How Partners For Kids is Expanding Its Nation-leading Care Coordination Program

Children who are considered “medically complex” have an acute, chronic diagnosis that requires frequent medical care. It can be difficult for the families of these children to schedule multiple appointments with care providers, fill prescription medications or acquire home medical equipment – especially if they are struggling with issues like a lack of transportation or a language barrier.

Since 2013, the Care Navigation program from Partners For Kids has helped these children and their families “navigate” the health care system. A team of registered nurses and licensed social workers has helped coordinate care for more than 26,000 children over the last decade, with significant declines in Emergency Department visits and hospitalizations for those children.

But Partners For Kids seeks to improve outcomes for all children, not just those considered the most medically complex. So it has embarked on projects to greatly expand what is already one of the United States’ most robust care coordination programs.

“We are committed to helping children who are most at-risk, but the health care system can be confusing, overwhelming and stressful for anyone,” said Kimberly Conkol, vice president of Clinical Integration at Partners For Kids. “We want to make a difference for as many families as possible.”

Partners For Kids is the nation's oldest and largest pediatric accountable care organization. It’s a partnership among Nationwide Children’s Hospital, Dayton Children’s Hospital and other care providers that is responsible for the health of more than 470,000 children covered by Medicaid managed care plans across 47 Ohio counties.

Most children who receive regular preventive care like check-ups and immunizations stay healthy most of the time. Partners For Kids works with primary care providers to ensure that care happens. It also has extensive experience coordinating care for medically complex children.

The organization’s care coordination program is now expanding in the middle ground between those relative health extremes:

• Broadening “Care Navigation.” Care Navigation is the intensive case management program that has already helped 26,000 children and their families efficiently coordinate their care teams to ensure timely and comprehensive health care. Care Navigation is now working with families who have more moderate needs on a one-to-one basis, including helping children who do not meet the definition of “medical complexity” but still face significant challenges.

• Introducing “Care Guides.” Partners For Kids launched its Care Guide program in 2022 for families with children who may not have chronic or complex conditions but have barriers or difficulties accessing the health care system, which might include finding a primary care provider, accessing benefits from programs like the Supplemental Nutrition Assistance Program, or scheduling transportation to and from appointments. As of October 2023, over 3,000 patients have been served in this program.

• Assisting patients to manage their chronic condition. About 10,000 children have been assisted by the care coordination team to manage chronic conditions like asthma and depression. Partners For Kids has embedded care coordination team members to help with asthma and depression management in Nationwide Children’s Primary Care Network, in an effort to extend resources to help prevent complications and avoid unplanned visits to health care facilities.

• Assessing gaps for all children. In 2023, Partners For Kids began the process of administering the Ohio Department of Medicaid Health Risk Assessment to all 470,000 children in its regions to identify needs that may not otherwise be apparent. As of October 2023, this has successfully identified needs for over 12,000 children and families and connected them to the appropriate resource or care coordination program to assist.

“It is amazing to consider the impact we can make through extension of the care coordination resources to the entire Partners For Kids population,” said Conkol.  “In the past decade, we have seen transformations such as children becoming successful in school after connection to behavioral health care, homeless families moving into apartments, and babies being reunited with their biological parents due to care coordination efforts. Expanding the scope of services to a larger population will open the opportunity to create many more stories like those.”