Indiana Complex Care Coordination Collaborative

Joined ten-state Collaborative Improvement and Innovation Network

Indiana was accepted into a ten-state 2017-2022 HRSA-funded Collaborative Improvement and Innovation Network (CoIIN) to Advance Care for Children with Medical Complexity. The COIIN for CMC established goals to improve:

1. Quality of life for children with medically complex conditions
2. Well-being of their families
3. Cost effectiveness of their care

ARPA Expansion

With American Rescue Plan Act Home and Community Based Services (HCBS) Stabilization Grant dollars from 2022 to 2025, the project expanded to embed 13 nurses across seven health systems serving over 900 children and adults in nine Indiana counties.

Over two years the expansion demonstrated success:

• Invited families had over 90% enrollment acceptance and over 80% two-year retention rates.
• Over 90% of surveyed families stated that their nurse helped with all three key components of care coordination:
  • navigating difficult referrals, funding issues and follow-up activities
  • finding needed services (e.g., transportation, equipment, home care)
  • connecting and communicating with the members of each child's team
• Clinical teams reported improved readiness to serve these complex patients with reduced burden of care across rural, mixed rural/urban and urban settings.
• A Medicaid claims analysis of 180 participants demonstrated a 10% reduction in emergency department visits and 32% reduction in hospitalization costs when comparing year 0 to year 2.

The embedded care coordination model’s success has extended from primary care to multispecialty teams at IU Health Riley Hospital for Children, including neuromuscular and spina bifida clinics.