Development of a Community-Based Medical Neighborhood for Children with Chronic Conditions

Background: 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. Objective: We describe the development and implementation of a community-based medical neighborhood (CBMN). Methods: 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). Results: 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. Conclusions: 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.