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Introduction

Public health nurses, especially Children with Special Health Care Needs (CSHCN) Coordinators, play an important role in assuring medical homes for children in Washington. This page describes how public health nurse CSHCN Coordinators partner with families, primary care providers and other service providers to support medical homes in Washington. CSHCN Coordinators may be especially interested in the samples of forms some coordinators are using to share information and enhance care coordination with physicians and other providers.

Who are CSHCN Coordinators?

CSHCN Coordinators are public health nurses located in the thirty-four local health departments or districts that serve all 39 counties.

The Coordinators serve children age birth to 18 years who have or are at risk of having a serious physical, developmental, behavioral or emotional condition; who require health and related services of a type and amount beyond what is generally required, and who reside in Washington State. Some children who are already part of the program may be able to continue services until the twenty-first birthday for purposes of transition to adult care.

The public health nurse CSHCN Coordinator helps families by:

  • Helping families access needed services for their child such as medical care and other intervention.
  • Referring families to health insurance programs and information, both private insurance and the state funded Medicaid Program.
  • Providing support to families and helping families help each other through parent support organizations.
  • Helping with concerns such as feeding nutrition, growth, development and behavior.
  • Providing nursing evaluations, screening and assessment.

Client referrals are made by families, schools, medical providers, and others to the CSHCN Coordinator in the county health department where the child lives. When funding for medical services is needed, the CSHCN Coordinator can facilitate referral to the Medical Assistance Administration (MAA) in the Department of Social and Health Services or the Supplemental Security Income (SSI) program to determine eligibility.

Services found to be medically necessary by the local CSHCN Coordinator and not covered by any other sources may be eligible for funding through the CSHCN program when funding is available and the family income is within certain limits

See brochures below for more descriptions of what CSHCN Coordinators can do.

What is a Medical Home?

A medical home is not a building, but rather a team approach to providing comprehensive primary health care services in a high-quality and cost-effective manner.

In a medical home the child or youth, his or her family, primary care physician, and other health professionals develop a trusting partnership based on mutual responsibility and respect for each other’s expertise. Partners share complete information with each other.

Together, families, health care professionals and community service providers (including CSHCN Coordinators) identify and access all medical and non-medical services needed to help the child and family.

How Do CSHCN Coordinators Support Medical Homes?

Public health nurse CSHCN Coordinators support medical homes in many ways, including care coordination and family support and education. CSHCN Coordinators are often the single best source of up-to-date information about what services are available locally and the exact steps needed to access them.

Many primary care providers refer their pediatric patients who have special needs to the CSHCN Coordinator to ensure their families receive needed services.  In many counties, the CSHCN Coordinator is able to make a home visit to all new families who would like a home visit.  The CSHCN Coordinator can find out the child and family’s needs, history, and concerns.  For children who receive services from many providers, the CSHCN Coordinator may demonstrate the care notebook or organizer and help the family order their own copy.  The coordinator can also help explain transportation options to medical appointments for families who do not have their own transportation or need special transportation.

“If a family or physician wants a hearing evaluation for a child, we know who in the region does hearing evaluations and what their phone numbers are.  We can call and find the closest person doing evaluations and if they take Medicaid coupons of the particular type the client has. “

Many families are unfamiliar with how to navigate the health care and community service systems.  CSHCN Coordinators can help these families feel more comfortable accessing services by modeling how to make appointments and get needed services by phone.  For example, in one county the CSHCN Coordinator finds it helpful to make the phone calls needed to coordinate services during the home visit, instead of back in the office.  This lets the family see how the Coordinator makes the calls and what she says.

Coordinators can try to problem solve situations with families that many doctors’ offices do not have the time or knowledge to do.  For example, many families do not know that if their child is eligible for Medicaid and still needs diapers or pull ups at age 3, they may be able to get these paid for.  The CSHCN Coordinator can tell the family what Medicaid contracted company ships diapers to their hometown, what forms are needed, and how to complete them.

“One family had a teenage boy who needed pull ups.  The company they were using said that only pink pull up diapers were available in that size.  The pink color was very upsetting for the boy and family.  I called other companies and found another company that had large pull up diapers that were not pink and that would take Medicaid.”

CSHCN Coordinators provide support to families in many ways.  They can link them with family support organizations, help them find low cost or free adaptive equipment, and help educate families about the early intervention and school services.  CSHCN also coach and encourage families to ask questions, document the child’s symptoms, voice their needs and priorities, provide feedback, and otherwise develop an effective medical home partnership with their child’s primary care provider and other health care providers.

Sample Communication Forms with Doctors and other Providers

It is important to let the medical home doctor or other primary care provider know about any medical or health related services the child is receiving.  The medical home provider needs to know this in order to provide comprehensive primary care, advise the family, assure care coordination, and serve as the central repository for all medical and health related records for the child.

CSHCN Coordinators frequently communicate with doctors and other health care providers about shared clients.  They may do this by phone, fax or email depending on the situation and provider preference.   The following are sample forms used by CSHCN Coordinators to communicate with and build partnerships with doctors and other health care providers with whom they share clients.

Notice to Provider of Public Health Nurse Involvement with Patient

Report to Provider

  • Adams County Health Department
    Summary of activities that have occurred with client and RN plan
  • Kittitas County CSHCN Program
    Update fax notifying provider that patient was recently seen, update and plan.
  • Snohomish County CSHCN Program
    Notice of receiving a referral for child, what the CSHCN Coordinator can do, and summary update on last home visit and current plan
  • Spokane County CSHCN Program
    Interactive form that includes date and type of contact with child, assessment information (height, weight, weight for height, head circumference, developmental screening results, and other screening), concerns/comments and recommendations/plan
  • Walla Walla CSHCN Program
    Notice of receiving a referral for child, the families’ concerns and priorities, and plans under consideration to address them.
    Referral Form from Public Health to Other Providers
  • Adams County Health Department
    Referral form to therapists and others for clients in either the CSHCN Program or 0-3 program. Includes Diagnosis/condition, primary home language, remarks, Rx, Insurance information, and other reports/evaluations attached if applicable.

Family Forms

CSHCN Program Brochures

Other Promotional Materials

Medical Home Promotion

In addition to helping individual families and primary health care providers with specific children with special needs, CSHCN Coordinators also promote and support medical homes at the population level.

Many CSHCN Coordinators are part of county-based Medical Home Leadership Network teams (see teams by county contact list).  Each team is typically composed of at least a CSHCN Coordinator, pediatrician or family physician, parent and an early intervention Family Resources Coordinator.  Each team identifies one or more priority needs in the community and strategies to improve access to medical homes in the county.

For more information, please contact Kate Orville, MHLN Co-Director at medhome.org or 206-685-1279.

Other Resources

Strengthening the Community System of Care for Children and Youth with Special Health Care Needs and Their Families: Collaboration Between Health Care and Community Service Systems (highly recommended)
by Suzanne Bronheim, Phd.D. Georgetown University Center for Child and Human Development & Thomas Tonniges, MD, American Academy of Pediatrics. Summer 2004.  27 pages.

Focus: Medical homes and organizing services for children and youth with special needs and their families so families can access them easily.

Excellent, practical resource with suggestions for how health care system representatives and representatives from the broader system of community services can:

  • become more aware of each other,
  • learn about the specifics of the other system
  • and communicate successfully to improve services for children and youth.

Other Pages of Interest on the Washington State Medical Home Website:


Page posted Dec. 27, 2005, rev. 1/6/06

  • Written by: Kate Orville, MPH
  • Additional Contributors: Callie Moore, RN, CSHCN Coordinator and Nursing Director for Adams County Health Department and the CSHCN Coordinators from local health departments who contributed communication forms.