Health care delivery for children with medical complexity (CMC) remains fragmented, which limits the potential to achieve optimal health and developmental outcomes. Traditionally, care coordination is initiated and managed within a single practice or entity, resulting in duplication of effort and persistence of unmet family needs. This project utilizes human-centered design (HCD) to rethink the process of care coordination for CMC. The goal is to design an approach to care integration across all sectors of care and support to achieve optimal health and wellbeing for the child. Through a series of HCD steps, the project reached the following conclusions: (1) Coordinated care can be a predictable "designed" pathway of care across multiple sectors of care, including medical, education, financial, and community services. (2) Building effective care coordination pathways and processes with a cross-sector collaborative approach results in care integration. (3) Care integration for CMC requires a series of feedback loops across the multiple services sectors, and a care coordinator's task is to actively manage the processes of the feedback loops. The essentials to successful care integration for CMC are (1) a cross-sector data and information platform with a shared plan of care; (2) a playbook of jointly designed, predictable care pathways; and (3) a designated care coordinator who is responsible for managing information flow and feedback. HCD methods can bring together a coalition of cross-sector stakeholders to pilot test the proposed elements of care integration.
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