Care Coordination That Helps Families and Cuts Costs

Ashley Honor would have more than enough on her plate as a single working mother supported by Medicaid. But Ashley, a part-time salesclerk in Winter Park, Fla., also has two children with cri du chat (cat’s cry) syndrome, named for the piercing sound made by infants who have the rare genetic disorder.

Jamari, 7, and Faith, 3, depend on wheelchairs and feeding and breathing tubes. For much of their lives, Ashley found herself taking one or both children to her hospital’s emergency department as often as every other month.

She knew her kids deserved better. That’s why she came to us. 

In the fall of 2020, Ashley made an appointment with a pediatrician at our hospital in Orlando. There, she was introduced to Conne McClure, one of our expert care coordinators. These registered nurses and social workers are the sherpas of our system: hard-working guides and burden-bearers who help manage complicated care. 

“Conne has helped me and my kids so much,” says Ashley. “She has assisted us in all sorts of ways and has listened to every concern I’ve had.”

Nemours Children’s employs about 36 care coordinators, in a program we began in 2018. Their work is wide-ranging and often deeply effective. They serve as the key points of contact for families confronting a multifaceted U.S. health system. They problem-solve with multiple care providers, government agencies and insurance firms and help parents advocate for children at school. With each family, they build relationships of trust, handling sensitive information and, often, frequent crises.

Working with Ashley and her children, Conne helped obtain at-home medical equipment including extra tubes so that the family wouldn’t suddenly run out — a reason for some of those many unnecessary hospital and emergency room visits. She saved Ashley precious time — and reduced her missed days at work — by arranging for a pharmacy to deliver medications, and for lab tests to be done at home. She has helped Ashley apply for more benefits from SNAP, the government food-aid program, and once ordered an Uber to get Ashley and Jamari to a doctor’s appointment when a Medicaid driver couldn’t get there in time.

Our care coordinators are just one of the ways we keep our vow to go “well beyond medicine.” Children may be referred to the program in any one of several ways, including by a community health worker, an emergency-department provider, or a school nurse. Researchers have found that this strategy not only helps patients but significantly reduces health care costs for hospitals and taxpayers.

“Now, knock on wood, the kids aren’t going to the emergency department anymore,” says Ashley. “If we have to go to the hospital, it’s just for doctors’ appointments.”

Ashley says she tells all her friends about the care she has received from Nemours. “I like the way they do business, the way they care about kids,” she says. “They’re more in tune and in depth on their care, and they’ve really improved my kids’ quality of life.”

The care coordinator program is a free service provided to eligible patients. Talk to your health care provider to learn more.