Providing a medical home: the cost of care coordination services in a community-based, general pediatric practice.

OBJECTIVE To determine the cost of unreimbursable care coordination services for children with special health care needs (CSHCN) in 1 community-based, general pediatric practice. METHODS A measurement tool was developed to quantify the precise activities involved in providing comprehensive, coordinated care for CSHCN. Costs of providing this care were calculated on the basis of time spent multiplied by the average salary of the office personnel performing the care coordination service. In addition, data were collected regarding the complexity level of the patient requiring the service, the type of service provided, and the outcome. RESULTS During the 95-day study period, 774 encounters that led to care coordination activities were logged, representing service provision to 444 separate patients. When these encounters were examined on the basis of clinical complexity of the patient, the most complex patients constituted 11% of the population of CSHCN yet accounted for 25% of the encounters. In addition, care coordination activities for these clinically complex CSHCN engaged office staff 4 times as long when compared with less clinically complex CSHCN. Overall, 51% of the encounters were attributable to coordinating care for problems not considered typically medical and included activities such as processing referrals with managed care organizations, consulting with schools or other educational programs, and providing oversight for psychosocial issues. On the basis of national salary and benefits data, the annual cost of the time spent coordinating care for CSHCN in this medical home model ranged from 22,809 dollars to 33,048 dollars (representing the 25th and 75th percentiles, respectively). CONCLUSIONS The costs of providing care coordination services to CSHCN in a medical home are appreciable but not prohibitive. Standardization of care coordination practices is essential because it makes the medical home more amenable to quality improvement interventions. Mechanisms to finance unreimbursable care coordination activities must be developed to achieve the Healthy People 2010 objective that all CSHCN have access to a medical home.