Indiana Complex Care Coordination Collaborative

The Indiana Complex Care Coordination Collaborative (IC4) is an innovative program made possible in cooperation with Indiana Family and Social Services Administration and funded via Section 9817 of the American Rescue Plan Act as a Home and Community Based Services (HCBS) Stabilization Grant.

IC4 delivers a virtual coaching program for primary care teams and embedded nurse care coordinators to improve care for targeted populations of patients who are at particular risk for care disparities and unmet needs. With expansion dollars, the project is building across the state to include both populations of children with medical complexity and adults with intellectual or developmental disabilities.

The model was initially piloted in three pediatric practices to serve children with medical complexity from 2019 to 2022 as part of a 10 state HRSA-funded Collaborative Improvement and Innovation Network (CoIIN) to Advance Care for Children with Medical Complexity. The COIIN for CMC established three 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

The initial participating pediatric practices serve families living in rural, mixed and urban settings:

• Witham Pediatrics in Lebanon/Zionsville/Crawfordsville
• ALL IN Pediatrics in New Albany/Salem
• IUH Riley Pediatric Care Center in Indianapolis. 

Each practice hired a nurse care coordinator to focus their full-time services on meeting the needs of 100 children with complex health conditions and their families. Family satisfaction surveys measure quality of life and well-being. Primary care team surveys measure wellness, teamwork and burden of care delivery. Successful responses from families and primary care teams prompted further expansion.

Peer-reviewed articles

1. Comeau M, Padlan AM, Houlihan B, Coleman C, Louis C, Brown T, Mann M. The Collaborative Improvement and Innovation Network for Children with Medical Complexity. Pediatrics January 2024; 153 (Supplement 1): e2023063424B.
2. Burrell M, Ciccarelli M. Identifying Children with Medical Complexity for Care Coordination in Primary Care Settings. Clinical Pediatrics, 62(7), 781–785, 2023.

Presentations

1. McClanahan N, Hennessy C, Linson K, Ciccarelli M. Building Partnerships for a Large Statewide Program in Providing Care Coordination to High-Risk Populations. Poster presentation, AMCHP annual meeting 2024.
2. Thomison E, McClanahan N, Paauwe H, Ciccarelli M. Parent Cafes: Providing Space to Connect for Family Caregivers in the World of Complex Care. Poster presentation, AMCHP annual meeting 2024.
3. McClanahan N. Building a Virtual Learning Community for Nurse Care Coordinators. Presentation, IUPUI Plater Moore Symposium, IUPUI Indianapolis, April 2024.
4. Guffey N, Ford S, Ciccarelli M. Piloting a Relational Social Determinant of Health Scale to include Empowerments and Determinants. Poster presentation, HEAL-R symposium, IUSM Indianapolis 2023.
5. Ciccarelli, Flaa L, McClanahan N, Swick A. Piloting a Complex Care Nurse Coordinator Curriculum. Poster presentation, Pediatric Academic Societies annual meeting 2023.
6. Swick A, Ciccarelli M, Flaa L, McClanahan N. Impact of Embedding a Coached Nurse for Complex Care Coordination in Primary Care. Poster presentation, Pediatric Academic Societies annual meeting 2023.
7. Ciccarelli M, Flaa L, McClanahan N, Swick A. Measuring Care Coordination Indicators in Primary Care to Improve Workflow. Poster presentation, Pediatric Academic Societies annual meeting 2023.
8. McClanahan N, Flaa L, Hennessy C, Linson K. Indiana Complex Care Coordination Collaborative Coaching and Curriculum Model. Panel presentation, AMCHP annual meeting 2023.