Care Coordination is an expanding field thanks in part to health care reform as well as evidence based studies indicating improvement in clinical outcomes of children as well as cost efficiencies. One example is Rhode Island’s Pediatric Practice Enhancement Project, which used parent partners to assist families with children with special healthcare needs in service coordination, resulting in a decreased in admissions within their target group (Silow-Carroll 2009). The Community-based Pediatric Enhanced Care Program provided through Brenner Children’s Hospital is another example of successful community-based care coordination for families of children with complex conditions making a difference for families (Murphy et al. 2012). Care coordination’s use of scheduling assistance across specialties and compilation of resources will continue to be a strong foundational element of successful care coordination (Taylor et al. 2013). Texas Children’s Health Plan in Houston, Texas, has been able to achieve statistically significant results in cost and admission reduction through utilizing embedded case managers to provide care coordination services to vulnerable children seen in high volume primary care offices (Treadwell 2014). Another example of cost savings is at Boston Children’s Hospital. Their Community Asthma Initiative conducted a cost analysis for their program realizing an adjusted net present value savings from decreased emergency room visits and decreased admissions of $83,863 for 102 patients (Bhaumik et al. 2013).

Transition programs as seen in the Adolescent Health Transition Project of the University of Washington (http://​depts.​washington.​edu/​healthtr) are also expected to be on the rise. The Washington program site provides not only resources and support to families in their area, but offers open source forms, checklists, and processes to families and healthcare professionals in establishing solid transition programs that respect the growing autonomy of the adolescent. A similar resource to support the growing programming recognizing the importance of providing a smooth transition to adult care is the national Center for Health Care Transition Improvement (http://​www.​gottransition.​org/​) organization which has resource toolkits for both families and health care providers.

Expansion of the Association of Maternal Child Health Programs (AMCHP) is another sign of growing innovation in the area of care coordination. The Oregon Care Coordination Program (CaCoon) is designated as a promising practice through the AMCHP Innovation Station (http://​www.​amchp.​org). The Oregon program fosters face-to-face contact with families of children with special healthcare needs. During 2012, 1,836 children received 8,979 visits from CaCoon nurses. Children involved in this program had a 10 % reduction in hospitalizations during 2010 over the prior year. In addition to the impact they have made for families in Oregon, this program has developed a program manual and assessment tools as well as webinar training available to sites/families across the nation. Funding from Health Resources Services and Administration (HRSA) is in the middle of their five-year cycle, encouraging states to pursue studies to uncover improved ways to support children with special health care needs through case management and care coordination efforts. The Medical Home Implementation for Children with Special Healthcare Needs grants have provided technical assistance and funding to address expansion of medical homes (care coordination being one of the six medical home domains). HRSA grant activity requires communication and spread of coordination ideas across the state. Ideas, run through quick cycle improvement, test processes thought to be helpful. An example in Texas is use of a Care Ambassador approach to engage adolescents with diabetes in their ongoing appointment and testing needs supporting care coordination and self-management skill development. These grant-funded sites are important for the future as each state shares its innovation with sites across the nation encouraging replication or modification which will influence future best practice for care coordination.

Another future change will include certification requirements for case managers as opposed to the existing model of preference for certification. This will establish consumer protections around the knowledge and capabilities of the professional providing services and legislative definitions and parameters for service expectations and outcomes. Development of additional payment for case management services, increased use of technology as part of care coordination delivery funded through public-private partnerships, creation of fellowships to increase professionalism, research into the efficacy of new case management and care coordination models, will also be in effect. Increased use of Accountable Care Organizations (ACO) and Medical Homes as entities providing care coordination will increase to impact emergency room expense. The outcomes of that family-centered support and results of coordination should be seen in a rise of ambulatory care with emergency room use diminished.

The advent of Health Insurance Exchanges and the availability of healthcare coverage to individuals previously uninsured open the potential consumer base for care coordination. Another important facet of the Affordable Care Act is removal of lifetime limits, something extremely important to families of children with significant disabilities. This additional focus on care coordination will play into requirement for professional licensure, national certification and continuing education to ensure Americans are receiving a consistent level of professional capability and protection. The inclusion of care coordination as a need and expectation of insurance coverage also necessitates payment from commercial insurers in addition to the Centers for Medicaid and Medicare Services payment for care coordination of Medicare recipients.

Defined payment for care coordination services results in requirements of measurement and accountability. Care coordination as a component in Accountable Care Organizations (ACO) will define its product through these quality measurements. Pediatric Demonstration Projects occurring between 2012 and 2016 will identify how ACO’s specifically focused on children will provide care for children enrolled in Medicaid and Children’s Health Insurance Programs. Findings from these demonstration sites will inform structure of pediatric ACO’s and move the payment and processes into the commercial systems. One of the known inclusions in these pilot sites is included behavioral health therapies in pediatric health homes. This role of psychiatry features both verbal and in-person on demand consultations for behavioral health issues (Martini and Houston 2013). Under this model of health service delivery, children will have greater access to behavioral health coordination with family focused coordination and communication of behavioral and physical health services.

Tips for Parents: Co-located or professional associations between primary care and behavioral health teams should be available to your child. Ask your primary care provider what arrangements are in place within their practice.

Tips for Health Care Professionals: There will be a challenge to move from autonomous practice to team communication behaviors. Ensuring access to psychiatry and social workers as well as development of communication and referral protocols are important.

Not surprisingly, use of lean strategies by case managers will be increasingly facilitated by managed care entities seeking to support improvements in population health. Using the quality initiative of lean and six sigma, will engage teams in finding efficiencies in processes to improve clinical and financial outcomes. One of the areas of lean review will be how to deal with children who have multiple health services use events for diagnoses categorized as potentially preventable. Potentially preventable emergency room visits, admissions and readmissions will play an important role to health plans and ACO’s as well as hospitals as there is likelihood of a diminished or absent payment for health services deemed preventable. To give some context to this issue, in 2010, the United States had 1,85,000 potentially preventable hospitalizations (Torio et al. 2013). To reduce these events, care coordination will be at the lead, performing post-discharge medication reconciliation and establishing follow up visits with the child’s care team to prevent readmission and reviewing barriers for individualized action in cases of readmission. Action to impact potentially preventable emergency room admissions includes active outreach to engage patients with care gaps of unfilled prescriptions or missed physician appointments, using motivational interviewing techniques to produce a call to action for chronic disease monitoring and preventive care.