Care Coordination
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Overview
Care coordinators are an essential component of the Medical Home team. In
this section of the Medical Home Portal, new and experienced care coordinators will
find information, ideas, and resources to provide optimal care coordination in the
Medical Home setting. Because the work of care coordinators varies in different
settings, you may find some pieces are more applicable to your job than others.
Periodically refer back to this section of the Medical Home Portal to consider
expanding aspects of care coordination as you broaden your professional
role.
Periodically refer back to this section of the Medical Home Portal to consider expanding aspects of care coordination as you
broaden your professional role.
The Care Coordination Process
The care coordination process includes identifying the target population,
assessing needs, planning care, implementing the care plan, and then evaluating
options and services to meet the child and family's individual needs.
- Identifying the Target Population
- Assessing Needs
- Care Planning
- Implementation
- Evaluation
Identifying the Target Population
Children and families with
multiple needs and those that require multiple services, providers and resources are
usually a good place to start. The term “Children and Youth with Special Health Care
Needs (CYSHCN)” is defined in the Questions section, above. Examples of children and
families with multiple needs and services include:
- Children who are newly diagnosed with special health care needs
- Families of CYSHCN who recently have moved into the state or to a different area of the state
- A child with a progressive condition that requires multiple interventions, hospitalizations, or interferes with attendance at school
- Families with multiple agencies involved in the care of their child o Families with limited financial resources
- Children who have a parent who is developmentally delayed, has a severe physical or mental condition, or a demonstrated lack of knowledge and skill needed to care for their child
- A child who has been abused or neglected
Assessing Needs
Children and Youth with Special Health Care
Needs (CYSHCN), their families, physicians, and community providers all benefit from
having a comprehensive needs and strengths assessment. The Medical Home should
conduct a comprehensive assessment that includes a biopsychosocial assessment of the
child and family as well as input from members of the child’s medical care team.
Assessments for care coordination of CYSHCN not only focus on the medical needs but
also on the family, psychological, socioeconomic and cultural needs. The assessment
phase is vital to the care coordination process as the information obtained becomes
the basis for the medical summary and the working care plan.
Optimally, the child and family review the child’s health status with
members of the Medical Home team and discuss problems and needs. The assessment
meeting is best done in person but can be done by phone. In an effort to obtain the
information some care coordinators have sent forms home for families to complete and
return. Assessment involves a continual process of reassessing by gathering
information and input from a variety of sources at different points in time to
update the plan of care.
Gabe's Care Mapprovides an example of
the needs of a child with special health care needs. The CMHI Pediatric Care Coordination Assessment (
157 KB) is an example of a family
and patient needs assessment form. The Utah Pediatric Care Coordination Information Checklist ( 171 KB) is another.
157 KB) is an example of a family
and patient needs assessment form. The Utah Pediatric Care Coordination Information Checklist ( 171 KB) is another.
Care Planning
Once the assessment is complete, the family
and Medical Home team can work together to discuss goals and steps needed to
reach those desired outcomes, and determine who will do each of these steps and
when they should be done. Information from the assessment may be incorporated
into 1-3 documents that can be easily shared with the family as well as other
care providers. The purpose is to quickly summarize key information relevant to
the child’s current and future health. Written components may include a Medical
Summary, a Working Care Plan, and/or an Emergency Treatment Plan. These
documents may be shared in print versions as well as electronically. Talk with
the family about their preferences for how this information is stored and
shared. You can also help the family develop a care notebook to keep these and
other documents organized.
Examples
The Medical Summary
The care coordinator can
develop a medical summary for the child’s care that concisely conveys
important information for the family and other care providers. The following
is a list of components of a medical summary that may be incorporated into a
Medical Summary form.
Examples of Medical Summaries:
Working Care Plan
The working care plan is a written framework combining the needs,
concerns and desired outcomes of the patient, family and Medical Home team
along with the medical treatment plan. These plans range from an organized
note written during a visit, to a more detailed plan of care developed
during a meeting with the family and Medical Home, to a comprehensive,
integrated plan developed by the child and family and a multidisciplinary
team. Regardless of how complex the Working Care Plan is, families must be
the center of the process in order to accomplish a successful care plan.
The critical components of the working care plan include:
Here are various forms you can tailor to your practice to make your own Working Care Plans:
-
Pre-Visit Focus Sheet (
38 KB)
-
Working Care Plan ( 39 KB)
-
NICHQ Medical Home Learning Collaborative - Actionable Plan of Care ( 27 KB)
-
Hitchcock Clinic - Concord Pediatric Care Plan ( 37 KB)
-
Gifford Medical Care Plan Part 1 ( 79 KB)
-
Gifford Medical Care Plan Part 2 ( 96 KB)
-
Family-Centered Care Assessment for Families (FCCA-F) ( 242 KB)
-
Utah Pediatric Shared Plan of Care template ( 72 KB)
Additional examples of care plans can be found at the American Academy of Pediatrics' Medical Care Plans / Assessment Forms.
Emergency Treatment Plans
Sometimes the Medical Summary includes emergency information (so it functions as both the summary and the emergency plan).
Some practices prefer a separate Emergency Treatment Plan for children with recurrent life threatening events. This plan can
include baseline vital signs, lab and diagnostic tests, current medications and therapies. The family can keep this information
readily available by keeping it on the fridge at home or putting it in a small container that stays with the child’s gear
(wheelchair, backpack, etc). As electronic medical records improve the ability to share information, emergency plans will
be easily shared among care providers in different settings.
Emergency Health Information Form - Utah is an example of an emergency treatment plan. See also the Utah School Asthma Action Plan ( 51 KB) and Sample Seizure Action Plan (University of Utah) ( 67 KB)
51 KB) and Sample Seizure Action Plan (University of Utah) ( 67 KB)
Implementation
The next step is to implement the care plan. Hopefully while you developed the Working Care Plan, you listed discrete tasks,
timeframes to complete these tasks, and names of the people who will carry out these tasks. The care coordinator organizes
and assists the family with resources, referrals, and coordination of care with specialty physicians, schools, and other agencies.
The care coordinator also assists the primary care provider in tasks necessary to implement the care plan.
Evaluation
Periodically reevaluate the plan of care and address new needs. Keeping the medical summary updated involves a continual
process of reassessing by gathering information and input from a variety of sources. Again, family-centered care is critical
to the ongoing success of all aspects of their child’s care, and the child and family should be paramount to this process.
Resources
Information & Support
Key resources include government insurance and benefits programs, advocacy groups, professional organizations.
For Professionals
www.benefits.gov
Free, confidential tool that helps you find government benefits and assistance.
Medicaid
Official U.S. government site for Medicaid services.
Medicare
Official U.S. government site for Medicare services.
Supplemental Security Income (SSI) Application Process for Children
The Supplemental Security Income (SSI) program pays benefits to disabled adults and children who have limited income and resources.
This page gives details on how to apply for SSI for a child.
Disability Resources
US Department of Labor's Disability Resources web page.
See also Office of Disability Employment Policy (ODEP) homepage: https://www.dol.gov/odep/
American Academy of Pediatrics
Provides information for pediatric providers including health information; practice guidelines; publications including the
journal "Pediatrics"; professional education resources; advocacy information; and links to local chapters. Also includes
a Parenting Corner for families.
Commission for Case Manager Certification
Provides information about the Certified Case Manager credential, requirements, and test.
National Center for Education in Maternal and Child Health
The NCEMCH at Georgetown University maintains an extensive aggregation of print and full-text materials from projects and
repositories. Search CYSHCN; Family Resources and School Resources.
Child and Adolescent Mental Health (NIMH)
Information about mental health conditions in children and adolescents, including a list of warning signs, featured videos,
and health hotlines; National Institute of Mental Health.