Utah Children's Care Coordination Network

What the UCCCN Is

The Utah Children’s Care Coordination Network (UCCCN) was formed in late 2014 to be a source of information, resources, tools, expert advice, and peer learning and support for pediatric and family practice staff members who help coordinate the care of patients. The UCCCN evolved from a Medical Home Demonstration project*, led by the Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ) and the Medical Home Portal, and is a partnership with the Utah Bureau of Children with Special Health Care Needs (UDOH) and Utah Family Voices at the Utah Parent Center.**
The UCCCN is coordinated by Mindy Tueller, MS, also Manager of the Medical Home Portal, and supported by Gabi Baraghoshi, RN, MPH (UPIQ Practice Coach), Chuck Norlin, MD (Director of the Portal), Tay Haines (Portal Services & Resources Coordinator), and Gina Pola-Money (Director of Utah Family Voices). Each of us will be available to provide advice and support to your care coordination staff and your practice.
Utah Children's Care Coordination Network

UCCCN Meetings

UCCCN meetings are held every 3rd Wednesday of the month from 8:30 to 10:00 am at the Utah Parent Center, 200 South 230 West, Suite 1101, Salt Lake City. To participate, contact Mindy Tueller (mindy.tueller@utah.edu) or Tay Haines (tay.haines@utah.edu).
Meetings engage Network members in:
  • Education about coordinating care for children, with an emphasis on those with chronic conditions and special health care needs and the family- and patient-centered Medical Home approach
  • Learning about local specialty and other service providers and other health-related resources for children and their families
  • Sharing challenging cases, great ideas, unique resources, and lessons learned
  • Using tools and techniques that will help your practice care for patients with special needs more efficiently and effectively, including new features that will soon be available on the Medical Home Portal.
The UCCCN also offers its members an email listserv to seek answers to questions, share ideas, and find support between meetings. For practices, the UCCCN can assist with job descriptions, guidelines related to care coordination, and finding tools and other resources. There are no charges for participation.

Topics and Presenters

Topics and presenters in 2016 have included:
Billing & Coding
Care Coordination Framework
Motivational Interviewing
IEPs and 504s
Medical Home Portal
Mental Health Integration
Mental & Behavioral Health
Asthma Management
Assessment and Care Planning
Summit Reinsurance
Utah Parent Center
Trauma Informed Care Network
Family Resource Facilitators Program
Valley Behavioral Health
Utah AAP Chapter Medical Home Champion for Asthma, Allergy and Anaphylaxis
Utah Asthma Program
Utah School Nurse Consultant
Utah Dept of Health CHARM System

Topics and presenters in 2015 have included:
Pediatric Care Coordination
Identifying Patients' Needs
Family-Centered Care in the Medical Home Model
Population Management and Registries
Behavioral Health
Utah Medicaid
U of U Pediatric Neurology & Comprehensive Care Clinics
Utah Family Voices
Utah Parent Center
Bureau of Children with Special Health Care Needs
University Developmental Assessment Center
Shriners Salt Lake Pediatric Orthopaedic Services
Utah Department of Health Asthma
Primary Children's Behavioral Health Services

UCCCN Learning Sessions

UCCCN learning sessions are designed primarily for individuals involved in coordinating care for pediatric patients but could be of value for clinicians, administrators, and other staff from primary care and specialty practices, insurers, and other health care organizations.
The first UCCCN learning session in October 2016 focused on “Improving Outcomes of Pediatric Care through Care Coordination,” with panels on implementing & improving care coordination, as well as funding it.
A second learning session in March 2017 focused on "Collaborating on Care Coordination," with representatives from SelectHealth, Healthy U, Health Choice, Molina, Regence, and Primary Specialty Services.

* funded by a CHIPRA Quality Demonstrations grant from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, awarded to the Utah Medicaid Program
** funded by a State Implementation Grant for Enhancing the System of Services for Children and Youth with Special Health Care Needs from the Health Resources and Services Administration, Maternal and Child Health Bureau


Information & Support

For Professionals

UCCCN 2015 Pediatric Care Coordination Survey summary (PDF Document 126 KB)
Questions and summarized responses of 39 UCCCN participants to questions on what care coordination-related activities their practices are currently doing.

Chronic Care Management Services Billing (PDF Document 84 KB)
A scenario to bill for CPT 99490 - Chronic Care Management (care coordination) services.

CMS Chronic Care Management Services Changes for 2017 (PDF Document 521 KB)
Chronic Care Management (CCM) services by a physician or non-physician practitioner and their clinical staff, per calendar month, for patients with two or more chronic conditions expected to last at least 12 months.

Coding and Reimbursement Health Care Transition Tipsheet 2017 (PDF Document 925 KB)
A 2017 Coding and Reimbursement health care transition (from pediatric to adult health care) tip sheet put together by Got Transition and the AAP with 2 new components.


Utah Pediatric Care Coordination Information Checklist (PDF Document 171 KB)
To be used as an assessment tool and in conjunction with the Utah Pediatric Shared Plan of Care.

Utah Pediatric Shared Plan of Care template (Word Document 72 KB)
To be used with the Care Coordination Information Checklist to coordinate care with all members of the care team, including families.


Author: Mindy Tueller, MS - 9/2015
Content Last Updated: 11/2016