This page provides tips and best practices from grantees on improving systems of care.
Epilepsy Foundation of Florida improved the co-management between physicians and the care coordination team in Miami, by assigning a designated "team" to the patients of each PCP, so that each physician will always be communicating with the same support team members for all their patients enrolled in CMS. The team includes a designated nurse, social worker and clerical staff. This system change is to improve care for children, ease administrative burdens for pediatricians and streamline services for families. It is also a step in helping pediatricians to build/improve a medical home for CYSHCN in their practices.
Florida developed a statewide Virtual Intake and Case Management system, including electronic health records that eliminated geographic boundaries for epilepsy services within the state, and reduced wait time for intake by 50% and wait time for an initial neurology appointment by 80%.
Florida provided 125 Miami-Dade, previously uninsured children with epilepsy with health insurance coverage through Title V, Children's Medical Services and enrolled 85 children, previously without a primary care physician, into a Medical Home.
The Epilepsy Foundation of Western/Central PA and the PA Medical Home Project are working together to extend their education and pediatric practice support . One example is joint education conferences offered to all pediatric providers, family medical home partners and community providers; and, expanded provider seizure management needs assessments of all PA pediatric providers that will help guide program development and identify priority pediatrician education needs. Working together increases the effectiveness of both initiatives and extends the influence of the programs beyond what either of them would achieve outside of the partnership.
California Learning Collaborative Team Replicable Models, Tools and Learning Collaborative Outcomes Provides replicable models, tools and other outcomes that came from the California Learning Collaborative Team.