Utah Children's Care Coordination Network

What the UCCCN Is

The Utah Children’s Care Coordination Network (UCCCN) was formed in late 2014 to be a source of information, resources, tools, expert advice, and peer learning and support for pediatric and family practice staff members who help coordinate the care of patients. The UCCCN evolved from a Medical Home Demonstration project*, led by the Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ) and the Medical Home Portal, and is a partnership with the Utah Maternal and Child Health Bureau (UDOH) and Utah Family Voices at the Utah Parent Center.**
The UCCCN is coordinated by Mindy Tueller, MS, also Manager of the Medical Home Portal, and supported by Gabi Baraghoshi, RN, MPH (UPIQ Practice Coach), Chuck Norlin, MD (Director of the Portal), Tay Haines (Portal Services & Resources Coordinator), and Gina Pola-Money (Director of Utah Family Voices). Each of us will be available to provide advice and support to your care coordination staff and your practice.
Utah Children's Care Coordination Network


UCCCN Meetings

UCCCN meetings are held every 3rd Wednesday of the month from 8:30 to 10:00 am at the USU Salt Lake Distance Education Regional Campus, 920 West Levoy Drive, Room 150, Taylorsville. Other USU regional campus sites throughout the state and a virtual option are also available. To participate, contact Mindy Tueller (mindy.tueller@utah.edu) or Tay Haines (tay.haines@utah.edu).
Meetings engage Network members in:
  • Education about coordinating care for children, with an emphasis on those with chronic conditions and special health care needs and the family- and patient-centered Medical Home approach
  • Learning about local specialty and other service providers and other health-related resources for children and their families
  • Sharing challenging cases, great ideas, unique resources, and lessons learned
  • Using tools and techniques that will help your practice care for patients with special needs more efficiently and effectively, including new features that will soon be available on the Medical Home Portal.
The UCCCN also offers its members an email listserv to seek answers to questions, share ideas, and find support between meetings. For practices, the UCCCN can assist with job descriptions, guidelines related to care coordination, and finding tools and other resources. There are no charges for participation.


Topics and Presenters

Topics and presenters in 2018 have included:
Topics Presenters
Early Hearing Detection and Intervention (EHDI) program and resources UDOH EDHI
Utah 2018 Legislative wrap up of healthcare and CYSHCN related bills Legislative Coalition for People with Disabilities
Meeting families where they are - discussion Summit Pediatrics, Integrated Services Program and Utah Family Voices
Improving Medical Home and Care Coordination South Main Clinic
Topics and presenters in 2017 have included:
Topics Presenters
Car Seat Specialty Clinic Shriners Children's Hospital
Student Transition and Youth Support Utah State Division of Rehabilitation
Family Support & Transition Services Easter Seals-Goodwill NRM
Music Therapy for CYSHCN Harmony Music Therapy
Behavioral Interventions and Supports in Schools Utah State Board of Education
Special Needs Planning Jaron Poulson, CFP
How Assistive Technology can help with Mental Healthcare Needs for Youth with Dual Diagnoses Utah Parent Center and Utah Center for Assistive Technology
IEP & 504 Questions Utah Parent Center
Autism System Development Program CSHCN Bureau, UDOH
Asthma resources for Utah pediatric practices Utah Asthma Program and the Utah Asthma Home Visiting Program

Topics and presenters in 2016 have included:
Topics Presenters
Medical Home Portal Staff
Care Coordination Framework Staff
Registries and Quality Improvement Processes Staff and UCCCN members
Billing & Coding University of Utah General Pediatrics
Motivational Interviewing Summit Reinsurance
IEPs and 504s Utah Parent Center
Mental & Behavioral Health Trauma Informed Care Network, DCFS, Valley Behavioral Health, Family Resource Facilitators Program
Asthma Management Utah Asthma Program, Utah AAP Chapter Medical Home Champion for Asthma, Allergy and Anaphylaxis
Assessment, Care Planning, Information Sharing Utah Dept of Health CHARM (Child Health Advanced Records Management) System
Early Childhood Development Office of Home Visiting

Topics and presenters in 2015 have included:
Topics Presenters
Pediatric Care Coordination & Identifying Patients' Needs Staff
Family-Centered Care in the Medical Home Model Utah Family Voices
Population Management and Registries UPIQ
Behavioral Health Primary Children's Behavioral Health Services
Pediatric Orthopaedic Services Shriners Children's Hospital - Salt Lake City
Integrated Services Program Bureau of Children with Special Health Care Needs
Asthma Management Utah Department of Health Asthma
Pediatric Neurology & Comprehensive Care U of U Dept of Pediatrics Clinics
Evaluation of children with or at risk for developmental delays University Developmental Assessment Center
Medicaid Services Utah Medicaid
IEPs and 504 Accommodations Utah Parent Center


Meeting Summaries and Resources of the Month

You can find meeting summaries, which include cases and helpful resources on the Resources of the Month page.


UCCCN Learning Sessions

UCCCN learning sessions are designed primarily for individuals involved in coordinating care for pediatric patients but could be of value for clinicians, administrators, and other staff from primary care and specialty practices, insurers, and other health care organizations.
The first UCCCN learning session in October 2016 focused on “Improving Outcomes of Pediatric Care through Care Coordination,” with panels on implementing & improving care coordination, as well as funding it.
A second learning session in March 2017 focused on "Collaborating on Care Coordination," with representatives from SelectHealth, Healthy U, Health Choice, Molina, Regence, and Primary Specialty Services.
The most recent learning session was held in March 2018. The topic was "Care Coordination: What do Families Value?" and included a panel of 6 parents of children with special needs and a panel of 5 clinicians consisting of primary care, mental health, and sub-specialists.

* funded by a CHIPRA Quality Demonstrations grant from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, awarded to the Utah Medicaid Program
** funded by a State Implementation Grant for Enhancing the System of Services for Children and Youth with Special Health Care Needs from the Health Resources and Services Administration, Maternal and Child Health Bureau

Resources

Information & Support

For Professionals

UCCCN 2015 Pediatric Care Coordination Survey summary (PDF Document 126 KB)
Questions and summarized responses of 39 UCCCN participants to questions on what care coordination-related activities their practices are currently doing.

Chronic Care Management Services Billing (PDF Document 84 KB)
A scenario to bill for CPT 99490 - Chronic Care Management (care coordination) services.

CMS Chronic Care Management Services Changes for 2017 (PDF Document 521 KB)
Chronic Care Management (CCM) services by a physician or non-physician practitioner and their clinical staff, per calendar month, for patients with two or more chronic conditions expected to last at least 12 months.

Coding and Reimbursement Health Care Transition Tipsheet 2017 (PDF Document 925 KB)
A 2017 Coding and Reimbursement health care transition (from pediatric to adult health care) tip sheet put together by Got Transition and the AAP with 2 new components.

Tools

Utah Pediatric Care Coordination Information Checklist (PDF Document 171 KB)
To be used as an assessment tool and in conjunction with the Utah Pediatric Shared Plan of Care.

Utah Pediatric Shared Plan of Care template (Word Document 72 KB)
To be used with the Care Coordination Information Checklist to coordinate care with all members of the care team, including families.

Authors & Reviewers

Initial Publication: September 2015; Last Update: February 2018
Current Authors and Reviewers (click on name for bio):
Author: Mindy Tueller, MS