Medical home transformation was the topic of a 2010 Agency for Healthcare Research and Quality call for proposals. The context at the time was one of the initiations of numerous adult primary care medical home projects in the wake of Transformed, a national medical home demonstration effort (Nutting et al. 2009). The study “Transformation in the Pediatric Medical Home: What Drives Change” was one of fourteen projects funded to collect and analyze practice characteristics contributing to “accomplished transformation” (McAllister et al. 2013). The notion that transformation is ever complete was a difficult concept to absorb by the twelve pediatric practices studied. Working on medical home improvements for 7 years these primary care teams were still busy improving. In fact, when interviewed each practice related ideas more fitting with continuous improvement than completed transformation. Four essential elements of effective medical home change are described in this study and include (1) quality improvement, (2) family centered care, (3) teamwork and (4) care coordination. These highly functioning practices enjoy a significant degree of senior leadership with encouragement and support for their medical home efforts. Their quality improvement initiatives benefit from devoted time and dedication to their tasks. Families of children with special health care needs serve as their improvement partners. Lead clinicians, care coordinators and families report frequent new discoveries about how to best design and deliver team-based care. While no team employed a designated coordinator of care at the beginning of their improvement efforts, today all but one of twelve practices employs one or more devoted care coordinators (McAllister et al. 2013).

There are numerous care coordination lessons to be learned from this study. Using a methodology of coded qualitative interviews, of over almost 6,000 coded quotes, over 4,000 are linked to coordination of care. Care coordination is best achieved in the context of relationships. The four essential elements are interdependent. Quality improvement takes a team. Teamwork must be valued with its work appreciated as vital. This necessitates highly effective team habits such as frequent meetings, agenda setting, adequate time for effective communication and accountable follow up of assigned tasks. More often than not the lead clinician serves as team leader, but decisions are rarely made without family members and care coordinators input and agreement (McAllister et al. 2013).

The relationship among the child, family and primary care clinician is key to a successful medical home. The contract of this relationship is that patients and families are empowered and supported to manage and coordinate care in partnership with their primary care team. Fundamental to family-centered care and to effective quality improvement is direct feedback from families to inform team-based care including care coordination. The child and family perspective; their current experience of care; and ideas they have for what would make care better are questions which need to be asked on a regular basis? The transformation study referenced revealed numerous developed family-friendly care processes and materials of which their use became care coordination roles and functions. The teams also tested new and specific approaches to care coordination including pre-visit contacts, separate care coordination visits and access options, and jointly created plans of care to name a few. The clinicians, families, and coordinators would debrief as a group, adapt approaches, re-plan for another try and/or mark any successful outcomes accordingly (McAllister et al. 2013).

Strong teamwork is a product of quality improvement, family engagement and care coordination. Among these four essential elements, you truly cannot have one with out the other (Fig. 5.1). Another medical home effort, the National Safety Net Medical Home Initiative reports similar findings (2014).

Shared plans of care have gained wide attention as a method very needed and when well executed instrumental to integrate multiple people, sources of information and input, and all recommended next steps with clear accountabilities. Plans of care are being looked to as a key tool to help coalesce multiple inputs into a comprehensive approach with clearly laid out steps and easy to use. The Center for Medical Home Improvement (1997–2013) collected and published work related to medical home improvements (Antonelli et al. 2009)

CMHI organized data collected from families as follows: we would like a system of care that provides us with:

It is clear that families would like a distilled summary of their child’s diagnosis and treatments, and a plan of care to effectively frame—who their child is, and what their strengths are. Families also want their pivotal role as the true constant and expert in the life and care of their child to be highlighted. Clinicians have also voiced their opinions, asking for a swift, comprehensive and accurate snapshot, or medical summary, to assist them in the delivery of care delivered under real time pressures and constraints. Shared plans of care are on deck as the next medical home “innovation” to develop and test. Will existing care coordination help us to achieve these aspirations or will these developments lead to better care coordination, or both?

In 2012 The Lucille Packard Foundation for Children’s Health (LPFCH) funded first the Center for Medical Home Improvement and subsequently the Indiana University’s School of Medicine, Children’s Health Services Research Division to work towards a consensus process for planned coordinated care, using plans of care. The charge was to define and describe the critical dimensions of a comprehensive integrated plan of care. The result is a LPFCH Brief; the brief outlines a model for coordination of care using plans of care. It includes underlying consensus principles (Table 5.2), a step-by-step approach to shared care-planning, and a companion learning guide for teams to use as they uptake the steps of the model (McAllister et al. 2014). The plan of care is conceptualized as a blend of traditional “medical summary” data merged with a “negotiated actions” component to capture goals, strategies, actions, person responsible and related accountabilities.