AL Journey Map Graphic

Team Alabama’s journey map illustrated by ConverSketch

Lead Organization

Alabama Department of Rehabilitation Services/Children’s Rehabilitation Services (Title V)

Family/Youth Engagement Partner

Family Voices of Alabama

Clinical Site

Children’s Rehabilitation Services

Project Aims

To improve communication within our state to determine the needs of children with medical complexity, beginning with identifying CMC through Medicaid & private insurer data run.

Project Description

The Alabama CoIIN state team, in conjunction with families and staff at the University of South Alabama (USA) Pediatric Complex Care Clinic and Children’s Rehabilitation Service, is implementing a comprehensive care coordination program to improve outcomes for CMC that focuses on patient and family quality of life. This is being accomplished through the establishment of a patient-centered medical home model and the use of Shared Plans of Care to improve communication among providers and families. To date, the Alabama team has developed a shared plan of care and hired a Care Coordinator who is providing care coordination services to children with medical complexity and their families at the USA Strada Patient Care Center Pediatric Complex Care Clinic.

Focus Area(s)

  • Family engagement
  • Care coordination
  • Transition