Helping the Sickest Children Navigate the Health Care System

Helping the Sickest Children Navigate the Health Care System 150 150 Jeb Phillips

Care coordination focuses on better outcomes for children with medical complexity.

Consider a child with cerebral palsy who needs a feeding tube to eat. She has special equipment for a basic life function. She requires regular visits with a primary care physician and specialists in neurology, orthopedics and gastroenterology. She has frequent acute infections that lead to emergency department visits.

“Just surviving day-to-day is intense for this child and her family,” says Sean Gleeson, MD, president of Partners For Kids. “It is very easy for these children to receive sub-optimal care, just because they have so many different points of contact with the health care system. Even when providers are doing their best for the patients, the coordination among services can be overwhelming for the family to manage.”

The group that Dr. Gleeson leads is working to change that with its care coordination program called Care Navigation. Partners For Kids is one of the oldest and largest pediatric accountable care organizations in the United States. It brings together Nationwide Children’s Hospital and more than 1,000 specialists and primary care doctors, and it is responsible for the health care of approximately 320,000 children in central and southeastern Ohio covered under Ohio’s Medicaid Managed Care Plans.

Partners For Kids focuses on keeping children healthy with regular wellness visits. But fragile newborns and some children with chronic diseases and behavioral health conditions need more than that. So in 2013, the organization began its care coordination program.

Care coordinators — social workers, nurses and quality outreach coordinators — individually work with families to help them navigate the health care system. They visit patients at home to gain insight into a family’s particular challenges. They can help schedule several physician appointments on one day, reducing the number of trips families must make.

Care coordinators may also attend physician appointments with patients; ensure patients get screenings and interventions they need for their individual conditions; help connect patients with useful community resources; and help patients learn self-management as they grow, so they can transition successfully to adult health care.

Data from 2014 show that patients enrolled in care coordination for at least 120 days saw hospital inpatient admissions and emergency department visits decrease.


Partners For Kids is working to expand the program to build on its success. The organization now has approximately 45 care coordinators. That number will more than double by 2017.

“Children with medical complexity spend the most time in the hospital, have some of the worst health outcomes, and their families have difficulty managing all that must be done,” says Kimberly Conkol, RN, Partners For Kids’ director of Care Navigation. “Care coordination helps change this reality for these patients. Our team works with the family to help them achieve their goals for the child.”


About the author

Jeb is the Managing Editor, Executive Communications, in the Department of Marketing and Public Relations at Nationwide Children's Hospital. He contributes feature stories and research news to PediatricsOnline, the hospital’s electronic newsletter for physicians and other health care providers, and to Pediatrics Nationwide. He has served as a communications specialist at the Center for Injury Research and Policy at The Research Institute and came to Nationwide Children’s after 14-year career as daily newspaper reporter, most recently at The Columbus Dispatch.