Montana healthcare providers, families & caregivers, and social & human service professionals share the same on-going overall goal for at-risk children and youth: Improved health and well-being outcomes of children, youth and their families.

A Montana interdisciplinary team is participating in a unique learning community centered on implementation of care coordination. Through workshop-structured learning opportunities, regular virtual meetings, and targeted technical assistance, the National Care Coordination Academy supports Montana efforts to acquire the essential knowledge, skills, and competencies for effective care coordination in the Big Sky.

Key Montana Team Outcomes

• Meaningful family and youth participation in healthcare decisions that impact their health and family well-being.
• Increased healthcare literacy among families and transitioning youth.
• Increased provider understanding of patient- and family-centered medical homes, how they function, and what is required to sustain them.
• Enhanced communication across health centers, systems and providers.

Connect to the Montana Team

Montana Team Member Listserv: MTCCA-L@LISTS.UMT.EDU

Team Leadership Contacts:

• Kim Brown

Team Resources

• Montana Team Overview and Invitation: one-page fact sheet describing Montana's team and how to join.
• Montana Team Working Files: Provides access to the working Action Plan, meeting agendas and minutes, Montana Team roster, and other team-related files.
• The National Care Coordination Standards for Children and Youth with Special Health Care Needs (CYSHCN) are designed to help state officials and other stakeholders develop and strengthen high-quality care coordination for children. They identify and assess the need for care coordination, engage families in the process, build a strong and supportive care coordination workforce, and develop team-based communication processes. Download the standards document.
• Pediatric Integrated Care Survey (PICS): A Family-reported survey instrument that measures family experiences of care integration. It is used to inform quality improvement and interventions to improve integration.  Available in English and Spanish.
• The Care Coordination Measurement Tool (CCMT) enables care providers to record the types of encounters that necessitate care coordination activities, the complexity level of the patient requiring care coordination, the activities performed, and the outcomes that occurred.

Open Pediatrics Connection

Go to the Open Pediatrics website.

National Care Coordination Academy materials are in the “My Courses” section of Open Pediatrics.  If you are unable to connect to your Open Pediatrics account, please contact Kim Brown.

Pediatric Care Coordination

The five module Pediatric Care Coordination Curriculum, 2nd Ed. (Antonelli, et al., 2020) is available on Open Pediatrics. This online video version uses a learning management system to guide learners through the content.

A hard-copy version of the Pediatric Care Coordination Curriculum, 2nd Ed. is available online.

Curriculum learning objectives

• Discuss key components of care coordination within an integrated model of care delivery
• Identify established tools and processes that can be used to implement key components of care coordination
• Apply tools and processes that support key components of care coordination to a case example

Target audience

• Physicians
• Nurse Practitioners
• Nurses
• Social Workers

Related Resources

• Framework to Promote High Value, Integrated Care
• Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple System. Turchi, R, and Antonelli, R. (PDF)
• Montana Pediatrics is a collaborative effort of innovative Montana pediatricians coming together to bring the convenience of technology enabled care to Montana's children. Behind the scenes, team members communicate directly with each other so healthcare is seamless and important information is not lost.

The National Care Coordination Academy is a Partnership of the Division of General Pediatrics and the Department of Accountable Care and Clinical Integration, Boston Children’s Hospital/ Harvard Medical School and the Collaborative Improvement and Innovation Network for Children with Medical Complexity at the Center for Innovation in Social Work and Health, Boston University School of Social Work, with support from the Health Resources and Services Administration, Maternal and Child Health Bureau.