1 child on Medicaid or CHIP

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination,

Intervention Description: N/A

Conclusion: - Young adults with mental health conditions face similar challenges during transition, including less access to care and higher rates of suicide than adolescents. - The barriers preventing more patients from getting effective transitional care have been well-documented, including confusion and feeling unsupported once they leave the pediatric setting, lack of time, training, and reimbursement for transition services, and ill-equipped adult-oriented providers. - The Six Core Elements of transition were developed for primary care providers to use within patient-centered medical homes, and specialty societies have affirmed the importance of several of the principles and practices recommended. - Child and adolescent psychiatrists should consider specific transition scenarios, including transitioning patients to college mental health services, treating youth with new onset psychosis during this vulnerable time period, and treating adolescent and young adults with intellectual or developmental disabilities (IDDs).

Study Design: Systematic Review

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid, Public Insurance (State), Care Coordination,

Intervention Description: Children with disabilities utilize more health-care services and incur higher costs than other children do. Medicaid Buy-In programs for children with disabilities have the potential to increase access to benefits while reducing out-of-pocket costs for families whose income exceeds Medicaid eligibility. This study sought to understand how parents and caregivers of Massachusetts children with disabilities perceive access to care under CommonHealth, Massachusetts’s Medicaid Buy-In program. Parents and caregivers (n = 615) whose children were enrolled in CommonHealth participated in a survey assessing the impact of the program. Qualitative data were coded across five access domains—availability, accessibility, accommodation, affordability, and acceptability.

Intervention Results: Data suggest that CommonHealth improves access to care for children with disabilities by providing the benefits that were limited in scope or unavailable through other insurance before enrollment and by making available services more affordable. Policy and administrative changes could improve the program and further increase access to care for children with complex, costly conditions.

Conclusion: Adopting a Medicaid Buy-In program may be an effective way for states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.

Study Design: Qualitative study

Setting: MassHealth CommonHealth Buy-In program, a Medicaid Buy-In program in Massachusetts

Population of Focus: Parents and caregivers of children with disabilities who are enrolled in the MassHealth CommonHealth Buy-In program in Massachusetts

Sample Size: 615 parents and caregivers whose children were enrolled in CommonHealth

Age Range: Children and youth ages 0-18 years and their adult parents and caregivers

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Technology-Based Support,

Intervention Description: A social worker coordinated medical care for children in foster care in a foster care medical home (FCMH) and tracked care coordination (CC) activities using a modified Care Coordination Measurement Tool© (mCCMT).

Intervention Results: The CC prevented 11 emergency department (ED) visits, 9 placement disruptions, and 42 patient privacy violations. Children assigned to a FCMH have diverse CC needs and benefit from social workers’ specialized skills.

Conclusion: In summary, the mCCMT findings demonstrated the needs of patients and benefits of social worker CC in enhanced primary care provision in a FCMH. Duplication and customization of this model is a robust option for improving outcomes for pediatric patients in the foster care system. The social worker’s specialization was paramount in ensuring that children in foster care had consistent, continuous, and comprehensive medical care. They made connections to community dental and mental health resources and prevented unnecessary ED visits (and the associated excessive health care costs). Our description of social worker activities specialized for children and youth in foster care offers a model of care for pediatric medical homes, particularly practices where there may be a larger proportion of children involved in the child welfare system. Our findings suggest that a dedicated social worker to oversee FCMH care management is a promising intervention for improving permanency outcomes for children in foster care and supporting the health and resiliency of foster families.

Study Design: The study design was a retrospective observational study. The study used a modified version of the Care Coordination Measurement Tool© (mCCMT) to collect data on care coordination encounters for children in foster care over an eight-month period. The study analyzed the data to describe the characteristics of the children, the care coordination activities provided, and the time spent on care coordination activities.

Setting: The study was conducted in a foster care medical home (FCMH) within a primary care clinic that served nearly 6,000 unique children during the eight-month study period. The FCMH was embedded in an outpatient pediatric and adolescent clinic, and the social worker coordinated medical care for children in foster care within this setting.

Population of Focus: The target audience for the study includes healthcare professionals, social workers, policymakers, and researchers interested in improving care coordination for children and youth in foster care. Additionally, the findings may be relevant to professionals working in pediatric medical homes, particularly those serving a larger proportion of children involved in the child welfare system.

Sample Size: 60 children in foster care

Age Range: The age range of the children included in the study was from 1 day to 18 years. The majority of the children were under the age of 5 years.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Quality Improvement, Shared Plans of Care

Intervention Description: The intervention described in the study is the Compass Care Program, which is a consultative complex care program designed to address the needs of children with medical complexity (CMC) receiving specialty care at the institution. The program provides complex care consultation for children across inpatient and outpatient settings, with the goals of proactively coordinating care, improving the quality of care for CMC, and enhancing caregiver satisfaction . The program aims to achieve these goals through a multidisciplinary approach that involves care coordination, specialized services, and ongoing support for the patients and their families.

Intervention Results: Participants had significant decreases in hospital admis- sions per patient month, length of stay per admission, hospital days per patient month, and charges per patient month following enroll- ment (P<0.01) without a tandem increase in readmissions within 7 days of discharge. There was no statistically significant difference in ED visits. Caregiver satisfaction scores improved in all domains.

Conclusion: Participation in a consultative complex care program can improve utilization patterns and cost of care for CMC, as well as experience of care for patients and families.

Study Design: The study utilized a pre-post design to evaluate the impact of the Compass Care Program for children with medical complexity (CMC) and their families. It compared baseline data for each patient from the 12 months before enrollment with post-enrollment data for all months after enrollment . This design allowed for the assessment of changes in utilization metrics and caregiver satisfaction after program enrollment.

Setting: The study was conducted in a tertiary care setting. The Compass Care Program, a consultative complex care program for children with medical complexity (CMC) and their families, was implemented across inpatient and outpatient settings within the tertiary care institution. This indicates that the program was designed to address the complex medical and social needs of CMC in both the hospital and outpatient care settings.

Population of Focus: The target audience for the study includes healthcare professionals, administrators, and researchers involved in the care of children with medical complexity (CMC) and their families. Specifically, pediatricians, pediatric specialists, hospital administrators, and researchers interested in complex care programs, care coordination, and improving outcomes for CMC would find the study relevant. Additionally, professionals and organizations involved in the development and implementation of consultative complex care programs in tertiary care settings may also benefit from the insights provided in the study.

Sample Size: The study enrolled 105 new patients into the Compass Care Program between June 1, 2015, and September 1, 2017. This sample size represents the population of children with medical complexity (CMC) who were enrolled in the program during the specified time frame.

Age Range: The study reports that at the time of enrollment, roughly half of the patients were between 0 and 1 year of age, while over 90% of patients were 9 years of age or younger.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Transition Assistance, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: To assess participation with a structured transition programme for adolescents with diabetes.

Intervention Results: Five hundrend and twelve adolescents who were to be transferred to adult care (476 type 1 (T1D) and 36 type 2 (T2D)), overall participation rate of 83%, 86% (408/476) with T1D compared to 47% (17/36) with T2D. Within the cohort of T1D, participation rates for Māori and Pacific were lower (74% and 77%, respectively) than New Zealand Europeans (88%, p = 0.020 and p = 0.039, respectively). Lower socio-economic status was associated with reduced participation (77%) compared to higher socio-economic status (90%, p = 0.002). Of the 476 T1D who participated, 408 (96%) subsequently attended at least one adult service clinic ("capture"). 42% attended an adult clinic within the planned 3 months, 87% at 6 months and retention in adult clinics over 5 years of follow-up was 78%. By contrast, the 68 young people with T1D who did not participate in the structured transition had a capture rate of 78% (p < 0.001) and retention of 63% (p = 0.036).

Conclusion: In adolescents with diabetes, a formal transition from a paediatric service was associated with high rates of adult capture and subsequent retention in adult care over a 5-year follow-up period. Low socio-economic status, Māori or Pacific ethnicity and T2D were associated with reduced participation in the structured transition programme.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Integration into Adult Care, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We tested the hypothesis that individuals who participated in the co-located model have greater retention in adult care compared to those who only received pediatric transition services.

Intervention Results: Individuals who participated in the co-location model were 1.9 times more likely to remain in adult care 12 (95%CI: 1.01, 3.47) and 24 (95%CI: 1.01, 3.70) months post pediatric care compared to those who did not participate. Individuals with HbSS/HbSβ0-thalassemia were 1.9 times more likely to be retained at 12 months compared to those with HbSC/HbSβ+-thalassemia/HbS/HPFH (95%CI: 1.12, 3.09). For every clinic encounter in the last 2 years of pediatric care, the odds of being retained at least 24 months after initiating adult care increased 1.1 times (95%CI: 1.02, 1.13).

Conclusion: Continuity of providers from pediatric to adult care may increase long-term retention in adult care. Longitudinal monitoring of adult outcomes is critical to identifying the efficacy of transition services

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Family-Based Interventions, Health Literacy

Intervention Description: N/A

Intervention Results: Compared with children in parent-led households, those in grandparent-led households had increased physical health conditions (oral health problems: 18.9% vs 13.1%, P = .0006; overweight/obesity: 40.3% vs 29.7%, P = .0002); emotional, mental, and developmental health conditions (attention deficit hyperactivity disorder: 16.3% vs 8.0%; behavioral/conduct problems: 13.9% vs 6.1%; depression: 6.6% vs 3.1%; learning disability: 13.9% vs 6.2%, P < .0001 for all); and special health care needs (28.2% vs 17.8%, P < .0001). They also had decreased prevalence of health care utilization (usual source of sick care: 65.7% vs 79.5%, preventive checkups: 64.6% vs 77.1%; preventive dental visits: 73.8% vs 80.6%; specialty care: 78.6% vs 90.2%, P ≤ .0001 for all) and increased prevalence of forgone care (5.9% vs 2.8%, P = .0020). After adjustment, the associations with caregiver type remained statistically significant for all emotional, mental, and developmental conditions listed; special health care needs; usual source of sick care and preventive checkups.

Conclusion: Grandparent caregivers may benefit from additional support to ensure that grandchildren receive timely health care services.

Study Design: We used 4 years of pooled data from the National Survey of Children's Health, representative of United States children ages 0 to 17 years, and applied bivariate analyses and logistic regressions adjusted for sociodemographic confounders to compare grandparent- and parent-led households on key measures of interest.

Setting: NSCH Survey; United States

Population of Focus: Granparent-led households w/ children

Sample Size: 117371

Age Range: 0-17

Intervention Components (click on component to see a list of all articles that use that intervention): , Care Coordination, Case Management

Intervention Description: The intervention was a coordinated asthma discharge bundle that included several components, such as tailored bedside education, enrollment in a community asthma prevention program (CAPP), facilitated discharge medication filling, and expedited specialty follow-up. The tailored bedside education included a review of the patient's asthma action plan, medication regimen, and inhaler technique. The CAPP enrollment involved a referral to a community-based program that provided asthma education, home visits, and environmental assessments. The facilitated discharge medication filling involved ensuring that patients had their medications filled before leaving the hospital. The expedited specialty follow-up involved scheduling a follow-up appointment with an allergy or pulmonology specialist within 30 days of discharge. The intervention was implemented from May 2016 to April 2017, and the study used statistical process control charts and difference-in-differences analysis to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital.

Intervention Results: From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; P = .02).

Conclusion: Yes, the study found statistically significant reductions in the monthly proportion of children experiencing a revisit to the ED or hospital within 30 days of a qualifying hospitalization. The average monthly proportion of children experiencing a revisit declined by 38%, from a historical baseline of 24% to 15%. The difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% CI: (−20.2, −1.8); p=0.02). The study also found significant improvements in the completion of various components of the asthma discharge bundle, including inpatient risk screener completion, tailored education, CAPP referral, facilitated discharge medication filling, and expedited specialty follow-up.

Study Design: The study design was a longitudinal quality improvement (QI) initiative supplemented with an assessment of robustness using difference-in-differences analysis. The study aimed to evaluate the effectiveness of a coordinated asthma discharge bundle in reducing repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalizations. The intervention was implemented from May 2016 to April 2017, and the study used statistical process control charts and difference-in-differences analysis to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital.

Setting: The study was conducted at a large, academic children's hospital in the United States. The target cohort for the study consisted of children who were admitted to the inpatient setting for asthma at this hospital. Additionally, the primary care for the eligible children was provided at three inner-city primary care centers affiliated with the hospital.

Population of Focus: The target audience for the study includes healthcare professionals, pediatricians, pulmonologists, allergists, hospital administrators, and policymakers involved in pediatric asthma care and population health management. Additionally, researchers and professionals interested in quality improvement initiatives and interventions aimed at reducing healthcare utilization for children with asthma may also find the study relevant.

Sample Size: The study sample consisted of 207 children between the ages of 2 and 17 who had been hospitalized for asthma exacerbations three or more times within the previous year. Of these, 79 children were enrolled in the intervention group, and 128 children were in the control group.

Age Range: The age group for this initiative was children ages 2-17 who were hospitalized for asthma at least three times in the prior year.

Intervention Components (click on component to see a list of all articles that use that intervention): Transition Assistance, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: The objective was to evaluate healthcare outcomes (continuity of care and healthcare utilization) for clients enrolled in LIFEspan.

Intervention Results: Prospective enrolment comprised 30 ABI, 48 CP, and 21 SB participants. Retrospective enrolment comprised 15 ABI and 18 CP participants. LIFEspan participants demonstrated significantly greater continuity of care (45% had engagement with adult services in the year following discharge at 18 years), compared to the prospective SB group (14%). Healthcare utilization data were inconsistent with no significant changes in frequency of physician office visits, emergency department visits, or hospitalizations for clients enrolled in LIFEspan in the year following discharge, compared to the 2 years prior to discharge.

Conclusion: Introduction of the LIFEspan model increased continuity of care, with successful transfer from pediatric to adult services for clients enrolled. Data on longer-term follow-up are recommended for greater understanding of the degree of adult engagement and influence of LIFEspan on healthcare utilization following transfer.

Intervention Components (click on component to see a list of all articles that use that intervention): Parent Engagement, Care Coordination, Provider Training/Education,

Intervention Description: This study evaluates the impact of a 6-month care management intervention for 206 children diagnosed with comorbid attention deficit hyperactivity disorder (ADHD) from a sample of 321 five- to 12-year-old children recruited for treatment of behavior problems in 8 pediatric primary care offices. Practices were cluster-randomized to Doctor Office Collaboration Care (DOCC) or Enhanced Usual Care (EUC). Chart reviews documented higher rates of service delivery, prescription of medication for ADHD, and titration in DOCC (vs EUC).

Intervention Results: Based on complex conditional models, DOCC showed greater acute improvement in individualized ADHD treatment goals and follow-up improvements in quality of life and ADHD and oppositional defiant disorder goals. Medication use had a significant effect on acute and follow-up ADHD symptom reduction and quality of life. Medication continuity was associated with some long-term gains.

Conclusion: A collaborative care intervention for behavior problems that incorporated treatment guidelines for ADHD in primary care was more effective than psychoeducation and facilitated referral to community treatment.

Study Design: Cluster-randomized trial

Setting: Eight pediatric primary care practices in the United States, including seven Children's Community Pediatric practices and one general academic pediatric practice affiliated with Children's Hospital of Pittsburgh

Population of Focus: Children with behavior problems who were receiving care in pediatric primary care practices

Sample Size: 321 children

Age Range: Children ages 5-12 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, Transition Assistance, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: The research aimed to analyse the implementation in an initial cohort of patients of a new programme of transition to adult care based on a case

Intervention Results: The cohort included 500 patients, with malignant brain tumour (n = 56 (11%)), obesity (n = 55 (11%)), type 1 diabetes (n = 54 (11%)), or other disease (n = 335 (67%)). Their median age at transfer was 19, and the sex ratio was 0.5. At median 21 months of follow-up, 439 (88%) had a regular follow-up in or outside the hospital, 47 (9%) had irregular follow-up (absence at the last appointment or no appointment scheduled within the time recommended), 4 had stopped care on doctor's advice, 4 had died, 3 had moved, and 3 had refused care. The programme involved 9615 case management actions; 7% of patients required more than 50 actions. Patients requiring most support were usually those affected by a rare genetic form of obesity.

Conclusion: Case managers successfully addressed the complex needs of patients. Over time, the cohort will provide unprecedented long-term outcome results for patients with various conditions who experienced this form of transition.

Intervention Components (click on component to see a list of all articles that use that intervention): Nurse/Nurse Practitioner, Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination, PROVIDER/PRACTICE

Intervention Description: Adolescents and young adults with special health care needs were enrolled in a randomized HCT CC intervention. Intervention participants received HCT CC as outlined in the 2011 clinical report. Perceptions of chronic illness care quality and CC were assessed at 0, 6, and 12 months.

Intervention Results: Intervention participants had a Patient Assessment of Chronic Illness Care score at 12 months of 3.6 vs 3.3 compared with participants in the control group (P = .01). Intervention participants had higher average scores for patient activation (3.7 vs 3.4; P = .01), problem solving (3.8 vs 3.4; P = .02), and coordination/follow-up (3.0 vs 2.5; P < .01). The Client Perceptions of Coordination Questionnaire revealed that intervention participants had 2.5 times increased odds to endorse mostly or always receiving the services they thought they needed and had 2.4 times increased odds to have talked to their provider about future care (P < .01).

Conclusion: Implementing recommended HCT CC practices improved patient or patient caregiver perception of quality of chronic illness care and CC especially among the most complex patients.

Study Design: Randomized controlled trial

Setting: Hospital/clinicbased

Population of Focus: SSI Medicaid MCO recipients with chronic conditions who spoke English and could complete surveys

Data Source: Patient Assessment of Chronic Illness Care (PACIC)15 and the Client Perceptions of Coordination Questionnaire (CPCQ)

Sample Size: 209 (105 intervention, 104 control)

Age Range: 16-22 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Telemedicine Systems (Inter-Hospital Systems), Quality Improvement, Targeting Interventions to Focused Groups

Intervention Description: N/A

Intervention Results: Those with No USC and Facility USCs increased 10 and 18 percent, respectively, while those with Person USCs decreased by 43 percent. Compared to those in the lowest income bracket, those in the highest income bracket were less likely to have a Facility USC. Among those with low incomes, individuals with No USC, Person, in Facility, and Facility USCs were more likely to have ED visits than those with Person USCs.

Conclusion: A growing number are reporting facilities as their USCs or none at all. The impact of these trends is uncertain, although we found that some USC types are associated with ED visits and hospital admissions. Tracking USCs will be crucial to measuring progress toward enhanced care efficiency.

Study Design: We stratified each USC category, by age, region, gender, poverty, insurance, race/ethnicity, and education and used regression to determine the characteristics associated with USC types, ED visits, and hospital admissions.

Setting: 1996-2014 Medical Expenditure Panel Surveys

Population of Focus: Low income individuals, those with no USC

Sample Size: 559762

Age Range: All ages, five categories

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner,

Intervention Description: Children known to child welfare are more likely to have poor health compared to the general population. Most children served by child welfare are served in their own homes. New Jersey implemented the Child and Family Nurse Program (CFNP) to provide nurse care coordination to address the health needs of children who remain in-home.

Intervention Results: Families served by CFNP experienced improvements in family protective factors and health-related quality of life from baseline to follow-up.

Conclusion: The study concluded that the Child and Family Nurse Program (CFNP) in New Jersey showed positive outcomes for families of children with medical needs known to child welfare. Families served by CFNP demonstrated improvements in family protective factors and health-related quality of life (HRQL) from baseline to follow-up. The findings indicated that the program had a positive impact on family well-being, as evidenced by the significant improvements in Family Functioning/Resiliency, Child Development/Knowledge of Parenting, and all three indicators of health-related quality of life. The study also highlighted the strengths and weaknesses of the research design and data collection methods, acknowledging the limitations of using parent self-report to measure outcomes. Despite these limitations, the study provided evidence of the potential effectiveness of CFNP in improving outcomes for families of children with medical needs known to child welfare. Overall, the study's conclusions supported the positive impact of CFNP on family well-being outcomes, emphasizing the potential benefits derived by the families served by the program.

Study Design: The study design is a retrospective cohort study that used data from the Child and Family Nurse Program (CFNP) in New Jersey from 2016 to 2017. The study aimed to describe the families served by CFNP and the services provided to them. The study also evaluated the impact of CFNP on family protective factors and health-related quality of life (HRQL) using a pre-post design. The study collected baseline and follow-up data from caregivers of children served by CFNP using surveys. The study design allowed for the identification of trends and patterns in the data and provided insights into the effectiveness of CFNP in improving outcomes for families of children with medical needs known to child welfare.

Setting: The setting for the study was New Jersey, where the Child and Family Nurse Program (CFNP) was implemented to improve health outcomes for children with significant health challenges who remain in-home. The study focused on the families served by CFNP in New Jersey from 2016 to 2017.

Population of Focus: The target audience for the study is policymakers and child welfare agency leaders who are interested in improving the health and well-being of children served by child welfare who remain in-home. The study provides evidence-based recommendations for improving care coordination for these children, specifically through the implementation of nurse care coordination programs like the Child and Family Nurse Program (CFNP). The study also provides insights into the strengths and weaknesses of the CFNP and the study design, which may be useful for policymakers and child welfare agency leaders who are considering implementing similar programs or conducting similar evaluations. Additionally, the study may be of interest to healthcare providers and researchers who are interested in improving the health outcomes of vulnerable populations.

Sample Size: The study included a sample of 304 families referred to the Child and Family Nurse Program (CFNP) during the study period. Of these, 297 families were eligible for the study.

Age Range: The study did not focus on a specific age range, but rather on families of children with medical needs known to child welfare who remain in-home. The index child in the study was on average 5.2 years of age, but the study did not exclude families based on the age of the child. Therefore, the age range of the children in the study is likely to be broad, ranging from infants to adolescents.

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visits, Care Coordination,

Intervention Description: The specific intervention involves a multidisciplinary team providing comprehensive home-based primary care for children with medical complexity. The program includes routine examinations, urgent sick visits, vaccinations, and coordination with subspecialists, as well as addressing the families’ psychosocial needs. The physicians provide primary care in the home if the patients live within the catchment area; otherwise, they are seen in the office. The intervention described in the PDF file aligns with a discernable strategy of providing comprehensive home-based primary care for children with medical complexity. The program involves a multidisciplinary team that includes physicians, social workers, and care coordinators who work together to provide care in the home setting. The PDF file describes a retrospective analysis of data collected from the program, which includes information on demographics, clinical characteristics, and health care use. The study analyzes the impact of the program on health care use and costs, and examines the association between the time-dependent post-enrollment health care use and numbers of home visits. Therefore, it is a study that analyzes a multicomponent intervention.

Intervention Results: We reviewed data collected from 121 patients. With our findings, we demonstrate that enrollment in our program is associated with reductions in average length of stay. More home visits were associated with decreased emergency department visits and hospitalizations. We also observed in patients with available cost data that total costs of care decreased after enrollment into the program.

Conclusion: Our model has the potential to improve health outcomes and be financially sustainable by providing home-based primary care to CMC.

Study Design: The study design of the multidisciplinary home visiting program for children with medical complexity is primarily retrospective in nature. The researchers reviewed medical records from their institution for patients enrolled in the program from July 2013 through March 2019. The study involved a retrospective analysis of data collected from the program, including demographics, clinical characteristics, health care use, and total costs of care for a subset of patients. The analysis included comparisons of pre- and post-program enrollment health care use, as well as the examination of the association between post-enrollment health care use events and numbers of home visits. Additionally, the study applied Cox proportional hazard models to examine the association between home visits and specific health care use outcomes, while adjusting for clinic visits and corresponding pre-enrollment health care use. Overall, the study design involves the retrospective analysis of data collected from the multidisciplinary home visiting program to assess its impact on health care utilization, costs, and the association between home visits and health care use events.

Setting: The study setting for the multidisciplinary home visiting program for children with medical complexity is a general pediatrics clinic in a large tertiary academic hospital located in an urban setting. The clinic serves nearly 9000 unique patients annually, with a population that is 87% Medicaid covered and primarily low-income. The clinic's patient population often experiences psychosocial complexity and barriers that limit their ability to access high-quality health care. The program was initiated as part of a Patient-Centered Medical Home demonstration project and has evolved to focus predominantly on children with medical complexity, providing both home and office-based care through a multidisciplinary team. Additionally, the program includes a complex care clinic within the physical space of the general pediatrics clinic to access the same multidisciplinary team, providing care that follows the program model, including extended appointment times, multidisciplinary support, and coordination with subspecialty appointments when possible.

Population of Focus: The target audience for the study of the multidisciplinary home visiting program for children with medical complexity includes healthcare providers, policymakers, and researchers interested in improving care for children with medical complexity (CMC). The study provides insights into the development, structure, and outcomes of a home-based primary care program for CMC, which can inform the design and implementation of similar programs in other settings. Additionally, the study highlights the challenges faced by families of CMC in accessing high-quality care and navigating the complex healthcare system, which can inform policy discussions around improving care coordination and access for this population. Finally, the study provides evidence of the effectiveness of a multidisciplinary home visiting program for CMC, which can inform future research on innovative models of care for this population.

Sample Size: The sample size for the study of the multidisciplinary home visiting program for children with medical complexity includes 121 patients enrolled in the program from July 2013 through March 2019. This sample size represents the cohort of children with medical complexity (CMC) included in the analysis. The study focuses on this cohort to assess the impact of the program on health care utilization, costs, and the association between home visits and health care use events.

Age Range: The study focuses on children with medical complexity (CMC), and the age range of the patients enrolled in the program is not explicitly stated in the PDF file. However, the study mentions that the median age at enrollment was 5.0 years, indicating that the program primarily serves children and young adolescents. Additionally, the study notes that the program enrolled 121 patients as CMC, and another 99 patients as high-risk newborns. Therefore, while the age range of the patients is not explicitly stated, the program appears to primarily serve children and young adolescents with medical complexity.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Home Visits, Prenatal Care Access,

Intervention Description: The intervention was a telephonic perinatal care coordination program that included risk assessment, patient education, coordination of care for home services and clinic appointments, coordination of interventions requested by care providers, and patient advocacy. The program was based on best management practices and agreed-upon methods of patient care delivery developed by a panel of experts organized by the Case Management Society of America (CMSA). The program was designed to improve both clinical and financial outcomes for low-income, high-risk pregnant women, particularly those from minority cultural and racial backgrounds

Intervention Results: The intervention was a telephonic perinatal care coordination program that included risk assessment, patient education, coordination of care for home services and clinic appointments, coordination of interventions requested by care providers, and patient advocacy. The program was based on best management practices and agreed-upon methods of patient care delivery developed by a panel of experts organized by the Case Management Society of America (CMSA). The program was designed to improve both clinical and financial outcomes for low-income, high-risk pregnant women, particularly those from minority cultural and racial backgrounds

Conclusion: The study concluded that the telephonic perinatal care coordination program led to increased mean birth weights for the treatment group when intervening variables were controlled. However, the mean gestational age at delivery was not significantly different between the treatment and control groups. Additionally, the program resulted in cost savings, with an average of $501.31 saved per patient in inpatient and outpatient costs combined. The study suggested that the telephonic case management model could be used with other populations to obtain similar results, indicating its potential for broader application

Study Design: The study utilized a quasi-experimental design, with a treatment group and a control group. The treatment group received the telephonic perinatal care coordination program, while the control group received standard care. The study aimed to evaluate the impact of the intervention on pregnancy outcomes for low-income, high-risk pregnant women

Setting: The study was conducted in two large obstetric clinics and a level-3 tertiary care center in Minneapolis, Minnesota, USA .

Population of Focus: The target audience for the study was low-income, high-risk pregnant women, particularly those from minority cultural and racial backgrounds , . The program aimed to demonstrate the value of telephonic perinatal case management for this specific population by improving both clinical and financial outcome

Sample Size: The initial number of participants in the treatment group was 64, and the number of participants in the control group was 59. However, due to the exclusion of twin gestations, the total of singleton pregnancies included in the analysis was 111, with 50 in the control group and 61 in the treatment group

Age Range: The age range of the participants was not explicitly stated in the study. However, the study did report that almost one in ten participants were age 19 or younger, and nearly one in ten were age 35 or older

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner, Technology-Based Support,

Intervention Description: The purpose of this study was to explore health-related quality of life (HRQL) and family impact in the context of an advanced practice registered nurse-delivered telehealth care coordination intervention for children with medical complexity (CMC). This was a secondary outcomes analysis of a randomized controlled trial with 163 families of CMC in an existing medical home. HRQL and family impact were measured using the PedsQL measurement model.

Intervention Results: Significant predictors of Year 2 child HRQL were baseline HRQL and the presence of both neurologic impairment and technology dependence. There was no significant intervention effect on child HRQL or family impact after 24 months.

Conclusion: Care coordination interventions for CMC may need to incorporate family system interventions for optimal outcomes in a range of quality of life domains.

Study Design: 163 children and their parental caregivers

Setting: A Special Needs Program certified in the Minnesota Health Care Homes Program (medical home for children with medical complexity)

Population of Focus: Children with medical complexity and their parental caregivers. To be eligible for the study, the identified child had to meet at least four of five Children with Special Health Care Needs (CSHCN) Screener criteria, which include the need or use of prescription medications, above routine use of health care services, a functional limitation, need or use of specialized therapies or services, and treatment or counseling for a developmental or behavioral problem.

Age Range: Children aged 2-15 years and their parental caregivers

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner, Shared Plans of Care

Intervention Description: To address the problem and alleviate burden for families, the Comprehensive Cerebral Palsy Program implemented a nurse‐led comprehensive interdisciplinary team approach to provide optimal care coordination to patients and families, using an Integrative Holistic Care Plan (IHCP). During an annual 3–4 hour Comprehensive CP Clinic appointment, a team of specialists meets with the family, and a holistic, evidence‐based plan of care is developed. The family‐centered care plan includes summaries of each discipline's plan of care with individualized goals, recommendations, and evidence‐based outcomes. After the visit, the plan of care is communicated with the family, primary care provider, and other community provi- ders to ensure continuity of care.

Intervention Results: Early in the program and electronic IHCP development stage, clinical, and financial outcomes were improved. In addition to significant cost savings, family satisfaction surveys showed continuous improvement in the areas of access, com- munication, and coordination of care.

Conclusion: Overall, the quality, effectiveness, and efficiency of care in the Comprehensive Cerebral Palsy Program, using the Integrative Holistic Care Plan, has resulted in improving health outcomes, decreasing cost, and increasing satisfaction of our CP patient population with complex needs. The data on reduced healthcare utilization, and improved family satisfaction support this conclusion. Based on the program success, additional state level funding to further enhance care coordination services and to formalize collaborations with Public Health Nurses from our catchment area was awarded and the program achieved NCQA Patient Centered Specialty Care Recognition.

Study Design: The article does not describe a specific research study with a traditional study design. Instead, it presents an original article detailing the development and implementation of an intervention, the Integrative Holistic Care Plan (IHCP), in the context of the Comprehensive Cerebral Palsy Program. The article discusses the implementation of the nurse-led comprehensive interdisciplinary team approach to provide optimal care coordination to patients and families, using the IHCP. Therefore, the article focuses on the description and outcomes of the implemented intervention rather than a traditional research study design.

Setting: Comprehensive Cerebral Palsy Program, Nationwide Children's Hospital, Columbus, Ohio

Population of Focus: The target audience for the study includes healthcare professionals, particularly those working in interdisciplinary clinics and caring for children and adults with cerebral palsy. This may include nurses, physicians, therapists, social workers, and other providers involved in the care of individuals with cerebral palsy. Additionally, the study may be of interest to healthcare administrators and policymakers involved in the development and implementation of care coordination programs for individuals with complex healthcare needs.

Sample Size: We have previously reported on the initial experience of 131 patients who received care in the Comprehensive CP Program during the first year of operation.

Age Range: The article does not describe a specific study with a defined age range but does appear to be child focused.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Shared Plans of Care

Intervention Description: The shared plan of care (SPoC) intervention described in the study is a care coordination tool designed to support children with special healthcare needs (CSHCN) and their families. The SPoC is a comprehensive care coordination document that focuses on patient and family goal setting. It is stored on an accessible, secure platform where healthcare information for CSHCN can be accessed by providers as well as families.

Intervention Results: Our results showed a decrease in primary care visits, hospitalizations, and ED visits for CSHCN after SPoC implementation, though only primary care visits reached significance. Mental health care visits were specifically found to decrease by 39% following employment of SPoC.

Conclusion: The use of SPoCs in CSHCN had a positive impact on healthcare utilization suggesting widespread use of this tool improved care coordination in this population.

Study Design: The study design is a retrospective observational study. The study analyzed data collected from electronic medical records (EMR) of children with special healthcare needs and mental health conditions who were seen in the Division of Child and Community Health’s Regional Centers in 2016. The study compared healthcare utilization outcomes before and after the implementation of shared plans of care (SPoC) as a care coordination tool. The study used statistical analysis to evaluate the impact of SPoC implementation on healthcare utilization outcomes, including the number of inpatient hospitalizations, emergency department visits, and primary care and outpatient psychiatry visits.

Setting: The setting for the study was the Division of Child and Community Health’s Regional Centers in Iowa.

Population of Focus: Who is the target audience for the study?

Sample Size: The study included a total of 15 subjects in the analysis.

Age Range: The study included children less than 18 years of age.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The study objective was to characterize the feasibility, acceptability, and short-term efficacy of a protocolized transition navigator (TN) intervention in AYA with SCD.

Intervention Results: Ninety-three percent (56/60) of enrolled individuals completed the intervention. Participation in the TN program was associated with significant improvement in mean transition readiness scores (3.58-4.15, P < .0001), disease knowledge scale (8.91-10.13, P < .0001), Adolescent Medication Barriers Scale (40.05-35.39, P = .003) and confidence in both disease (22.5-23.96, P = .048) and pain management (25.07-26.61, P = .003) for youth with SCD.

Conclusion: The TN intervention was acceptable to youth with SCD, feasible to implement at an urban academic medical center, and addressed barriers to transition identified by the youth. Longer-term assessment is needed to determine if the TN intervention improved successful transfer to and retention in adult care.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner,

Intervention Description: The intervention described in the article to increase care coordination for children is the key worker role in children's cancer care. The key worker is a designated healthcare professional who acts as a consistent point of contact for families throughout the cancer trajectory, providing support, information, and coordination of care. The key worker is responsible for facilitating communication between healthcare professionals and families, coordinating care across different healthcare settings, and providing emotional support to families.

Intervention Results: Participants included: 22 nurse specialist key workers, 103 parents, 85 professionals and 10 children/young people. Qualitative and quantitative data were woven together, to best illuminate key worker services. Four main models of care were described as well as the context of care and process of care. Key working effectiveness centred around three pillars: care coordination; expert knowledge, experience and expertise; relationship. These were essential to improved family experience, emotional wellbeing, and delivery of individualized care closer to home.

Conclusion: Our findings support the notion that key working effectiveness was dependent upon three pillars: coor- dination; knowledge, expertise and experience; and relationship. But in certain conditions, such as a varia- tion in context, this placed limits on enacting the three pillars, and the positive experience of the family was diminished. When they worked well, key worker roles reduced the fragmented nature of services, families placed a great value on their role, wanting to retain the same key worker from diagnosis, beyond treatment into long-term care. Retaining these roles, where they are already in place, or including, if not, we would highly recommend, factoring into budgets to sustain such roles. Service need influenced the type of key worker model in place, our findings enrich these models, and evidence the importance of clinical teams describing what is needed for their patients, in terms of coordination, consistency and continuity in care. Variations in model delivery should be wel- comed, but need to be evaluated, to ensure patient outcomes, patient experience, and equity of access to services remains.

Study Design: This project carried out an evaluation using case studies: specifically, an “intrinsic” case study, where the case itself was the key worker role. Other participants (parents, children, young people, and professionals) were linked to each case and their practice. Case study research takes a holistic approach (it considers the case within its context) and is characterized by a convergence of diverse sources of data, which provide a means of considering the multiple elements likely to shape and influence the case, in this context the key worker role. To understand and reveal complexities of the case, we collected multiple sources of data that centre on the key workers’ role. Reporting of findings followed the Good Reporting of a Mixed-methods Study (GRAMMS) guidelines. The GRAMMS checklist is available as a supplementary file.

Setting: The study was conducted across principal treatment centers for children with cancer in England, Wales, and Scotland.

Population of Focus: The target audience for the study includes healthcare professionals, policymakers, and researchers involved in the treatment and care of children with cancer.

Sample Size: The sample size for this study included 103 parents, 10 children/young people, 22 key workers, and 85 professionals from various healthcare roles who worked closely with the key worker and families across different sites. Additionally, 31 individual interviews and 12 focus group interviews were conducted as part of the data collection process.

Age Range: young people under the age 16 years.

Intervention Components (click on component to see a list of all articles that use that intervention): Access, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE, COMMUNITY, Collaboration with Local Agencies (Health Care Provider/Practice)

Intervention Description: N/A

Intervention Results: Although most US adolescents had a usual source of care (91%), only about one-half (51%) had access to a PCMH. Disparities in the prevalence of PCMHs were seen by race/ethnicity, poverty, and having special health care needs. There were lower adjusted odds in having a PCMH for Hispanic (aOR, 0.56; 95% CI, 0.45-0.68) and black adolescents (aOR, 0.55; 95% CI, 0.46-0.66) compared with white adolescents. Those living below 4 times the poverty level had lower adjusted odds of PCMH access. Adolescents with 3-5 special health care needs had lower adjusted odds (aOR, 0.43; 95% CI, 0.35-0.52) of having a PCMH compared with adolescents without any special health care needs. Other than receiving family centered care, every component of PCMH was slightly lower in 2011-2012 compared with 2007.

Conclusion: PCMH access was lower among minorities, those living in poverty, and those with multiple special health care needs. These disparities in PCMH access among these typically underserved groups call for further study and interventions that would make PCMHs more accessible to all adolescents.

Study Design: Data on adolescents ages 12-17 years (n = 34 601) from the 2011-2012 National Survey of Children's Health were used in this cross-sectional study to determine what proportion had access to a PCMH. Multivariable logistic regression was used to calculate the odds of having a PCMH, adjusting for sociodemographic characteristics and special health care needs. Comparisons were made to distribution of PCMH in 2007.

Setting: NSCH survey; United States

Population of Focus: Adolescents

Sample Size: 34601

Age Range: 12/17/2024

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner,

Intervention Description: The intervention described in this study is the integration of nurse care managers into the medical home setting for children with special health care needs (CSHCN) . The nurse care managers were responsible for coordinating care for CSHCN, including providing education and support to families, facilitating communication between healthcare providers, and ensuring that patients received appropriate and timely care. The nurse care managers worked closely with pediatric house staff and attending faculty to provide comprehensive care for CSHCN.

Intervention Results: Three medical home-based nurse care managers were integrated into four pediatric hospital affiliated practices in a large, urban center. The number of ED visits and inpatient admissions were statistically significantly decreased post-intervention (p < 0.05).There was also a decrease in the number of subspecialty visits, but it was close to the threshold of significance (p = 0.054). There was no impact noted on primary care visits.

Conclusion: This quality improvement project demonstrates that nurse care managers who are integrated into the medical home of CSHCN can potentially decrease the utilization of ED visits and hospital admissions as well as subspecialty visits.

Study Design: The study utilized a quality improvement project design to evaluate the impact of integrating nurse care managers into the pediatric medical home for children with special health care needs (CSHCN) . The project evaluated the health care utilization for primary care, subspecialty care, emergency department visits, and inpatient care using a pre- and post-intervention design. The study compared the number of visits before and after the integration of nurse care managers to assess the impact on healthcare utilization.

Setting: The setting for the study was the Ambulatory Care Network at NewYork-Presbyterian Hospital.

Population of Focus: The target audience for the study is healthcare providers, policymakers, and researchers who are interested in improving care coordination for children with special health care needs (CSHCN) in the medical home setting. The study's findings may be of particular interest to healthcare providers and policymakers who are involved in the care of CSHCN and are looking for strategies to improve care coordination and reduce healthcare costs. Additionally, researchers interested in quality improvement projects and interventions to improve care for CSHCN may find the study's methodology and results informative.

Sample Size: The study involved 673 children who received longitudinal care coordination support from nurse care managers in the pediatric medical home.

Age Range: The study did not specify a specific age range for the children with special health care needs (CSHCN) who received care coordination support from nurse care managers in the pediatric medical home. However, the study did report the mean age of the population subsets for inpatient, ED, outpatient medical home, and outpatient subspecialty visits, which was 8 years.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Care Coordination, Nurse/Nurse Practitioner,

Intervention Description: There is a rising number of children with special health care needs (CSHCN) in the pediatric medical home anThis quality improvement project evaluated the impact on CSHCN of the integration of nurse care managers in the pediatric medical home. From October 2015 through February 2019, 673 children received longitudinal care coordination support from a care manager. Health care utilization for primary, subspecialty, emergency department (ED) and inpatient care was reviewed using pre and post design.d their care coordination is complicated and challenging. We aimed to integrate nurse care managers to coordinate care for such patients, and then evaluate, if this improved health care utilization.

Intervention Results: Three medical home-based nurse care managers were integrated into four pediatric hospital affiliated practices in a large, urban center. The number of ED visits and inpatient admissions were statistically significantly decreased post-intervention (p < 0.05).There was also a decrease in the number of subspecialty visits, but it was close to the threshold of significance (p = 0.054). There was no impact noted on primary care visits.

Conclusion: This quality improvement project demonstrates that nurse care managers who are integrated into the medical home of CSHCN can potentially decrease the utilization of ED visits and hospital admissions as well as subspecialty visits.

Study Design: Pre-post study

Setting: Four pediatric hospital-affiliated practices in a large, urban center in the United States

Population of Focus: Children with special health care needs who were enrolled in the four pediatric hospital-affiliated practices in a large, urban center in the United States

Sample Size: 673 patients who received the nurse care manager intervention across the four medical homes

Age Range: CYSHCN 0-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Shared Plans of Care

Intervention Description: The intervention described in the study involved a care coordination model using a family-centered, goal-oriented Shared Plan of Care (SPoC) with a cohort of children with complex neurodevelopmental disorders. The intervention included previsit assessments, planned care visits, SPoC development, and 6-month care coordination. The study aimed to explore family outcomes associated with the implementation of this care coordination/SPoC intervention.

Intervention Results: empowerment, and worry. Times 1 and 2 survey data were collected from a total of 70 families. Results: Analysis shows significant improvement in care coordination access, SPoC use, goals achieved, needs met, family empowerment, and reduced worry. There was no significant change in family-professional partner- ships and reported SPoC use.

Conclusion: Findings provide preliminary evidence that a care coordination model using a family-centered, goal-oriented SPoC is a feasible and effective approach with a cohort of children with complex neurodevelopmental disorders and is associated with improved family outcomes. Replication studies are warranted and should include a control group, prolonged time period, additional validated outcome measures, and measurement of costs and professional impact.

Study Design: The study utilized a pre-post intervention design to evaluate the effects of a care coordination intervention with children with neurodevelopmental disabilities and their families. This design involved collecting data from participants at two time points: Time 1 and Time 2, allowing for the assessment of changes before and after the intervention.

Setting: The study was conducted in a children's hospital ambulatory care setting in Indiana.

Population of Focus: The target audience for the study includes healthcare professionals, researchers, and organizations involved in the care of children with neurodevelopmental disabilities and their families. Additionally, policymakers and stakeholders interested in improving care coordination and outcomes for children with complex neurodevelopmental disorders may also find the study relevant and informative.

Sample Size: The final study sample included 70 participants with complete data at Times 1 and 2

Age Range: These participants were children aged 2 to 10 years.

Intervention Components (click on component to see a list of all articles that use that intervention): Pediatric to Adult Transfer Assistance, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To evaluate the impact of structured transition from pediatric to adult inflammatory bowel disease (IBD) services on objective patient outcomes, including disease flares, admission rates, and healthcare resource use.

Intervention Results: A total of 129 patients were included: 95 transition patients and 34 non-transition patients. In the 12 months post-index visit, transition patients had fewer disease flares (P = 0.05), were more likely to be steroid-free (71% vs 41%, P < 0.05), and were less likely to have an emergency department visit leading to hospital admission (5% vs 18%, P < 0.05). During this period, the mean estimated overall cost of care per patient was £1644.22 in the transition group and £1827.32 in the non-transition group (P = 0.21).

Conclusion: Structured transition from pediatric to adult IBD care services was associated with positive and cost-neutral outcomes in patients with pediatric IBD.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner, Technology-Based Support,

Intervention Description: A quality improvement project assessed the gaps in care, identified high-risk patients, and developed a novel pediatric trauma care coordinator (PTCC) nursing position to bridge the gap.

Intervention Results: In the 12-month preimplementation period, 14 patients had a costly return to health care (CRH) rate of 14%, compared with the 12-month postimplementation period in which 18 patients had a CRH rate of 0%. Patients received a mean of 21.2 communication events and 14.1 intervention events from the PTCC in the postimplementation period.

Conclusion: The novel PTCC nursing position has addressed a critical gap in the recovery of severely injured children at this pediatric trauma center. A nurse seems to be the ideal type of provider for this position due to the trust relationship with families linked to the medical knowledge to communicate efficiently and effectively with the other providers. The utilization of the existing trauma registry provides a cost-effective tool to collect enhanced outcome data for ongoing quality assessment. The general application of the program to other centers is difficult to determine as local resources vary between pediatric trauma centers. Value assessment and durability of the impact on CRH warrant further investigation.

Study Design: The study is described as a quality improvement project, which indicates that it focuses on implementing and evaluating changes in a healthcare setting to improve patient care and outcomes.

Setting: The setting for the study was a pediatric trauma center. The study was conducted in a single institution, and the pediatric trauma program was developed within this institution.

Population of Focus: The target audience for the study includes healthcare professionals involved in pediatric trauma care, such as trauma nurses, trauma coordinators, pediatric surgeons, and other healthcare providers working in pediatric trauma centers. Additionally, the study may be of interest to hospital administrators, quality improvement professionals, and researchers in the field of pediatric trauma care.

Sample Size: In the 12-month preimplementation period, 14 patients had a CRH rate of 14%, compared with the 12-month postimplementation period in which 18 patients had a CRH rate of 0%.

Age Range: The study does not specify an age range for the pediatric trauma patients included in the program.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Mobile Programs,

Intervention Description: The intervention involved the implementation of mobile complex care plans (MCCPs) for children with medical complexity (CMC) enrolled in a complex care program. The MCCPs were individualized, updated quarterly, integrated within the electronic health record (EHR), and made accessible to parents through an online patient portal (OPP) on their mobile devices.

Intervention Results: The results of the study "Mobile Complex Care Plans to Enhance Parental Engagement for Children With Medical Complexity" are as follows: 1. Feasibility: a) In the one-year study period from September 1, 2016, to August 31, 2017, 94% of eligible patients (n = 47) received 162 mobile complex care plans (MCCPs). b) Seventy-four percent of parents (n = 35) reviewed MCCPs online, indicating a high level of engagement with the care plans. c)Forty-six percent of parents who reviewed MCCPs (n = 16) sent a follow-up message, and the care team responded within a median time of 7.2 hours, demonstrating timely communication between the care team and parents. 2. Parental Engagement and Experience: a) In qualitative interviews, parents identified MCCPs as an important reference and communication tool that improved their understanding of their child's overall medical situation. b) The MCCPs were perceived as facilitating parental engagement and delivering timely communication with the care team, as reported by the parents. 3. Care Coordination: The study demonstrated that integration of MCCPs into care coordination for children with medical complexity (CMC) was feasible and facilitated parental engagement. Overall, the study findings indicated that mobile complex care plans (MCCPs) for CMC in a complex care program were feasible, facilitated parental engagement, and delivered timely communication. The MCCPs were perceived as important reference and communication tools by parents, contributing to improved understanding of their child's medical situation and enhancing care coordination.

Conclusion: As the CMC population grows and their care coordination needs further intensify, care plans will play an increasingly vital role to prevent key information from “falling through the cracks.” As care plans are more widely implemented, complex care programs will need an efficient approach that engages parents. By fully leveraging the EHR and OPP, our novel MCCPs offer the potential for care plans to fulfill their promise of being a patient-centered, dynamic, and comprehensive blueprint for CMC, their parents, and their care team.

Study Design: The study utilized a mixed methods design. It combined quantitative and qualitative approaches to evaluate the feasibility and impact of mobile complex care plans (MCCPs) for children with medical complexity (CMC) enrolled in a complex care program. The quantitative aspect of the study involved assessing the prevalence of home Internet and computer/mobile device access among parents of CMC enrolled in the Complex Care Service (CCS) program. Additionally, the study quantified the utilization of MCCPs by eligible patients and the level of parental engagement with the MCCPs. The qualitative component of the study involved conducting interviews with parents to gain insights into their experiences with MCCPs and to understand the impact of MCCPs on parental engagement, parent experience, and care coordination. The qualitative interviews provided additional depth and context to complement the quantitative data analysis, allowing for a comprehensive understanding of the intervention's effects on the target population.

Setting: The setting for the study described in this article was a complex care program for children with medical complexity (CMC) in Durham, North Carolina.

Population of Focus: The target audience for the study includes healthcare professionals and researchers involved in the care of children with medical complexity (CMC), particularly those working in complex care programs or similar settings. Additionally, the study findings may be of interest to professionals involved in care coordination, pediatric healthcare technology, and patient engagement. Furthermore, the study's focus on mobile health innovations and their impact on parental engagement and care coordination suggests that professionals in the fields of mobile health, digital health, and health informatics may also find the research relevant.

Sample Size: The sample size for the study was 50 participants. All participants were children with medical complexity (CMC) enrolled in the Complex Care Service (CCS) program in Durham, NC. The study used structured criteria to identify high-need, high-cost patients to receive mobile complex care plans (MCCPs) as part of the intervention. Of the 50 participants, 47 were eligible to receive MCCPs, and 94% of those eligible received MCCPs during the one-year study period. The study also included qualitative interviews with parents of eligible participants to gather insights into their experience with MCCPs.

Age Range: 0.4 to 18.5 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Transition Assistance, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: This study evaluated the services delivered within a care coordination program at a transition consultation center for CSHCN. It also compared the advancement of youth by age group toward graduation criteria.

Intervention Results: The comparison of services for those with diagnoses of autism spectrum disorder, cerebral palsy and Down syndrome were uniformly high in supporting primary care and health care financing. Medicaid waiver assistance was provided more frequently to younger adolescents while older adolescents more commonly received support in all other graduation criteria, including primary and specialty care, healthcare financing and decision-making supports.

Conclusion: Youth served in a transition care coordination program receive a high volume and broad array of services. There are some variations in the types of services by diagnosis and level of support need. Older youth show greater advancement toward graduation criteria. Practice implications: This in-depth chart review provides a valuable description of the activities of care coordinators serving CSHCN enduring transition. It enables development of targeted strategies for building care coordination programming and sets an example for the design of future research studies on this topic.

Intervention Components (click on component to see a list of all articles that use that intervention): , Care Coordination

Intervention Description: Importance: Children with medical complexity (CMC) frequently experience fragmented care. We have demonstrated that outpatient comprehensive care (CC) reduces serious illnesses, hospitalizations, and costs for high-risk CMC. Yet continuity of care for CMC is often disrupted with emergency department (ED) visits and hospitalizations. Objective: To evaluate a hospital consultation (HC) service for CMC from their outpatient CC clinicians. Design, setting, and participants: Randomized quality improvement trial at the University of Texas Health Science Center at Houston with an outpatient CC clinic and tertiary pediatric hospital (Children's Memorial Hermann Hospital). Participants included high-risk CMC (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrolling in our clinic) receiving CC. Data were analyzed between January 11, 2018, and December 20, 2019. Interventions: The HC included serial discussions between CC clinicians, ED physicians, and hospitalists addressing need for admission, inpatient treatment, and transition back to outpatient care. Usual hospital care (UHC) involved routine pediatric hospitalist care. Main outcomes and measures: Total hospital days (primary outcome), PICU days, hospitalizations, and health system costs in skeptical bayesian analyses (using a prior probability assuming no benefit).

Intervention Results: From October 3, 2016, through October 2, 2017, 342 CMC were randomized to either HC (n = 167) or UHC (n = 175) before meeting the predefined bayesian stopping guideline (>80% probability of reduced hospital days). In intention-to-treat analyses, the probability that HC reduced total hospital days was 91% (2.72 vs 6.01 per child-year; bayesian rate ratio [RR], 0.61; 95% credible interval [CrI], 0.30-1.26). The probability of a reduction with HC vs UHC was 98% for hospitalizations (0.60 vs 0.93 per child-year; RR, 0.68; 95% CrI, 0.48-0.97), 89% for PICU days (0.77 vs 1.89 per child-year; RR, 0.59; 95% CrI, 0.26-1.38), and 94% for mean total health system costs ($24 928 vs $42 276 per child-year; cost ratio, 0.67; 95% CrI, 0.41-1.10). In secondary analysis using a bayesian prior centered at RR of 0.78, reflecting the opinion of 7 experts knowledgeable about CMC, the probability that HC reduced hospital days was 96%.

Conclusion: Among CMC receiving comprehensive outpatient care, an HC service from outpatient clinicians likely reduced total hospital days, hospitalizations, PICU days, other outcomes, and health system costs. Additional trials of an HC service from outpatient CC clinicians are needed for CMC in other centers.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Referrals, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER, Telephone Support

Intervention Description: Children ages 12 to 42 months old who receive well-child care at a community health center serving predominantly Hispanic families were recruited and randomly assigned to intervention and control groups. Families in the intervention group were connected with 2-1-1, in which a trained care coordinator conducted developmental screening over the phone using the Parental Evaluation of Development Status Online system and made referrals to intervention services on the basis of developmental risk. The 2-1-1 care coordinator then followed-up with families to assist with connections to evaluations and services.

Intervention Results: One hundred and fifty-two children were randomly assigned to intervention (n = 77) and control (n = 75) groups. On the basis of intention-to-treat analyses, significantly more children assigned to the intervention group were referred (32% vs 9%; P = .001) and were receiving services (16% vs 1%; P = .002) within 6 months compared with children assigned to usual care alone.

Conclusion: Telephone-based developmental screening and care coordination through 2-1-1 appears to be an effective approach for increasing the numbers of young children referred to, and receiving, intervention services for developmental delays.

Setting: Community-based

Population of Focus: Children and families

Intervention Components (click on component to see a list of all articles that use that intervention): Integration into Adult Care, Transition Assistance, Care Coordination, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: In 2018, we initiated a transition clinic structure, integrating an Internal Medicine - Pediatrics trained Adult Rheumatologist in a Pediatric Rheumatology clinic to guide this transition. Our goal was to improve transition outcomes. We report the methods of this clinic and its preliminary outcomes.

Intervention Results: The transition clinic Adult Rheumatologist saw 177 patients in 2 years, and 57 patients were eligible for, approached, and successfully enrolled in the registry. From this registry, all patients reviewed the Transition Policy with the Adult Rheumatologist and 45 (78.9%) completed at least one Transition Readiness Assessment. Of the 22 patients for whom transition was indicated, all were successfully transitioned to an Adult Rheumatologist. 17 (77.3%) continued care post-transition with the transition clinic Adult Rheumatologist, and 5 (22.7%) continued care post-transition with a different Adult Rheumatologist. The median time between the last transition clinic visit and first Adult clinic visit was 5.1 months.

Conclusion: Our results are an improvement over transition rates reported elsewhere that did not implement our model. We believe that this structure could be applied to other primary care and subspecialty clinics.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Community Health Workers (CHWs),

Intervention Description: The Coordination of Healthcare for Complex Kids (CHECK) program is a healthcare innovation project designed as a quality improvement project to provide comprehensive care coordination in children insured by Illinois Medicaid with chronic disease. The CHECK model consisted of community health workers (CHWs) supported by pediatricians, subspecialists, behavioral health providers, and legal experts. All were focused on helping families navigate the complex healthcare system. This design provides an opportunity to investigate the effectiveness of CHWs integrated with the healthcare system (29–32).

Intervention Results: Children engaged in CHECK were more likely to be female (p=.046) and to identify as Black and/or Hispanic/Latino than enrolled-only children. School absence was not different between the groups. Average total cost for engaged children was 21.3% more than enrolled-only children the first year (p=.027) but did not differ by the second year (p=.948). At baseline, 68.1% of the cohort had at least one ED visit 12 months prior to CHECK, this reduced to 49.5% post-1 and 41.9% post-2. Engaged children were 21% more likely to visit an ED (p=.010) and 40% more likely to have a controller.

Conclusion: CHECK program receipt was associated with improved healthcare utilization and controller prescriptions. School attendance did not change. The CHECK model offers potential pathways to support low-income children with asthma.

Study Design: The study design is a retrospective analysis of the Coordination of Healthcare for Complex Kids (CHECK) program, which ran from December 1, 2014, through August 31, 2017. The study used healthcare utilization claims data from Illinois Medicaid to evaluate the impact of the CHECK program on school absence, healthcare utilization, asthma prescriptions, and cost in low-income school-aged children with asthma. The study also assessed whether the amount of community health worker (CHW) services received was associated with changes in outcomes.

Setting: The study was conducted in Chicagoland, which includes vulnerable communities in Chicago, Illinois. The CHECK program was housed at the University of Illinois at Chicago

Population of Focus: he target audience for the study includes healthcare professionals, policymakers, researchers, and organizations involved in pediatric asthma care coordination, health disparities, and health equity initiatives. The study's findings and lessons learned are relevant to those interested in improving pediatric asthma outcomes and addressing health disparities in vulnerable populations.

Sample Size: The sample size of the study included a total of 2,668 children with asthma who were enrolled in the CHECK program. Among them, 1,701 children were classified as having a medium baseline risk, and 185 children had a high baseline risk. The sample size reflects a diverse cohort of varying severity and control of asthma, including children with other chronic conditions.

Age Range: The study included patients who were 0-25 years old and insured by Illinois Medicaid. However, for this analysis, the CHECK cohort was limited to school-aged children (K-12) attending Chicago Public Schools

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Training (Parent/Family), Nurse/Nurse Practitioner,

Intervention Description: Hospital discharge offers an opportunity to initiate coordination of follow-up care, preventing readmissions or emergency department (ED) recidivism. We evaluated how revisits and costs of care varied in a 12-month period between children in a care coordination program at our center (enrolled after hospital discharge with a tracheostomy or on a ventilator) and children with complex chronic condition discharges who were not enrolled.

Intervention Results: Seventy patients in the program were compared with 56 patients in the control group. On bivariate analysis, the median combined number of hospitalizations and ED visits in 2018 was lower among program participants (0 vs 1; P 5 .033), and program participation was associated with lower median total costs of care in 2018 ($700 vs $3200; P 5 .024). On multivariable analysis, care coordination program participation was associated with 59% fewer hospitalizations in 2018 (incidence rate ratio: 0.41; 95% confidence interval: 0.23 to 0.75; P 5 .004) but was not significantly associated with reduced ED visits or costs.

Conclusion: The care coordination program is a robust service spanning the continuum of patient care. We found program participation to be associated with reduced rehospitalization, which is an important driver of costs for children with medical complexity.

Study Design: The study design is a retrospective cohort study. The study aimed to compare the outcomes of children with complex chronic conditions who were enrolled in the C5 program with a similar group of children who were not enrolled in the program. The study used electronic medical records to assess hospital revisits and total costs of care for both groups over a 12-month period. The study also analyzed patient characteristics, including age, gender, race, and insurance status, to compare the two groups.

Setting: The study was conducted at a rural tertiary-care academic medical center in the southeastern United States. The Center for Children with Complex and Chronic Conditions (C5) program was established at this university-affiliated medical center to provide care coordination for children with complex chronic conditions.

Population of Focus: The target audience for the study is healthcare professionals and policymakers who are involved in the care of children with complex chronic conditions. The study provides evidence regarding the effectiveness of a care coordination program for children with complex chronic conditions, which can inform the development of similar programs in other healthcare settings. The study's findings can also be used to guide healthcare policies aimed at improving care coordination for children with complex chronic conditions, particularly in rural areas where access to care may be limited.

Sample Size: The sample size for the study consisted of 70 patients in the C5 program and 56 patients in the control group.

Age Range: The study included children aged under 1-17 years.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Social Supports, Prenatal Care Access,

Intervention Description: The Michigan Plan for Appropriate Tailored Healthcare in Pregnancy (MiPATH) recommendations focused on the appropriateness of key aspects of prenatal care delivery for average-risk pregnant individuals. The interventions and components of prenatal care delivery addressed in the recommendations included: 1. Prenatal Visit Schedules: This involved determining the appropriate timing and frequency of prenatal visits, including care initiation, visit timing and frequency, and routine pregnancy assessments. 2. Integration of Telemedicine: The recommendations provided guidance on the integration of telemedicine, including virtual visits and home devices, into prenatal care delivery for average-risk pregnant individuals.

Intervention Results: The results of the Michigan Plan for Appropriate Tailored Healthcare in Pregnancy (MiPATH) recommendations included the development of more flexible prenatal care delivery for average-risk individuals. The expert panel, consisting of 19 clinicians and researchers, provided recommendations for key aspects of prenatal care delivery, including prenatal visit schedules, integration of telemedicine, and care individualization. The panelists agreed that a risk assessment for medical, social, and structural determinants of health should be completed as soon as individuals present for care. Additionally, the panel provided recommendations for prenatal visit schedules, integration of telemedicine, and care individualization. The recommendations aimed to ensure that individuals are connected to needed services as early as possible and to match individuals' needs to services delivered.

Conclusion: The conclusions of the Michigan Plan for Appropriate Tailored Healthcare in Pregnancy (MiPATH) recommendations highlighted the need for more flexible and individualized prenatal care delivery for average-risk pregnant individuals. The study emphasized the importance of individualizing care, incorporating telemedicine, and considering both medical conditions and social and structural determinants of health in routine care delivery. The MiPATH recommendations were developed to address the limitations of the existing prenatal care guidelines, which have remained largely unchanged since 1930. By providing more flexible prenatal care choices, including options for visit frequency, monitoring plans, and the inclusion of telemedicine, the recommendations aimed to tailor care based on patient preference and needs in consultation with practitioner recommendations. The study also acknowledged the limitations of the recommendations, including the reliance on expert consensus due to the lack of robust evidence in certain areas. Additionally, the panel considered prenatal care delivery in an ideal setting, and the real-world considerations, such as late presentation to care and lack of supporting resources, were recognized as important areas for future research and policy recommendations. The MiPATH recommendations were described as the initial step in an ongoing process, with plans to obtain input from various stakeholders, including patients, professional societies, public health representatives, and payers, to garner diverse perspectives on the new recommendations. Furthermore, ongoing efforts, such as a systematic review by the Agency for Healthcare Research and Quality, were planned to capture additional supporting evidence for key aspects of prenatal care delivery. In conclusion, the MiPATH recommendations aimed to redesign prenatal care to be more effective, efficient, and equitable for pregnant individuals nationwide, taking into account the evolving landscape of prenatal care delivery and the individualized needs of pregnant individuals. ,

Study Design: The Michigan Plan for Appropriate Tailored Healthcare in Pregnancy (MiPATH) recommendations were developed using an appropriateness study design, specifically the RAND Corporation and University of California Los Angeles Appropriateness Method (RAM), which is a modified Delphi process. The appropriateness study involved six phases: 1. Definition and scope of key terms 2. Literature review and data synthesis 3. Case scenario development 4. Expert panel selection, engagement, and scenario revision 5. Expert panel introduction and appropriateness rating (round 1) 6. Expert panel meeting and appropriateness rating (round 2) 7. Expert panel review of findings The goal of the study was to generate recommendations for components of prenatal care delivery across common average-risk pregnancy conditions. The RAM method was selected for this panel because of its rigor, evidence-based methodology, and ability to incorporate existing evidence and expert opinion to arrive at clinical recommendations. The study received institutional review board exemption from the University of Michigan (HUM00188505). The MiPATH recommendations offer more flexible prenatal care delivery for average-risk individuals.

Setting: The Michigan Plan for Appropriate Tailored Healthcare in Pregnancy (MiPATH) recommendations were developed through a panel process using the RAND Corporation and University of California Los Angeles Appropriateness Method. The panel consisted of 19 clinicians and researchers who represented expertise across maternity care, pediatrics, telemedicine, and social and structural determinants of health. The panelists were selected based on their expertise and were not limited to a specific setting. The recommendations were developed for average-risk pregnant individuals (i.e., individuals not requiring care by maternal-fetal medicine specialists) and were not limited to a specific geographic or healthcare setting. The recommendations were developed to be applicable to a wide range of settings and circumstances.

Population of Focus: The target audience for the Michigan Plan for Appropriate Tailored Healthcare in Pregnancy (MiPATH) recommendations includes a diverse group of stakeholders involved in prenatal care delivery, such as: 1. Maternity Care Clinicians: The recommendations provide important guidance for maternity care clinicians, including obstetricians, midwives, and other healthcare professionals involved in prenatal care delivery. 2. Patients: MiPATH plans to obtain input from patients to ensure that their perspectives are considered in the development and implementation of the recommendations. 3. Professional Societies: Input from professional societies is sought to ensure that the recommendations align with established standards and best practices in prenatal care. 4. Public Health Representatives: Involvement of public health representatives is important to ensure that the recommendations address broader public health goals and priorities related to prenatal care. 5. Payers: Input from payers, such as insurance companies and healthcare payers, is sought to ensure that the recommendations align with payment models and reimbursement structures. The goal is to garner diverse perspectives on the new recommendations from a wide range of stakeholders, including patients, professional societies, public health representatives, and payers, to ensure that the recommendations are well-informed and aligned with the needs of various stakeholders involved in prenatal care delivery.

Sample Size: The Michigan Plan for Appropriate Tailored Healthcare in Pregnancy (MiPATH) panel consisted of 19 clinicians and researchers who participated in the development of the recommendations. This panel was selected based on their expertise in maternity care, pediatrics, telemedicine, and social and structural determinants of health. The panelists were involved in a rigorous process using the RAND Corporation and University of California Los Angeles Appropriateness Method to develop the recommendations for prenatal care delivery. The sample size of 19 panelists reflects the expertise and diversity of perspectives involved in the development of the MiPATH recommendations.

Age Range: The panelists involved in the development of the recommendations were clinicians and researchers with expertise in maternity care, pediatrics, telemedicine, and social and structural determinants of health, and their age range is not specified in the published literature.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Patient Navigation, Referrals,

Intervention Description: The first key MHQI strategy was a mental health–social work (MH-SW) electronic referral (Fig 1) through the shared EHR, implemented in September 2014. The electronic referral allows medical providers to make a direct referral to on-site mental health or social work services. The second significant MHQI strategy was a social work follow-up protocol, first implemented in December 2014, which has iteratively evolved over time (Fig 2). This begins with either a warm referral or through accessing the weekly electronic referral report. Then, the social worker communicates with each patient and offers options on the basis of the patient’s needs, which may include referrals to outside resources, care coordination, or brief counseling or therapy within the clinic and assistance with appointment scheduling.

Intervention Results: Rates of patients scheduling first appointments remained steady. First appointment show rates improved from 51% to 78%. Overall use of mental health appointments increased initially then lowered when emphasis shifted to treatment readiness before scheduling. Overall show rates for mental health appointments improved from 67% to 77%.

Conclusion: The electronic referral and social work protocol, along with other collaborative strategies, helped facilitate improved uptake and use of mental health services within an integrated care setting.

Study Design: Quantitative analysis of quality improvement data over 26 months Intervention: Implementation of 1) an electronic referral to mental health and social work services integrated into the electronic medical record; and 2) a social work follow-up protocol to coordinate referrals and assist patients in accessing treatment.

Setting: Adolescent primary care clinic at an academic medical center

Population of Focus: Adolescent patients ages 12-17

Sample Size: Referral and appointment data, sample size not reported

Age Range: 12-17 years old

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Consultation Systems (Hospital), Quality Improvement,

Intervention Description: For more efficient and timelier enrollment into our care coordination program, we created a best practice alert within our electronic medical record to help overcome the challenges in timely identification of CSHCN. The best practice alert has helped us to provide care coordination benefits to our patients earlier in their hospital course. The purpose of this paper is to describe a quality improvement initiative to improve the early identification of CSHCN on hospital admission through the development of a best practice alert.

Intervention Results: The BPA was turned on in May of 2020. The BPA fired 259 times between May 2020 and February 2021. Of the total BPA activations, 22% (57) were accepted by a provider and resulted in a consult for care coordination. On further evalua- tion of the 22% compliant with accepting the BPA, we discovered that many providers were choosing to “snooze” the order or were writing in a comment stating that COC is not applicable for this patient. If the admitting physician “snoozes” the order, this merely suppresses the BPA for that specific provider for 1 hr. If any other providers enter the EMR during that same hour, they are presented with the BPA. If no other providers are in the chart and 1-hr passes, the original provider will see the BPA again once they sign into the patient’s EMR. There is currently no limit to the num- ber of times a BPA can be “snoozed” by a provider. Our aim to achieve timely identification of CSHCN who may benefit from care coordination on admission was only partially met. Compliance of 22% of successful consults for COC after BPA activation suggests an opportunity for improvement in this process. In addition to providing more focused educational opportunities about the importance and benefits of the BPA, discussions with providers to learn about their reasons for not accepting the BPA also needs to occur. Evaluation of the timing of the BPA, number of times allowed to “snooze,” and other operational characteristics of the workflow will be evaluated. We will persist with a goal of initiating care coordination for > 50% of the CSHCN who meet the criteria on admission. Further improvements will be made to reach our quality improvement project goal to expedite care coordination and improve care for CSHCN during the hospital admission process. This quality improvement process which enhanced our current pediatric complexity tool to better identify CSHCN on admission who may require care coordination services through the development of a BPA, will continue to need refinement and evaluation over time. Further development and evaluation of the workbench reports will assist us in understanding additional benefits to connecting appropriate patients with care coordination. For example, analysis of timely enrollment into the program and readmission rate within 30 days is an important aspect to track. Ongoing evaluation and fine-tuning will help identify additional gaps in our care coordination system.

Conclusion: Classifying children with complex medical conditions according to the level of complexity can be complicated. Although experienced care coordination programs may be able to identify some patients who would benefit from these services, creating a complexity tool with a BPA in the EMR is helping a Midwestern children’s hospital streamline the process to increase sensitivity and specificity for CSHCN. Despite the tool’s limitations and the potential need for ongoing revisions, the usage of complexity tools and BPAs will become critical to target pediatric patient populations that have high usage of resources and services requiring the need for care coordination ongoing. Creating and imple- menting new ways to assist with the early identification of CSHCN requires new and innovative thinking to help achieve more comprehensive, individualized, and focused care. CSHCN requires focused care coordination now and in the future. With further development of care coordination programs across the country and the development of identi- fication tools, including BPAs, we would hope to see a more streamlined connection for successful care coordination services for CSHCN. The traditional systems of care may not be fully meeting the needs of CSHCN. The coexistence of a care coordination program with a complexity tool to include a BPA for enrollment is an approach that is impor- tant in capturing the need for early services. The creation of this coexistence is essential for enhancing outcomes and providing a smooth transition from hospital to home. By identifying this specific patient population on admission, navigation of a complex and ever-changing medical system with the assistance of a care coordinator earlier can help maintain our commitment to improving the health and well- being of CSHCN. CSHCN at our children’s hospital continues to benefit from COC and the care coordination team. The BPA is successful at identifying the potential beneficiaries of care coordination at an early stage, as identified by our recent audit; however, we will need to continue to refine the pro- cess. In addition, there will always be a need for the contin- ued presence of care coordinators at daily medical rounds and huddles to provide that consistent assessment and abil- ity to identify CSHCN who may not be acknowledged by an automated process. The definition of CSHCN is ever-chang- ing as well, and opportunities and strategies to identify those who will most benefit from care coordination will continue to evolve.

Study Design: The provided document does not explicitly state a study design for the quality improvement initiative described. The document describes the implementation of the initiative, the outcomes, and the ongoing evaluation and refinement of the process. Therefore, the study design is likely a quality improvement initiative or program evaluation, rather than a traditional research study with a specific study design.

Setting: The study was conducted at the University of Iowa Stead Family Children's Hospital in Iowa City, IA. The setting for the study was within the Care Coordination Division and Department of Nursing at the children's hospital.

Population of Focus: The target audience for the study is healthcare providers and administrators who work with children with special health care needs (CSHCN) in hospital settings.

Sample Size: The provided document does not explicitly state a sample size for the study. However, it does say that the best practice alert (BPA) tool (i.e. the intervention) was turned on in May of 2020 and fired 259 times between May 2020 and February 2021. Of the total BPA activations, 22% (57) were accepted by a provider and resulted in a consult for care coordination.

Age Range: The document does not explicitly mention a specific age range for the study. However, it does indicate that the BPA looks for required elements in the patient’s EMR on admission, and that one of the elements that trigger an inpatient BPA to fire included aged ≤ 18 years.

Intervention Components (click on component to see a list of all articles that use that intervention): Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We identified and treated young adults with type 1 diabetes who had been lost to follow-up during their transfer from pediatric to adult care, comparing their clinical, psychosocial, and health care utilization outcomes to participants receiving continuous care (CC) throughout the transition to adult care. Individuals in their last year of pediatric care (CC group, n = 51) and individuals lost to follow-up in the transfer to adult care ("lapsed care" [LC] group, n = 24) were followed prospectively for 12 months. All participants were provided developmentally tailored diabetes education, case management, and clinical care through a structured transition program.

Intervention Results: At baseline, LC participants reported lapses in care of 11.6 months. Compared with CC participants, they had higher hemoglobin A1C (A1C; p = .005), depressive symptoms (p = .05), incidence of severe hypoglycemia (p = .005), and emergency department visits (p = .004). At 12-month follow-up, CC and LC participants did not differ on the number of diabetes care visits (p = .23), severe hypoglycemia (no events), or emergency department visits (p = .22). Both groups' A1C improved during the study period (CC: p = .03; LC: p = .02). LC participants' depressive symptoms remained elevated (p = .10), and they reported a decline in life satisfaction (p = .007). There was greater loss to follow-up in the LC group (p = .04).

Conclusion: Our study suggests that, for young adults with a history of lapses in care, a structured transition program is effective in lowering A1C, reducing severe hypoglycemia and emergency department utilization, and improving uptake of routine diabetes care. Loss to follow-up and psychosocial concerns remain significant challenges in this population.

Study Design: Prospective cohort

Setting: Hospital-based

Population of Focus: Young people with type 1 diabetes

Data Source: Surveys, A1c readings, medical records

Sample Size: Continuous care = 51; Lapsed care = 24

Age Range: 19-25 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Education on Disease/Condition, YOUTH, Planning for Transition, Pediatric to Adult Transfer Assistance, Integration into Adult Care, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Children's hospitals must provide developmentally appropriate care to increasing numbers of young adults with complex healthcare needs as they transition to adult-oriented care. This article describes the patients, service, and short-term outcomes of an interprofessional healthcare transition (HCT) consult team comprised of nurses, social workers, a community health worker, and physicians. The Adult Consult Team's tiered population framework stratifies patients by medical complexity. The team coordinates HCT services for patients with the highest complexity. Patients at least 18 years old are eligible if they have at least two specialists or an intellectual or developmental disability (IDD). Through a comprehensive medical and psychosocial assessment, the team prepares patients/families for adult-oriented healthcare.

Intervention Results: The Adult Consult Team received 197 referrals from July 2017 to June 2018. Patients had at least two specialists (73%), IDD (71%), technology dependence (e.g., gastrostomy tube, 37%) and Medicaid insurance (57%). The team assisted patients seen in its outpatient clinic with navigating mental health services (39%), insurance issues (13%), IDD services (15%), and the guardianship process (37%) and creating comprehensive care plans.

Conclusion: The Adult Consult Team transferred 30 patients with medical complexity to adult primary and specialty care, significantly improving pediatric inpatient and outpatient capacity for pediatric-aged patients. A broad range of young adult medical, psychosocial, legal, educational, and vocational needs were addressed.

Study Design: Cohort pilot evaluation

Setting: Hospital/clinicbased (Large tertiary-care children’s hospital and ambulatory) network located in an East Coast urban community

Population of Focus: Patients aged 18 and older who had not transitioned from pediatric to adult care who need specialty care from at least two specialties and/or had an intellectual or developmental disability

Data Source: Medical records

Sample Size: 197 patient referrals; at analysis, 97 were seen in consultation

Age Range: Mean age 20.4 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Technology-Based Support, Expert Support (Provider),

Intervention Description: The quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP-specialist communication. The primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the neurology and gastroenterology departments from April 1, 2014, to October 31, 2016. PCPs completed an electronic consult form, and if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times, and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction.

Intervention Results: A total of 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within 3 business days. Eighteen percent of specialty visits were deferred and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (P < .001), and completion rates improved from 58% to 70% (P < .01), but referral volumes remained stable (25 per month to 23 per month; P = .29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals.

Conclusion: Implementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not affect referral volume. This system could serve as a model for other health care organizations and specialties.

Study Design: Program evaluation

Setting: A primary care clinic at Boston Children’s Hospital (BCH), which is a hospital-based, urban pediatric clinic serving approximately 16,000 patients

Population of Focus: Primary care providers (PCPs) at the primary care clinic at Boston Children’s Hospital (BCH) who placed electronic consults using the Shared Care system; Patients who were referred through the Shared Care system

Sample Size: 82 primary care providers (PCPs) who placed 510 electronic consults using the Shared Care system during the pilot period; A total of 426 unique patients were referred through the Shared Care system during the study period

Age Range: Adult providers; Children and youth ages 0-17 years

Intervention Components (click on component to see a list of all articles that use that intervention): , Care Coordination, Nurse/Nurse Practitioner, Non-Traditional Providers

Intervention Description: Approximately 20% of school-age children have a vision problem. Screening is an effective way to detect visual impairments, although only if adequate follow-up is available. Here, we evaluate the impact of hiring full-time nurses in four underserved schools on the likelihood of increasing follow-up for treatment after vision screening. First, we compared descriptive screening follow-up data from the intervention schools with that of five matched schools with part-time nurses in San Jose, California, from 2008 to 2012. The intervention schools had around 2800 low-income, minority children each year, and the five comparison schools had around 3445. Secondly, we conducted a qualitative analysis of open-ended survey responses from 129 teachers in the nine participating schools.

Intervention Results: In the final year, 96% of the students screened and referred for possible vision problems in schools with full-time nurses were followed up and examined by a health care provider. Yet, only 67% of students screened in comparison schools were examined.

Conclusion: Teachers in schools with full-time nurses reported that follow-up of vision problems and getting glasses for students was the most beneficial activity performed by the nurses. School nurses can effectively increase medical care coordination and follow-up of vision screening in low-income communities.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Referrals, Educational Material,

Intervention Description: To identify the diverse services required by families of children with special health care needs (CSHCN) and identify the specific care coordination (CC) efforts associated with the most common types of observed diagnoses. Requested services were categorized into specific sectors, and CC efforts were quantified by observed diagnoses and defined sectors. CC service data were extracted and analyzed from patient encounters over 4 years (2009-2013) in a department database. This included descriptive information about referrals and linkages to medical, dental, and behavioral health providers and to state, private, and community agencies. Diagnostic classifications and CC sectors were defined to enable categorization.

Intervention Results: A total of 2682 CSHCN records were reviewed. The majority (59%) required services/resources in 1 to 2 sectors, 24% required services/resources in 3 to 5 sectors, and 17% required services/resources in 6 or more sectors. Including informational service, the most frequently required sectors across the study population were education, financial, medical/dental, social connections, and advocacy. Children diagnosed with autism spectrum disorder had the highest needs across all sectors.

Conclusion: Most CSHCN and their families use a substantial amount of CC time and effort to secure services from diverse sectors. High-quality and efficient CC requires an understanding of the specific needs of these CSHCN and their families and how to link them to a diverse array of services and resources.

Study Design: Retrospective observational study

Setting: Center for Care Coordination at Connecticut Children's Medical Center in Hartford, Connecticut

Population of Focus: Children and youth aged 0 to 21 years who were identified as having special health care needs and were served by the MHI program at the Center

Sample Size: 2682 CYSHCN

Age Range: CYSHCN aged 0 to 21 years

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, Integration into Adult Care, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We describe HCT outcomes within the University of Maryland STEP Program, which is built upon integration of an adult HIV provider and navigator into the pediatric clinic, and coordinated collaboration between pediatric and adult HIV multi-disciplinary care teams.

Intervention Results: In the STEP cohort, linkage to adult care was 94% and 12 month retention in adult care (95%) was statistically higher compared to the historical cohort. Rates of viral suppression did not differ pre- and post-HCT among STEP Program patients.

Conclusion: These results support the concept of an integrated pediatric and adult HIV HCT model though the ability to achieve sustainable HCT success will require further study.

Intervention Components (click on component to see a list of all articles that use that intervention): Community Health Workers (CHWs), Prenatal Care Access, Care Coordination,

Intervention Description: The intervention being evaluated in the study is the Health Start Program (HSP) in Arizona. The HSP is a community health worker (CHW) home visiting perinatal support program. CHWs are required to complete 12 hours of continuing education per year . The HSP aims to provide support to at-risk, racially and ethnically diverse, rural, and urban mothers and children in Arizona. The program focuses on improving maternal and child health outcomes by providing various forms of support, including prenatal care, newborn health, and child health up to 5 years of age. The program involves home visits and aims to address the significant challenges and barriers to obtaining healthcare services faced by under-resourced women in Arizona. The specific details of the intervention activities and content are not explicitly outlined in the study protocol

Intervention Results: It primarily focuses on the evaluation protocol, data sources, outcome measures, and the methodology used for assessing maternal and child health outcomes using administrative data.

Conclusion: The study aims to meet the federal Home Visiting Evidence of Effectiveness (HomVEE) standard for evidence-based effectiveness. The study will use a matched comparison group design that meets the published standard for HomVEE's moderate rating. The study will evaluate the impact of the HSP on multiple maternal, infant, and child health outcomes using a combination of four data source

Study Design: The study design is a retrospective, propensity score-matched observational study. The study uses a matched comparison group design that meets the published standard for Home Visiting Evidence of Effectiveness (HomVEE) moderate rating. The study aims to evaluate the impact of the Health Start Program (HSP) on multiple maternal, infant, and child health outcomes. The study uses a combination of four data sources: the HSP database, Vital Records Birth Data, Hospital Discharge Data, and Arizona State Immunization Information System. The study employs propensity score matching (PSM) to create a synthetic comparison group to observe the "counterfactual" to HSP participation, that is, what would have happened in the absence of the program. The study will compare outcomes between HSP mothers and those matched to them by the propensity score

Setting: The setting for this study is the state of Arizona in the United States. Arizona is the sixth largest state in the US, with a population of 6.8 million people. The state is unique in its racial and ethnic diversity, with a higher proportion of Latino and American Indian residents compared to the national average. Additionally, nearly a quarter of the population lives in rural areas, where poverty rates are almost double that of the national poverty rate. The Health Start Program (HSP) is a statewide program that employs community health workers (CHWs) in 14 distinct Arizona counties to engage at-risk, low-income mothers and improve maternal and child outcomes .

Population of Focus: The target audience for the Health Start Program (HSP) in Arizona includes at-risk, low-income, and racially and ethnically diverse pregnant women and their families. The program aims to engage this specific demographic to improve maternal and child outcomes by providing support, education, and advocacy through the use of community health workers (CHWs) who reflect the ethnic, cultural, and socioeconomic characteristics of the communities they serve. The HSP is designed to address the needs of under-resourced women and families who may face significant challenges and barriers to obtaining healthcare services, particularly prenatal care

Sample Size: However, the protocol does mention that the analytic population is of sufficient size to detect meaningful program effects from low-frequency events, including preterm births, low and very low birth weights, maternal morbidity, and differences in immunization and hospitalization rates over a relatively long period. The study also notes that lack of statistical power is not a significant issue for this project, despite the respective sizes of the intervention and comparison populations

Age Range: The study focuses on maternal and child health outcomes within the context of the Health Start Program (HSP) in Arizona. While the specific age range of the children included in the study is not explicitly mentioned, the outcomes evaluated are related to prenatal care, newborn health, and child health up to 5 years of age. Therefore, the study likely encompasses maternal and child health outcomes from prenatal care initiation through early childhood, covering a broad age range from prenatal to early childhood stages

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Collaboration with Local Agencies (Health Care Provider/Practice), Shared Plans of Care

Intervention Description: This report will describe a care support project that delivered shared plans of care to providers and families of children with medical complexity. This program was built around carefully constructed care support teams where each member had clearly defined roles and responsibilities. The teams worked collaboratively to improve provider communication, create SMART (Specific, Measurable, Assignable, Realistic, and Timely) goals, and perform task tracking. This process created a scaffolding to support community physicians, allowing patients to remain in their local medical homes and to access services closer to home and reducing hospital admissions and emergency room overutilization.

Intervention Results: We found a statistically significant decline in the number of hospital admissions and mean length of stay—38% (P = .00056) and 43% (P =.041). We did find emergency room visits decreased by 14%, yet this was not statistically significant (P = .1455; Table 4). While we do not have a control group, we can say that our results mirrored the results of the CARE study that had a sample size more than 20 times the size of ours.

Conclusion: The 4C project, a multidisciplinary approach offering care support to CMCs, improves key measure of health outcomes. We described a process that outlines the roles and responsibilities of each team member in a care coordination team for CMC’s. Each team cared for a caseload of 100 very complex families, which mirrored the experience of the CARE study. Systems undergoing health transformation will need to consider investing in teams and information systems that can support complex care coordination.

Study Design: The study design is not explicitly stated in the article. However, the article describes the experience of implementing the Consultative Collaborative Coordinated Care (4C) program in two small pediatric programs and the outcomes of the program. The study evaluated the program's outcomes, including key measures of health outcomes, and compared them to the results of the Coordinating All Resources Effectively (CARE) study.

Setting: The setting for the study was two small pediatric programs created by the Consultative Collaborative Coordinated Care (4C) program. The 4C program was funded by the Center for Medicare and Medicaid Innovation award program from 2013 to 2017 and was a care support project within two pediatric hospitals that delivered shared plans of care (SPOC) and care coordination for children with medical complexity (CMC). The two pediatric hospitals were located on opposite sides of Massachusetts.

Population of Focus: The target audience for the study includes healthcare professionals, pediatricians, nurses, and other care providers involved in the care of children with medical complexity (CMC). Additionally, policymakers, administrators, and organizations involved in the development and implementation of care coordination programs for children with complex medical needs would also find the study relevant. T

Sample Size: The sample size of the study involved a total of 335 participants. However, a specific subset of this sample, consisting of 205 participants, was used for the analysis and reporting of the study's outcomes and results.

Age Range: The study did not specify a specific age range for the participants. However, the study focused on children with medical complexity (CMC), which typically includes children with chronic and complex medical conditions that require ongoing care and management. The age range of children with medical complexity can vary widely, from infancy to adolescence.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination,

Intervention Description: The article describes a specific intervention called the "4C Program" which is a multicomponent intervention designed to provide intensive care coordination for children with medical complexity (CMC). The intervention includes a team of healthcare professionals, including a complex care pediatrician, nurse care coordinator, social worker, and family navigator, who work together to develop individualized care plans for each patient. The intervention is based on a shared plan of care (SPOC) that includes specific goals and timelines for each patient, and is designed to support community physicians and allow patients to remain in their local medical homes. The article describes the implementation and outcomes of the 4C Program at two academic medical centers in Massachusetts. The article does not specifically mention whether the 4C Program increases the percentage of children with medical complexity who have a personal doctor. However, the program is designed to support community physicians and allow patients to remain in their local medical homes, which may increase the likelihood that they have a personal doctor. The program also includes a nurse care coordinator who works to enhance communication between families and the medical team, which may also improve access to primary care providers.

Intervention Results: The study describes the implementation of the 4C Program, which delivered shared plans of care to providers and families of children with medical complexity. The program was built around carefully constructed care support teams, and each member had clearly defined roles and responsibilities. The teams worked collaboratively to improve provider communication, create SMART (Specific, Measurable, Assignable, Realistic, and Timely) goals, and perform task tracking. The process created a scaffolding to support community physicians, allowing patients to remain in their local medical homes and to access services closer to home, while reducing hospital admissions and emergency room overutilization . The study also mentions that the 4C Program was composed of two teams with identical structures based at two academic medical centers on opposite sides of the state. Each team cared for a case load of 100 very complex families, and the results of the assessment informed the team's development of a care plan. Through an iterative quality improvement process, distinct workflows were established, and roles and responsibilities were defined to ensure that all tasks were completed and tracked in an efficient, timely manner. This workflow allowed team members to cross-cover, picking up tasks where others left off, and provided a blueprint for sustainability at each site after the project funding ended . Overall, the study demonstrates the successful implementation of a complex care coordination program in a small setting, with a focus on improving care for children with medical complexity and their families.

Conclusion: This process created a scaffolding to support community physicians, allowing patients to remain in their local medical homes and to access services closer to home and reducing hospital admissions and emergency room overutilization.

Study Design: The article does not provide a detailed description of the study design. However, it appears that the study is a program evaluation of the 4C Program, which was implemented at two academic medical centers in Massachusetts. The study describes the implementation and outcomes of the program, including the development of individualized care plans for each patient, the composition of the care support teams, and the key health care outcomes for the participants of the program. The study also includes a statistical analysis of the data for 205 individuals who had Medicaid coverage before and after enrolling in the program, which showed a statistically significant decline in the number of hospital admissions and mean length of stay, and a non-statistically significant decrease in emergency room visits

Setting: The 4C Program was implemented at two pediatric hospitals as part of the Consultative Collaborative Coordinated Care (4C) program, which was funded by the Center for Medicare and Medicaid Innovation award program from 2013 to 2017. The program was specifically designed to extend and tailor care coordination programs to smaller pediatric settings, addressing the need to support children with medical complexity in settings beyond large children's hospitals

Population of Focus: The target audience for the 4C Program described in the study is children with medical complexity (CMC) and their families. The program aims to provide care support to this specific population by delivering shared plans of care to providers and families of children with medical complexity. Additionally, the program is designed to support community physicians in caring for these children, allowing patients to remain in their local medical homes and access services closer to home while reducing hospital admissions and emergency room overutilization

Sample Size: The study involved a total of 335 participants in the 4C Program. Additionally, the data analysis specifically focused on a sample of 205 individuals who had Medicaid coverage before and after enrolling in the program

Age Range: The article does not provide a specific age range for the participants of the 4C Program. However, the program is designed to support children with medical complexity, which typically includes children with chronic and complex medical conditions that require ongoing medical care and support. The study describes the development of individualized care plans for each patient, which suggests that the program is tailored to the specific needs of each child. The study also reports the age at the time of enrollment for the participants, with a mean age of 8.38 and a standard deviation of 5.78

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Pediatric to Adult Transfer Assistance, Planning for Transition, Integration into Adult Care, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Developing and evaluating effective transition interventions for young people (16-25 years) with inflammatory bowel disease (IBD) is a high priority. While transition clinics (TCs) have been recommended, little is known about their operating structures and outcomes. This study aimed to gain insight into the value of a TC compared with direct handover care. Data collection included: semistructured interviews with professionals (n=8), observations during consultations with young people (5×4 hours), medical chart reviews of patients transferred 2 to 4 years prior to data collection (n=56 in TC group; n=54 in control group) and patient questionnaires (n=14 in TC group; n=19 in control group).

Intervention Results: At the TC, multidisciplinary team meetings and alignment of care between paediatric and adult care providers were standard practice. Non-medical topics received more attention during consultations with young people at the TC. Barriers experienced by professionals were time restrictions, planning difficulties, limited involvement of adult care providers and insufficient financial coverage. Facilitators experienced were high professional motivation and a high case load. Over the year before transfer, young people at the TC had more planned consultations (p=0.015, Cohen's d=0.47). They showed a positive trend in better transfer experiences and more satisfaction. Those in direct handover care more often experienced a relapse before transfer (p=0.003) and had more missed consultations (p=0.034, Cohen's d=-0.43) after transfer.

Conclusion: A TC offer opportunities to improve transitional care, but organisational and financial barriers need to be addressed before guidelines and consensus statements in healthcare policy and daily practice can be effectively implemented.

Study Design: Controlled mixed-methods evaluation (control group and other controls)

Setting: Clinic-based (2 outpatient IBD (Inflammatory Bowel Disease) clinics)

Population of Focus: Young people with IBD transitioning to adult care

Data Source: Semi-structured interviews, observations during consultations, medical charts, and patient questionnaires

Sample Size: 54 patients

Age Range: 16-25 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Integration into Adult Care, Pediatric to Adult Transfer Assistance, Planning for Transition, Nurse/Nurse Practitioner, YOUTH, Education on Disease/Condition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We compared the clinical long-term course of 24 patients with and 11 patients without structured transition care within 24 months before and 24 months after transfer from paediatric to adult health care. Socio-economic parameters and quality of life were assessed by IBD Questionnaire (IBDQ-32) and additional items. Treatment costs were calculated for medication, surgery and hospitalisation.

Intervention Results: The percentage of transfer group patients with an IBD-related intestinal complication was higher compared to the transition group (64% vs. 21%, p = 0.022). We also found a tendency towards a higher number of IBD-related surgery in the transfer group compared to the transition group (46% vs. 13%, p = 0.077). Transfer group patients received higher mean cumulated doses of radiation compared with the transition group (4.2 ± 5.3 mSv vs. 0.01 ± 0.01 mSv, p = 0.036). Delayed puberty was only noted in the transfer group (27%, p = 0.025). Mean expenditures for surgeries and hospitalisation tended to be lower in the transition group compared to transfer group patients (744 ± 630€ vs. 2,691 ± 4,150€, p = 0.050). Sexual life satisfaction was significantly higher (p = 0.023) and rates of loose bowel movements tended to be lower (p = 0.053) in the transition group.

Conclusion: Structured transition of adolescents with IBD from paediatric into adult health care can lead to important clinical and economic benefits.

Study Design: Retrospective study design

Setting: Clinic-based (Pediatric department of a health clinic)

Population of Focus: Patients with IBD transferring to adult care

Data Source: Medical records, patient questionnaires

Sample Size: 24 patients with transition care

Age Range: 17-22 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner,

Intervention Description: A shared care model was implemented in 2006 in Queensland to fa- cilitate paediatric oncology, haematology and palliative care patients receiving care as close to home as possible. Following initial diagnosis, care planning and treatment at the tertiary children's hospital, appropriate local care was coordi- nated by Regional Case Managers (RCMs) established at each of 10 Shared Care Units (SCUs). This enabled safe and quality regional care supported by a state- wide network providing clinical governance and education. This paper examines learnings from 15 years of this shared care.

Intervention Results: The paper reviews the attributes, knowledge and experience required for RCMs. Standards of care were supported through education workshops, clinical placements, chemotherapy credentialing, guidelines and standards. RCMs facilitated communication and information sharing with the tertiary centre, advocated for their cohort of patients locally and streamlined and supported the family's experience of care.

Conclusion: The RCM role provided invaluable clinical leadership for the care of paediatric oncology, haematology and palliative patients across Queensland. As new treatments evolve, the expertise and coordination provided by the RCMs will be even more critical. Achieving high-quality shared care outcomes is underpinned by the RCMs drive to achieve statewide safety and support for this cohort of children.

Study Design: The study design involves a mixed-methods approach, incorporating both quantitative and qualitative methods to evaluate the implementation of a statewide model of shared care for paediatric oncology, haematology, and palliative care patients across Queensland. The study includes a survey of staff from Shared Care Units (SCUs) and focus group interviews with Regional Case Managers (RCMs) to assess the attributes, knowledge, and experience required for RCMs, as well as the standards of care supported through education workshops, clinical placements, chemotherapy credentialing, guidelines, and standards. This mixed-methods approach allows for a comprehensive evaluation of the role of RCMs and the implementation of shared care for paediatric oncology, haematology, and palliative care patients, providing a more holistic understanding of the challenges and successes of the statewide model.

Setting: Ten hospitals throughout Queensland facilitated a statewide model of shared care for paediatric oncology, haematology and palliative care patients, supported by a tertiary hub in Brisbane.

Population of Focus: The target audience for the study is healthcare professionals, policymakers, and researchers interested in improving the care of paediatric oncology, haematology, and palliative care patients across Queensland. The study's findings and recommendations may be of interest to healthcare professionals and policymakers involved in the planning, implementation, and evaluation of shared care models for paediatric oncology, haematology, and palliative care patients in other regions or countries.

Sample Size: The online survey was distributed to regional care managers (RCMs) with 12 responses, including all of the 10 current RCMs and 2 past incumbents. Two focus groups were conducted consisting of a total of 10 RCMs and 6 Clinical or Registered Nurses supporting RCMs.

Age Range: While the specific age range is not explicitly mentioned, the study addresses the care of patients in the paediatric age group, which typically includes individuals from birth to 18 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination

Intervention Description: The transition program was designed to provide additional support during transition of care and was introduced 6 months prior to referral to adult diabetes care. The intervention was 18 months long and spanned six clinic visits (three pediatric and three adult). There were also two clinic visits in the 12 months of follow-up, so the total number of study visits was eight. Central to the program were transition coordinators (TCs) at each site who provided a link between pediatric and adult diabetes care. The TCs were Certified Diabetes Educators who provided transitional education and clinical support where appropriate. The role of the TC was to assist participants during the visits in the first 18 months, maintain contact with participants between the visits (by phone, text messages, or e-mail), facilitate support for insulin adjustments and sick day/hypoglycemia management during regular hours, send reminders and help reschedule appointments, and assess needs and facilitate referrals to other services (e.g., psychology, social work, nurse educator, or dietitian). The TCs also provided specific transition-related education and education materials and at the last pediatric visit a bio sketch of the adult endocrinologist to whom the participant had been referred as well as written instructions and maps to navigate adult diabetes centers.

Intervention Results: We randomized 205 participants, 104 to the transition program and 101 to standard care. Clinic attendance was improved in the transition program (mean [SD] number of visits 4.1 [1.1] vs. 3.6 [1.2], P = 0.002), and there was greater satisfaction with care (mean [SD] score 29.0 [2.7] vs. 27.9 [3.4], P = 0.032) and less diabetes-related distress (mean [SD] score 1.9 [0.8] vs. 2.1 [0.8], P = 0.049) reported than in standard care. There was a trend toward improvement in mean HbA1c (8.33% [68 mmol/mol] vs. 8.80% [73 mmol/mol], P = 0.057). During the 12-month follow-up, there was no difference in those failing to attend at least one clinic visit (P = 0.846), and the mean change in HbA1c did not differ between the groups (P = 0.073). At completion of follow-up, the groups did not differ with respect to satisfaction with care or diabetes-related distress and quality of life.

Conclusion: Transition support during this 18-month intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but these benefits were not sustained 12 months after completion of the intervention.

Study Design: RCT

Setting: Hospitals/Clinics

Population of Focus: Young adults with type 1 diabetes

Sample Size: 205

Age Range: 17-20 years

Intervention Components (click on component to see a list of all articles that use that intervention): Continuity of Care (Caseload), Policy/Guideline (State), Care Coordination,

Intervention Description: N/A

Intervention Results: Persons with complex disabilities more frequently experienced continuity (83.7%) than persons without disabilities and those with basic disabilities (60.7% and 65.6%, respectively, p < 0.001). Seldom or never being sick was the most frequently reported reason for not having a usual provider; more persons without disabilities (64%) reported this reason than persons with disabilities (basic: 41.9%, p < 0.001; complex: 26.6%, p = 0.001). Persons with disabilities more frequently reported visiting different providers for different needs and not having a usual provider due to the costs of medical care than persons without disabilities.

Conclusion: Future research needs to examine the influence of continuity on healthcare disparities among persons with complex disabilities. Policies and practice must be attentive to how proposed changes to the healthcare system potentially reduce access to care among persons with disabilities.

Study Design: Pooled 2-year data from panels 14-16 (2009-2012) of the Medical Expenditure Panel Survey were examined. Working-age adults (18-64) were categorized as having no disability, basic disabilities, or complex disabilities. Persons were categorized having provider continuity (provider throughout the period) or discontinuity (gaining or losing providers during the period). χ2 and multinomial logistic regressions were used to examine outcomes by disability status.

Setting: Medical Expenditure Panel Survey

Population of Focus: Persons with disabilities

Sample Size: 26867

Age Range: 18-64

Intervention Components (click on component to see a list of all articles that use that intervention): Counseling (Parent/Family), EMR Reminder, Care Coordination, Integration into Adult Care, Pediatric to Adult Transfer Assistance, Planning for Transition, PARENT_FAMILY, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The Multidisciplinary Intervention Navigation Team (MINT) was developed to decrease variations in pediatric to adult medical transitions. System-level goals were to (1) increase provider and leadership engagement, (2) increase transition tools, (3) increase use of electronic medical record-based clinical decision supports, (4) improve transition practices through development of transition policies and clinical pathways; (5) increase transition education for patients and caregivers; (6) increase the adult provider referral network; and (7) implement an adult transition consult service for complex patients (MINT Consult).

Intervention Results: Between July 2015 and March 2017, MINT identified 11 transition champions, increased the number of divisions with drafted transition policies from 0 to 7, increased utilization of electronic medical record-based transition support tools from 0 to 7 divisions, held seven psychoeducational events, and developed a clinical pathway. MINT has received more than 70 patient referrals. Of patients referred, median age is 21 years (range, 17-43); 70% (n = 42) have an intellectual disability. Referring pediatric providers (n = 25) reported that MINT helped identify adult providers and coordinate care with other Children's Hospital of Philadelphia specialists (78%); and that MINT saved greater than 2 hours of time (48%).

Conclusion: MINT improved the availability, knowledge, and use of transition-related resources; saved significant time among care team members; and increased provider comfort around transition-related conversations.

Study Design: Cohort pilot evaluation

Setting: Hospital-based (Free-standing tertiary pediatric academic hospital (Children’s Hospital of Philadelphia (CHOP))

Population of Focus: Patients aged 17-43 who had not transitioned from pediatric to adult care for medically complex patients

Data Source: Transition Readiness Assessment Questionnaire; electronic medical records; surveys

Sample Size: Total number not given, but there were 80 consults given over 2 years; 74 were deemed appropriate referrals

Age Range: 17-43 years (median age 20)

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Training (Parent/Family),

Intervention Description: Despite the importance of practice-based care coordination, only 42.3% of children with special health care needs (CYSHCN) met all needed components of care coordination as defined by the Maternal Child Health Bureau. Recognizing that children with medically complex conditions often have lower rates of achieving care coordination within a medical home, the Region 4 Midwest Genetics Collaborative worked with families to develop a training to empower families in care coordination. The Care Coordination: Empowering Families(CCEF) training provides families with the knowledge, tools, and resources to engage with health, education and family support systems.

Intervention Results: The results of the study suggest that the Care Coordination: Empowering Families (CCEF) training program is a promising practice for facilitating medical home use among children and youth with special health care needs (CYSHCN). The findings indicate that families who attended the training report being the primary source of care coordination for their children, and 83.7% see their role in their child’s healthcare changing as a result of the training. The data suggest that the training impacted how the family interacts with the child’s doctor, including initiating conversations to prepare their child for transition to adult health care. Further, families report system-level improvements 1 year later compared to the pre-training assessment. The study also found that the CCEF training shows promise for improving care coordination-related skills among caregivers of CYSHCN from diverse backgrounds. While Hispanic participants scored lower on the English version of post-training quiz items, African American participants were more likely to endorse a role in their child’s healthcare changing as a result of the training. All other evaluation findings seem to indicate similar benefit across race and ethnicity.

Conclusion: The CCEF training shows promise for improving care coordination-related skills among caregivers of CYSHCN from diverse backgrounds. While Hispanic participants scored lower on the English version of post-training quiz items, African American participants were more likely to endorse role in their child’s healthcare changing as a result of the training. All other evaluation findings seem to indicate similar benefit across race and ethnicity. By empowering caregivers with knowledge and skills related to care coordination, these caregivers are more able to affect positive change within their child’s healthcare systems. By partnering with HRSA funded programs and family and disease specific organizations in the recruitment of training participants, the training curriculum shows promise for use by these initiatives and others in addition to genetic services and the regional genetic networks. With a pilot expansion effort already underway, CCEF may become an evidenced-based training that certified facilitators from other HRSA grantees can use to improve core outcomes for clients they serve.

Study Design: The study utilized a longitudinal design to evaluate the impact of the Care Coordination: Empowering Families (CCEF) training program. Data were collected from training participants at three time points: pre-assessment, post-training (immediately after training), and 1-year follow-up. The pre-assessment and 1-year follow-up surveys were designed to mirror each other to evaluate the long-term training impact. The study was approved by the Michigan Public Health Institute Institutional Review Board, and participants were asked to create a personal identification code to link surveys across time without accessing identifiable information.

Setting: The setting for the study was seven pilot states within the Midwest region of the United States.

Population of Focus: The target audience for the study is family caregivers of children and youth with special health care needs (CYSHCN).

Sample Size: The sample size of the study was 190 caregivers who participated in one of ten Care Coordination: Empowering Families (CCEF) trainings in 2013. All training participants completed the pre and post-training assessments, and 80 participants (a response rate of 42%) completed the 1-year follow-up assessment.

Age Range: The age range of the children and youth with special health care needs (CYSHCN) in this study is not explicitly stated. However, the mean age of the children in the study was 8.9 years at the pre-assessment and 9.6 years at the 1-year follow-up assessment. The range of child age was 0-27 years at the pre-assessment and 1-28 years at the 1-year follow-up assessment.

Intervention Components (click on component to see a list of all articles that use that intervention): Nurse/Nurse Practitioner, Counseling (Parent/Family), Care Coordination, Integration into Adult Care, Pediatric to Adult Transfer Assistance, Planning for Transition, PARENT_FAMILY, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Reaching a certain age, juvenile idiopathic arthritis (JIA) patients in paediatric care are transferred to adult care. An increased disease activity after transfer and increased dropout has been suggested, however, evidence is scarce. Our aim is to determine whether the process of transition is associated with increased disease-activity and dropout, and to identify associated factors. During a 3-year prospective transition cohort study, paediatric patients (14-17yrs) were transferred to adult care. Paediatric (10-13yrs) and adult JIA patients (18-27yrs) were used as control groups. Demographic and disease-related items were obtained yearly. Non-parametric tests were used to compare differences between the groups and mixed models to evaluate disease activity over time, measured by JADAS27 and DAS28. Dropout was defined as not attending the clinic for 2 consecutive visits.

Intervention Results: Groups did not differ regarding baseline variables of subtype, gender, uveitis, ANA-, RF- or HLA B27-positivity and current or past DMARD use. Median disease activity was not different between groups during follow-up. Transfer was not associated with disease activity. Dropout rate was 12%, and was significantly higher in patients under transition (22%) compared with paediatric (3%) and adult care (10%). Patients who dropped out had significantly lower disease activity at baseline and were using less MTX, but did not differ regarding subtype, ANA, RF and HLA-B27.

Conclusion: The process of transition in JIA is not associated with an increase in disease activity, however, this period carries a risk for drop out especially in patients with low disease activity.

Study Design: e Longitudinal transition cohort study

Setting: Clinic-based (Out-patient clinics of university hospitals)

Population of Focus: Juvenile idiopathic diabetes 1 patients transferring to adult care

Data Source: Medical records

Sample Size: 64 patients

Age Range: 14-17 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL, School-Based Health Centers, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE, Pediatric to Adult Transfer Assistance, Care Coordination, Quality Improvement/Practice-Wide Intervention

Intervention Description: This pilot study implemented and assessed the use of a structured HCT process, the Six Core Elements of HCT, in two school-based health centers (SBHCs) in Washington, DC. The pilot study examined the feasibility of incorporating the Six Core Elements into routine care and identified self-care skill gaps among students. Quality improvement methods were used to customize, implement, and measure the Six Core Elements and HCT supports.

Intervention Results: After the pilot, both SBHCs demonstrated improvement in their implementation of the structured HCT process. More than half of the pilot participants reported not knowing how to find their doctor’s phone number and not knowing what a referral is.

Conclusion: These findings indicate the need for incorporating HCT supports into SBHCs to help students build self-care skills necessary for adulthood.

Study Design: Cohort pilot evaluation

Setting: Schools

Population of Focus: High school students

Sample Size: 560

Age Range: Grades 9-12

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: At a medium-sized pediatric hospital with no formal transition support program, we developed and evaluated the use of a single-session transfer clinic as an initial quality improvement intervention to improve patient satisfaction, clinic attendance, and knowledge of transition related issues.

Intervention Results: All patients and parents who attended reported high levels of satisfaction with the clinic. Providers were also mostly positive regarding their participation. Feedback from the first clinic was used to modify the structure of the second clinic to better meet the needs of participants and to allow the clinic to run more efficiently. The use of group sessions and adapting resources developed by other diabetes programs were viewed favourably by participants and lessened the burden on staff who delivered the clinic.

Conclusion: A half-day transfer clinic is a viable step towards improving patient and parent satisfaction during the transition into adult care without requiring additional staff or significant expenditures of new resources. This type of clinic can also be incorporated into a larger program of transition supports or be adopted by programs serving young adults with other chronic diseases