Abstract
Children with chronic conditions have unmet health needs. Coordinated Healthcare for Complex Kids (CHECK) is a demonstration project with aims to improve health outcomes using an innovative approach to community-based health care. We describe the development and implementation of a community-based medical neighborhood (CBMN). The CHECK CBMN used several novel approaches to partner with clinical and community organizations, including care coordination software, advisory board participation, and an external social service referral database (SSRD). The CHECK CBMN executed 25 formal partnership agreements. We hosted 15 advisory board meetings, participated in 43 community events, and made 1,443 community-based social service referrals. We provided 43 trainings on pediatric chronic conditions and participated in four community in-service trainings. The CHECK CBMN contributes to the understanding of how innovative processes and collaboration can improve care coordination for children with chronic conditions through community and clinical partnerships.
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