Team Indiana’s journey map illustrated by ConverSketch

Lead Organization

Indiana State Department of Health

Children’s Special Health Care Services (CSHCS) (Title V)

Family/Youth Engagement Partners

About Special Kids

Family Voices Indiana

Clinical Site

Indiana University Department of Pediatrics and Indiana University Health Physicians

Project Aims

Using a primary-tertiary care coordination collaborative, we will create comprehensive, functional, fluid shared plans of care (SPoCs) for all 300 identified families within 3 years which will be utilized by the family and all providers.

Project Description

The Indiana CoIIN state team is creating a primary-tertiary care team collaborative with the goal of identifying unmet need and improving communication for families involved in three selected primary care practices. These goals are being met through the development and implementation of comprehensive, functional, and fluid Shared Plans of Care in conjunction with nurse care coordination to improve service delivery and quality of care for families. To date, the Indiana team has built a state Pediatric Complex Care coordination team and initiated nurse care coordination in three primary care practices across the state.

Focus Area(s)

• Family engagement
• Care coordination
• Improved access to care for CMC living in rural communities, including telemedicine
• Alternative payment methods