PROJECT MANAGEMENT PLAN – The Influence of Comprehensive Care Coordination on Patients with Chronic Medical Conditions and Special Healthcare Needs in a Community Pediatric Residency Program Continuity Clinic
Vision StatementOur vision is to educate, motivate, and empower vulnerable patients and young physicians by clarifying the roles of existing resources, streamlining communication among stakeholders, and utilizing a team-based strategy to deliver excellent care.
Team ObjectivesOur objectives were as follows:

  • Study the influence of team-based comprehensive healthcare coordination on outcomes of children with complex healthcare needs in a pediatric resident continuity clinic at Heartland Community Health Clinic-Armstrong

  • Study the feasibility of providing comprehensive coordination in a resident’s continuity practice and creating a framework of resources and strategies for sustainability

  • Understand the educational needs of pediatric residents in preparation for future practice

Success FactorsThe most successful parts of our work were as follows:

  • The level of patient engagement that was achieved

  • The trust that patients put in the team (they kept in close contact and made extraordinary efforts to keep their appointments)

  • The small clinical wins (successful visits with subspecialists, approval for medications or durable medical equipment)

  • The increased understanding/fund of knowledge about nonmedical challenges, such as guardianship and disability enrollment

  • The significant increase of PCP continuity in a resident clinic

  • The decrease in no-shows for mental health visits

  • The decrease in ED/urgent care visits (average charge per ED visit was $2,244)


We were inspired by the commitment of the parents of our patients and their ability to overcome barriers with our help and also the commitment of the residents to their patients despite busy work schedules.
BarriersThe largest barriers encountered were research issues: families often did not bring their binder to the office visit and some data were difficult to obtain/track (eg, medication compliance). Family issues such as instability of living situation, lack of transportation, and limited access to telephones were also barriers. Finally, researcher issues such as residents’ schedules being affected by work duty hours and their panels having a limited number of spaces each clinic day were other barriers. We worked to overcome this challenge by increased access to care with direct social work contact and regularly scheduled appointments with the care team and by regularly reassessing patient needs with patient care team meetings.
Lessons LearnedThe single most important piece of advice to provide another team embarking on a similar initiative is to make sure resident continuity is the highest priority for children with special healthcare needs in the residency clinic setting, utilizing whatever resources the clinic has available to make this happen (schedulers, dedicated RN coordination, etc.). This continuity has improved the team’s ability to build relationships and their ability to care for the patients. Also, follow strict protocols throughout the entire research process and meet regularly to discuss the protocol itself.
More advice is as follows:

  • Pay attention to the enrollment process and exclusion criteria (adequate numbers, adequate enrollment period, scripted individual enrollment to include educating families about their commitment to the project and introducing families to the entire team to get them excited)

  • Choose data that are easily obtained and not dependent on patient behavior (eg, patient binders) and regularly review that the data are being documented properly, systematically, and in a timely fashion

  • Obtain funding to help patients and families overcome barriers such as transportation needs or telephone access