How to best deliver care to children with chronic illness: cystic fibrosis as a model

Abstract

Purpose of review: Children with special healthcare needs benefit when there is close coordination of care for their chronic disease between specialists and primary care providers. The importance of coordination between primary and specialty care has become better recognized with the increased attention to a comprehensive 'medical home' model of care.

Recent findings: Care coordination requires close communication between primary care providers and specialty care centers. Primary care providers are in an ideal position to assist patients and families by providing care coordination, not only within the healthcare system, but also between the healthcare system and community services and schools. Coordination is best undertaken at the physician practice level, utilizing a team approach. Nonphysician staff provide added value in coordination of care for patients and families. Opportunities for reimbursement for this care are being developed.

Summary: Coordination of care for the many children with special healthcare needs can be realized using existing resources. Using cystic fibrosis as an example, implementation methods within pediatric primary care practices are presented and discussed.