In October 2007, Project BLOOM (BLOOM) received a supplemental grant from the Substance Abuse and Mental Health Services Administration to, in part, develop a care coordination model focusing on the integration of behavioral and physical health for children. To meet this objective, BLOOM sponsored four monthly forums between May and August 2008 in which 91 stakeholders from across the state were invited to attend.

Forum participants, under the direction of BLOOM staff and members of a leadership team, developed a Colorado Care Coordination Plan and that includes:

• a description of care coordination principles, values, a mission and outcomes;
• essential qualities of care coordination;
• recommendations for families, providers, and systems-level agencies on how to increase the efficiency with which care coordination services are provided and received; and
• recommended next steps.

Forum participants determined that care coordination services are centered on the following five essential qualities:

(1) Relationship-Building;
(2) Culturally Competent Care;
(3) Family Focused and Strengths-Based Services;
(4) Active Interagency Collaboration/Information and Referral; and
(5) Process and Outcomes Evaluation.

The Colorado Care Coordination Plan includes these key recommendations for (1) Families/consumers of care coordination-related services, (2) Care coordinators and providers of services, and (3) Systems-level agencies that develop care coordination policies and programs:

1. Promote and have access to a client-centered electronic safety net personal health record for improving care coordination and allowing 24/7 access of information

2. Universal health care that covers all health (oral, behavioral, mental, and physical) and covers long term care

3. The Colorado Medical Home Standards and System of Care Values and Principles are applied and prioritized throughout the provision and receipt of care coordination services

4. Adopt the “no wrong door” process by which families/consumers access care coordination services
5. Identify and participate in the development of outcomes and support the monitoring and evaluation of these outcomes

6. Utilize and be the recipient of culturally competent practices

7. Engage in continued multi-disciplinary system assessment in order to identify unmet needs

A Care Coordination Toolkit was developed to foster the integration of the Medical Home and System of Care approaches and to promote authentic partnerships between families and providers.