Integrated Care Program

Integrated Care is Important to Everyone!

Problem Statement:

Family/ Patient Perspective
A national sample of parents whose children have special health care needs reported
that 37% of the time, their child’s care team members rarely or never explained who
was responsible for different elements of their child’s care1. Families expect this to be 100%.

Referring Provider Perspective
More effective care could be offered in the primary care setting
if consulting subspecialists would give clear and
actionable information that addressed their concerns.

Subspecialist Perspective
Knowing why the primary care provider refers the patient to
the subspecialty setting would allow them to know what
has been done to date, and what is expected from them.

 

Today’s care teams are challenged to coordinate activities and recommendations across settings. Often , families must take the lead on these responsibilities. Along with adding substantial strain to families, these challenges often result in uncoordinated and inefficient care. Integrated care is the seamless provision of health services, from the perspective of the patient and family, across the entire care continuum and is essential to achieving the best health outcomes for every patient. Care coordination is the set of activities and functions that is necessary to create and implement a multidisciplinary plan of care in partnership with the patient and family2.

The Integrated Care Program at Boston Children’s Hospital creates and validates processes, tools, and measures that improve the integration of patient care across the healthcare continuum. Our goal is to improve care integration within and across settings and disciplines-- especially for patients with complex and chronic conditions. We measure success by our impact on outcomes of quality and safety, patient and provider experience, and cost of care. In recognition of our work across the United States, our team is honored to be serving in its third year as the National Center for Care Coordination Technical Assistance. In partnership with the National Center for Medical Home Implementation at the American Academy of Pediatrics, we receive funding from the US Maternal and Child Health Bureau to support implementation of our tools across the states and territories.

A selection of our key tools is on the left hand tab. Please contact us if you would like to learn more about our approach to measuring and improving care coordination and integration.

Please contact us if you would like to learn more about our approach to measuring and improving care integration. In addition to sharing implementable resources, our team offers technical assistance to help you improve outcomes of care for children and youth.

For further information, please contact integratedcare@childrens.harvard.edu.

Program Leadership:

Richard Antonelli, MD, MS, Medical Director, Integrated Care

Casey Fee, SM, Program Manager, Integrated Care

Hannah Rosenberg, MSC, Project Manager, Integrated Care

1 Ziniel SI, Rosenberg HN, Bach AM, Singer SJ, Antonelli RC. Validation of a Parent-Reported Experience Measure of Integrated Care. Pediatrics. 2016; 138(6).

2Turchi R, Antonelli R. Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. American Academy of Pediatrics policy statement, Pediatrics. 2014.