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The division of general and community pediatrics at Indiana University School of Medicine recently received funding for expansion of a primary care embedded nurse care coordinator project.

$4 million grant for complex care provides vital opportunities to children and families in Indiana

Mary Ciccarelli, MD

Mary Ciccarelli, MD

INDIANAPOLIS—The division of general and community pediatrics at Indiana University School of Medicine recently received funding from the Indiana Family and Social Services Administration/Office of Medicaid for expansion of a primary care embedded nurse care coordinator project. The project will focus on improving the quality of care for people with complex health and social needs while also lessening the burdens that families experience in navigating complex health systems.

“The key innovation that we are creating is to coach and train care coordinators so they get up to speed as quickly and efficiently as possible,” said Mary Ciccarelli, MD, Morris Green Professor of Pediatrics and professor of clinical medicine. “Nurse care coordinators oversee a registry of patients with high care needs to provide them with healthcare and community service facilitation, cross-team communication and family education.”

Ciccarelli, as the principal investigator of this study, works within a transdisciplinary leadership team and statewide advisory organizations. Over the next 2-3 years, the Indiana Complex Care Coordination Collaborative (ICCCC) team will support the hiring of 30 nurses to embed into primary care practices across the state. This will include pediatric practices which serve children with medical complexity covered by Medicaid and adult practices which serve adults with intellectual or developmental disabilities who are receiving Bureau of Developmental Disabilities waiver services.

The $4 million grant is made possible through the Home and Community Based Services (HCBS) enhanced Federal Medical Assistance Percentage (FMAP) funds from the American Rescue Plan. The money will fund the training model and hiring of nurses.

As part of a 10-state collaborative funded by the Health Resources and Services Administration, this project was initially piloted in 2019 in 3 pediatric practices at All IN, Witham and Riley Children’s Health primary care across rural, semi-rural and urban communities.  This curriculum and coaching model showed improved satisfaction from families as well as the health care team.

“We learned that families are thrilled with the opportunity to have help managing and organizing complicated care needs,” said Ciccarelli. “We’ve equally learned that the primary care teams are thrilled to have this assistance and it helps them feel like they can approach the care of these children with more confidence and ability.”


IU School of Medicine is the largest medical school in the U.S. and is annually ranked among the top medical schools in the nation by U.S. News & World Report. The school offers high-quality medical education, access to leading medical research and rich campus life in nine Indiana cities, including rural and urban locations consistently recognized for livability.