1. Care Coordination as a Continuous Partnership
Module 2:
Care Coordination as a
Continuous Partnership

3. What is care coordination?
Richard C. Antonelli, MD, MS, FAAP
Boston Children’s Hospital

4. RIPIN Peer Care Coordinator
Yamillette Hernandez
RIPIN Peer Care Coordinator

5. Core Components

6. Questions and tips for building partnerships with families
Questions to better understand the child and who they are as a family
To better understand how families manage and cope with their child’s health condition and find/accept the support of others
To better understand the family’s needs, and how we, as Care Coordinators can help

7. What does care coordination look like for a patient, their family and for health professionals?

8. RIPIN Peer Care Coordinator
Mary Ann Heran
RIPIN Peer Care Coordinator

9. Parents as practitioners in pediatrics
Always consider the nature, extent and depth of parenting practices
When we extend ourselves to acknowledge parents’ skills, knowledge, and values, we put ourselves in the position to learn more deeply from each other and to partner more effectively on behalf of children with complex healthcare needs
Parents are experts on their children and should be granted the moral weight of other professionals on the healthcare team

10. PARENT PEER PERSPECTIVE
What do you think families want healthcare professionals to know about WHO they are as a family, about HOW they are coping with their child’s diagnosis, and about THEIR needs?
2. Often health care professionals are considered to be “good readers of people”. As a Peer Care Coordinator, what have you found to be the most effective way of “reading people”, that is, how do you gain the knowledge of the child and family, assess their needs, and respond to their concerns? How do you know when you are reading children and families correctly?
3. As a Care Coordinator and a parent, how do you set realistic expectations for yourself in getting to know families? What are the barriers or obstacles in getting to know families? How can tools, procedures, and protocols either help or hinder the process of getting to know families on their own terms?
4. How can tools, procedures, and protocols either help or hinder the process of getting to know families on their own terms? How can you tell if they are helping or hindering? How do you know when the needs of the fmily are being served, versus meeting your own professional needs (to document information, for example) or the needs of the medical practice in which you work?
4. In Dr. Antonelli’s curriculum, he refers to a story about a family with a child afflicted with a severe and life-threatening condition that worsens over time. He speaks of how the burden of the family increases as the child’s condition worsens. In that story, a family member says, “No one ever came to me and said, THIS REALLY STINKS!”. From the perspective of a parent and a Care Coordinator, what do you think the family member was trying to convey? Do you think that often we become so focused on helping families manage that we forget to acknowledge the extent of the emotional turmoil that they family may be experiencing? As a Peer Care Coordinator, what is it like for you when the primary thing you have to offer is compassion and empathy but there is nothing that can be “fixed”? When and how do you extend yourself at times like that? How do you manage your own feelings at these times?

11. How has having a care coordinator enhanced medical home in your practice?

12. Care Coordination Success Story

13. Resources and Citations

14. Contact Information
Valerie Ahern - RIPIN
Peer Support Manager
Yamillette Hernandez – Pediatric Associates/RIPIN
Peer Care Coordinator
Mary Ann Heran – EOHHS Katie Beckett/RIPIN
Parent Consultant/Care Coordinator