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Background Care coordination (CC) involves a critical, cross-cutting set of activities. In the United States (US), consensus about core functions and competencies is lacking; ambiguity exists regarding disciplines, outcomes, measures, and financing. Effectively transitioning care from pediatric to adult systems of care remains a significant challenge. Objective Present a newly developed, multidisciplinary framework for CC, including definition, characteristics, competencies, levels, outcomes, as well as recommendations for future policy, research and education. Look at challenges currently facing youth with special health care needs attempting to transition to adult systems of care. Results Developing a family-centered system of health care requires full engagement of patients, youth, and families in the planning and implementation process. The CC framework offers strategies including clarification of definition of CC, role descriptions, characteristics, core competencies, levels of service, and culturally-effective approaches. The framework also details anticipated outcomes resulting from the experience of receiving and providing highly effective coordination of care. The family-centered ‘medical home’ is highlighted as a hub for community-based CC. Functional relationships and communications are assumed at points of engagement along the health care continuum and across community partner organizations. The CC framework provides a structured approach to empower youth with chronic conditions and their families/caregivers to address and overcome some of the challenges of transitioning care from pediatrics to adult health systems. Conclusions To achieve a high performance health care system, it is essential to create, sustain, and measure the performance of an integrated, consistent CC infrastructure. This is systematically lacking at the present time in the US. Driving this transformation will be the creation and implementation of multiple elements and promoting factors within the healthcare system and across multiple sectors of the broader community. These factors will enable effective transitions from pediatric to adult health care systems.

Effective transitions for youth from pediatric to adult systems of care: the role of care coordination in integration