Care Coordination Workgroup

Definition

In June 2015, the NCC Medical Home and Transition Workgroups were merged to create the NCC Care Coordination Workgroup.  This newly formed workgroup will use the skill and expertise from the older workgroups to address issues in care coordination including medical home and transition concerns.  The NCC Care Coordination Workgroup aims to promote care in a medical home setting, which the American Academy of Pediatrics defines as “accessible, continuous, comprehensive, coordinated, compassionate, family-centered, and culturally effective.” This involves cooperation between all of the systems involved in supporting the affected individual. The workgroup defines the Patient-Centered Medical Home (PCMH) as “an approach to providing comprehensive primary care for children, youth and adults,” and the approach is thought to be especially effective for individuals with chronic conditions. The workgroup is currently evaluating medical home activities in throughout the RCs and considering potential projects for improving communication among providers.

Mission Statement (Agreed Upon by the NCC Medical Home Workgroup in October, 2012)

The American Academy of Pediatrics defines care in a medical home as accessible, continuous, comprehensive, coordinated, compassionate, family-centered, and culturally effective.3  

Care Coordination: Ideally, care coordination should include all systems that support the affected individual, including social service agencies and schools.  In order to function across multiple systems or settings, care coordination functionalities must exist within each setting and maintain effective communication links….The basic elements of care coordination include an iterative, dynamic care plan, an explicit mutually understood definition of roles, and the identification of the locus of condition management.  

AAP, AAFP, ACP, and AOA Joint Principles on the Patient Centered Medical Home: 
Please note HRSA uses this definition.