Care Coordination
A strong connection and relationship between the child/youth, the family
and the primary care provider is essential for patients with special
health care needs. Management of the primary condition and prevention
of secondary complications are important components of care for children and youth with special health care needs. Health promotion, treatment of minor illnesses, and maintenance
of wellness are also important, although at risk of being neglected
when more urgent care needs are present.
Parents are valuable partners in the care of their child or youth with special needs.
Care is enhanced when the parental skills and input are validated.
Parents know their child far better than others who assist in managing
their care. As much as possible, parents should be given tools and
permission to partner in managing their child's care.
Chronic Care Management
- Develop a care plan with the family and child (see Provider Tools)
- Review and coordinate medications and treatments, especially
when multiple providers are involved
- Provide anticipatory guidance, including expectations related
to the specific chronic illness
- Address transitions (see Transition Timelines)
- At time of diagnosis
- Transitions in neurodevelopmental and educational programs
- Transition into adulthood
- Recognize and support family needs
- Give information about their child's condition
- Assist in accessing other sources of information
- Recognize the range of prognosis and possible outcomes
for their child
- Acknowledge and build on child's strengths
- Reinforce parent's skills and abilities
- Validate parent's participation in their child's care
- Involve child, if appropriate, in their care
- Encourage knowledge of condition
- Support assent and consent to medical interventions
- Transition care tasks to child whenever possible
- Family stress
- Parent and family self-care needs
- Financial support
- Parent to Parent support
- Sibling support
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Local Services
We invite you to view the Washington Medical Home website Resources and Support pages Quick Key Contacts and Resources by County for links to local public health nurses, family resources coordinators and other service providers who can assist with with care coordination for your patients and families.
Care Coordination Toolkit from the Center for Children with Special Needs
Developed for professionals who coordinate care for children in Washington State. Includes resources for professionals, families and for teens and their families. This kit includes only resources developed with funding from the Children with Special Health Care Needs (CSHCN) Program of the Washington State Department of Health.
http://cshcn.org/planning-record-keeping/what-care-coordination
Excellent Care Coordination Resources and
Information
Care Coordination
Care Coordination for Children and Youth with Special Health Care Needs in Washington State (April 2010)
Children with special health care needs have more difficulty obtaining adequate care coordination than typically developing children. An estimated 34% of CYSHCN in Washington receive care coordination, the majority of which takes place in a doctor’s office. This care coordination data monograph was created to describe components of care coordination within a medical home for these children with complex needs, based on national and state-level data.
(revised monograph coming shortly- PDF will be posted summer 2010)
Tools for Coordinating Care
Identified and collected by the National Center of Medical Home Initiatives for Children with Special Needs. Provides tools to assist in the coordination of care at the practice, community, and state level.
www.medicalhomeinfo.org/tools/coordinating%20care.html
Topics:
Care Coordination Resources and Information
Medical Care Plans/Assessment Forms - National Center of Medical Home Initiatives for Children with Special Needs
www.medicalhomeinfo.org/tools/assess.html
- Medical Information Plans
- Emergency Plans
- Working (action) Care Plans and Medical Summaries
- Child History and Fact Sheet
Dr. Stephens' Chronic Case Management Forms
Family-Initiated Care Planning Forms
Care Coordination; Care plans, visit focus sheets and more...
Medical Home Portal
www.medicalhomeportal.org/clinical-practice/building-a-medical-home/care-coordination
Continuous, Comprehensive, Coordinated Care Resources
Fact Sheets, Policy Statements, Articles and Reports
National Center of Medical Home Initiatives for Children with Special Needs
www.medicalhomeinfo.org/publications/continuous.html
Comprehensive Care Planning Packet - Link
This packet contains information about the essentials of comprehensive care planning for children with special health care needs (CSHCN). Three distinct types of documents present medical information plans, emergency plans, and working (action) care plans.
Care Coordination Toolkit: Proper Use of Coordination of Care Codes with Children with Special Health Care Needs
Developed by the Center for Infants and Children with Special Needs, Cincinnati Children's Hospital Medical Center and the National Center of Medical Home Initiatives for Children with Special Needs.
Toolkit provides information on billing for the coordination of care with descriptions of individual codes and proper documentation and an easy-to-follow billing slip.
The appendices include:
- Identification of Children and Youth with Special Health Care Needs: Tools and Strategies
- How to Label/Flag the Chart: Tools and Strategies Forms
- How to Negotiate with Public and Private Insurers: Tools and Strategies
- Selected Vignettes
- www.medicalhomeinfo.org/tools/continuous.html#tool
Care Coordination in the Medical Home: Integrating Health and Related Systems of Care for Children With Special Health Care Needs
Council on Children With Disabilities
Pediatrics 116 (5) : 1238-1244, Nov 2005.
[Abstract] [Full Text] [PDF]
Utah Medhome Portal
http://medhome.med.utah.edu/about/aboutCare.cfm
Continuous, Comprehensive, Coordinated Resources
National Center of Medical Home Initiatives for Children with
Special Needs
www.medicalhomeinfo.org/publications/continuous.html
Medical Care Plans/Assessment Forms
National Center of Medical Home Initiatives for Children with
Special Needs
www.medicalhomeinfo.org/tools/assess.html
Early Intervention and School Services
Role of the Pediatrician in Family-Centered Early Intervention Services
Committee on Children With Disabilities
Pediatrics 107 (5):1155-1157, May 2001. [Abstract] [PDF]
The Pediatrician's Role in Development and Implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP)
Committee on Children With Disabilities
Pediatrics 104 (1):124-127, Jul 1999. [Abstract] [PDF]
Family Support Programs
The Pediatrician's Role in Family Support Programs
Committee on Early Childhood, Adoption, and Dependent Care
Pediatrics 107 (1):195-197, Jan 2001. [Abstract] [PDF]
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