The IU School of Medicine Complex Care Coordination Technical Assistance Center is a transdisciplinary team of skilled nurse care coordinators, social workers, clinicians and family representatives. Together they have the advanced expertise to train and support new and curious care coordinators to improve the delivery of patient-and-family-centered care which assesses and addresses the comprehensive needs of patients, families and/or caregivers. Their targeted training curricula focus on serving children with medical complexity and/or adults with intellectual or developmental disabilities (IDD). The center is part of the Department of Pediatrics Division of General and Community Pediatrics.
The technical assistance team’s work includes:
- An infrastructure for professionalizing care coordination with formal curricula and professional development coaching to promote job success and advancement and to maintain satisfaction in this field of work.
- Participation in the orientation, the high intensity curriculum and the longitudinal learning collaborative speeds the growth of care coordinator skills to achieve competency in key milestones and provide high quality care.
- Individualized coaching in care coordination processes is reinforced through chart auditing, quality indicator feedback and competency milestone assessment.
- Standardized accurate health system, government, and community service information is synthesized, collated and distributed to care coordinators and families, with semi-annual assessment of family satisfaction.
- An infrastructure for building patient/family-centeredness engages patients and families in all levels of the process, using enhanced care coordinator communication skills and the model of Parent Café.
- Collaborates to proactively Identify needs and strengths and incorporate them together into next step actions to accomplish goals.
- Engages the patient and/or family in alignment with their self-advocacy ability to actuate outcomes.
- Refines health care utilization through skill-building in self-management, empowerment and resiliency.
- An infrastructure for building advanced medical homes to address chronic care management for patients with medical complexity and IDD, primarily within primary care.
- Delivers frontline tools for care management of key populations.
- Facilitates learning collaboratives with both physician champions and participating clinicians.
- An infrastructure for disseminating information and linking stakeholders in care coordination and service delivery across the state.
- Produces and disseminates scholarship across care coordination, patient/family centered care and chronic care management.
- Builds a community of practices of key stakeholders through a statewide advisory committee.