Public health plays an important role in assuring medical homes for children with special health care needs in Washington.  Thirty percent of the federal Maternal and Child Health Block Grant is dedicated to serving children and youth with special health care needs and their families.

County public health departments or districts have a CYSHCN program which can partner with families, primary care providers and other service providers to support medical homes in Washington.


Who are CYSHCN Coordinators?

CYSHCN Coordinators are typically public health nurses but sometimes social workers or community health workers and are located in the thirty-five 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 availability of services from the public health CYSHCN Coordinator varies by county.  Services may include:

  • 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

Examples of County CSHCN Program Activities and Resources

How Do CYSHCN Coordinators Support Medical Homes?

Public health  CYSHCN Coordinators support medical homes in many ways, including care coordination and family support and education. CYSHCN 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 CYSHCN Coordinator to ensure their families receive needed services.  In many counties, the CYSHCN Coordinator is able to make a home visit to all new families who would like a home visit.  The CYSHCN Coordinator can find out the child and family’s needs, history, and concerns.  For children who receive services from many providers, the CYSHCN 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.  CYSHCN 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 CYSHCN 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 CYSHCN 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.”

CYSHCN 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.  CYSHCN 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.