Tools for Coordinating Care
This section provides tools to assist in the coordination of care at the practice, community, and state level.

Care coordination is a process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health. Care coordination for children with special health care needs often is complicated because there is no single point of entry into the multiple systems of care, and complex criteria frequently determine the availability of funding and services among public and private payers. Economic and sociocultural barriers to coordination of care exist and affect families and health care professionals. In their important role of providing a medical home for all children, primary care physicians have a vital role in the process of care coordination, in concert with the family. ¹

The Care Coordination Process

• Assessing and Identifying Needs - Activities performed by a care coordinator are based upon a comprehensive assessment that includes a psychosocial assessment of the child and family. Identification of needs is the first step in the care coordination process. Develop and use an assessment tool which will assist in gathering the information you will need to develop a plan of care.
  
  
• Developing a Plan of Care - After identifying the needs, a plan of care is developed with the family and goals and outcomes discussed. The care coordinator may clarify with the family which action steps the family will address and which will be addressed by the care coordinator.
  
  
• Implementation - The plan is implemented and actions are taken to work towards the desired outcomes. Identified service providers and programs all work towards fulfilling the needs of the family. The care coordinator organizes and assists the family with resources, referrals, coordination of care with specialty physicians, with schools and other agencies.
  
  
• Evaluation - Periodic evaluations to reassess the plan of care and address new needs are performed continually. ²

The AAP policy statement “The Medical Home” lists the desirable characteristics of coordinated care within the medical home, including the following:

1. A plan of care is developed by the physician, practice care coordinator, child, and family in collaboration with other providers, agencies, and organizations
   involved with the care of the patient.
   -Information on Care Plans
2. A central record or database containing all pertinent medical information, including hospitalizations and specialty care, is maintained at the practice. The record is accessible, but confidentiality is preserved.
   - Information on Documentation and Sample Forms
3. The medical home physician shares information among the child, family, and consultant and provides a specific reason for referral to appropriate pediatric medical subspecialists, surgical specialists, and mental health/developmental professionals.
   -Information on Care Notebooks
4. Families are linked to family support groups, parent-to-parent groups, and other family resources.
   -Information available on each Medical Home State Page - "Family Corner" (Click on your state)
5. When a child is referred for a consultation or additional care, the medical home physician assists the child and family in understanding clinical issues.
   -Information and Tips for Providers on Communicating with Families
6. The medical home physician evaluates and interprets the consultants’ recommendations for the child and family and, in consultation with them and subspecialists, implements recommendations that are indicated and appropriate.
7. The plan of care is coordinated with educational and other community organizations to ensure that special health needs of the individual child are addressed.

Definitions of Care Coordination by Provider, Funder, and Agency
Includes:
Physician Directed Care Coordination,
Case Management - Enhanced / Targeted
AMCHP Definitions for Title V, Medicaid, Early Intervention

- Prepared by: Ron S. Levin MD, Director, Center for Infants and Children with Special Needs - Cincinnati Children’s Hospital Medical Center.

Care Coordination Definition and Principles General
Includes:
Outcomes of Care Coordination
Stages of Care Coordination Process and Associated Activities

- Prepared by the Care Coordination Work Group of the Massachusetts Consortium for Children with Special Health Care Needs

1. Pediatrics 2008; 122 e209-e216; Care Coordination for Children and Youth With Special Health Care Needs: A Descriptive, Multisite Study of Activities, Personnel Costs, and Outcomes. Richard C. Antonelli, Christopher J. Stille, and Donna M. Antonelli.

2. Pediatrics 2005;116: 1238–1244; Care Coordination in the Medical Home: Integrating Health and Related Systems of Care for Children With Special Health Care Needs.

3. Medhome Web Portal: Care Coordination

Last updated July 1, 2008