Name
Creating Force Multipliers for Integrated Care Management in the Pediatric Medical Home
Description

This presentation demonstrates how Burlington Pediatrics/Mebane Pediatrics has operationalized team-based care coordination to extend the reach and impact of pediatric primary care providers. By strategically deploying care navigators, social workers, and referral specialists to manage low-complexity patient needs, the practice has created "force multipliers" that enhance patient engagement, improve access to community resources, and allow care managers to focus on higher-complexity clinical decision-making. The integration of text messaging platforms for broad, low-touch outreach has further amplified the team's capacity to proactively connect with families, demonstrating a scalable model for comprehensive pediatric medical home implementation.

Speakers
Yun Boylston, MD
MoRhonda Foxx, CMA
Megan Smith
Cassandra Webb, RN
Isabelle Whetzel
Content Level
All Audience
Tags
Care management, Complex Patient Care, Social determinants of health or SDoH
Session Type
Concurrent
Objective 1
Describe how a team-based care model that allows all members to work at the top of their license to maximize practice capacity and provider efficiency.
Objective 2
Apply evidence-based principles of care coordination to shift from reactive problem-solving to systematic, population-based health management in the pediatric medical home.
Objective 3
Identify key workflow modifications and team roles necessary to operationalize integrated care management within existing practice infrastructure and resource constraints.
Content Reference 1

Yonek J, Lee CM, Harrison A, Mangurian C, Tolou-Shams M.Key Components of Effective Pediatric Integrated Mental Health Care Models: A Systematic Review. JAMA Pediatrics. 2020;174(5):487-498. doi:10.1001/jamapediatrics.2020.0023.

Content Reference 2

Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care. Journal of the American Academy of Child and Adolescent Psychiatry. 2023;62(2):91-119. doi:10.1016/j.jaac.2022.06.007.

Content Reference 3

Walter HJ, Vernacchio L, Correa ET, et al. Five-Phase Replication of Behavioral Health Integration in Pediatric Primary Care. Pediatrics. 2021;148(2):e2020001073. doi:10.1542/peds.2020-001073.

Content Reference 4

Van Cleave J, Boudreau AA, McAllister J, et al.Care Coordination Over Time in Medical Homes for Children With Special Health Care Needs. Pediatrics. 2015;135(6):1018-26. doi:10.1542/peds.2014-1067.

Content Reference 5

5. Patient- And Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems. Pediatrics. 2014;133(5):e1451-60. doi:10.1542/peds.2014-0318. 6. Berset AE, Burkhardt MC, Xu Y, Mescher A, Brinkman WB. Effect of Electronic Outreach Using Patient Portal Messages on Well Child Care Visit Completion: A Randomized Clinical Trial. JAMA Network Open. 2022;5(11):e2242853. doi:10.1001/jamanetworkopen.2022.42853. 7. Berset AE, Burkhardt MC, Xu Y, Mescher A, Brinkman WB. Effect of Automated and Personalized Outreach Messages on Well-Child Visit Catch Up: A Randomized Clinical Trial. Academic Pediatrics. 2024;24(6):914-921. doi:10.1016/j.acap.2023.11.017. 8. Debinski B, Daniel SS, Rigdon J, et al. A Pilot Randomized Controlled Trial of Text Messages to Improve Well-Child Visit Attendance After No-Show. Academic Pediatrics. 2024 Nov-Dec;24(8):1210-1219. doi:10.1016/j.acap.2024.06.003. 9. Tan CXY, Chua JS, Shorey S. Effectiveness of Text Message Reminders on Paediatric Appointment Adherence: A Systematic Review and Meta-Analysis. European Journal of Pediatrics. 2024;183(11):4611-4621. doi:10.1007/s00431-024-05769-z. 10. DeCamp LR, Godage SK, Valenzuela Araujo D, et al. A Texting Intervention in Latino Families to Reduce ED Use: A Randomized Trial. Pediatrics. 2020;145(1):e20191405. doi:10.1542/peds.2019-1405. 11. Lin E, Noritz G Home Health Care of Children, Adolescents and Young Adults With Complex Medical Needs: Clinical Report.. Pediatrics. 2025;156(3):e2025073171. doi:10.1542/peds.2025-073171. 12. Noritz G, Davidson L, Steingass K. Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy. Pediatrics. 2022;:e2022060055. doi:10.1542/peds.2022-060055.