Care Coordination Resources

Below are additional resources related to care coordination and supporting children with special healthcare needs.

Review these resources to get a better understanding of the supports available to the patients you serve and share relevant resources with your patients.

AAP’s National Resource Center for Patient/Family-Centered Medical Home: This is a technical assistance center focused on improving the health and well-being of children and youth with special health care needs and their families by enhancing the patient/family-centered medical home.
The National Care Coordination Standards for Children and Youth with Special Health Care Needs (CYSHCN): The standards outline the components of high-quality care coordination for CYSHCN and are designed to help identify and assess the need for care coordination, engage families in the care coordination process, build a strong and supportive care coordination workforce, and develop team-based communication processes.
Developmental Screening Toolkit: Developmental screening is one way to identify children with special health care needs in your clinic. Screening all children ages 0-5 improves early detection of developmental delays and disabilities in children and provides an important avenue for referring children to early intervention services.

Local Referral Resources

Families Helping Families: The Bureau of Family Health partners with Families Helping Families (FHF) to give families of children and youth with special healthcare needs (CYSHCN) extra support. FHF works to help children gain independence and integrate into the community through resource linkage services, peer support, education, and training. Their staff includes individuals with disabilities and family members of those with disabilities who are familiar with navigating the systems. FHF Community Resource Specialists are available to help families connect to resources and services that can help them. They have the knowledge and skills to work with families of CYSHCN. Community Resource Specialists can help families by providing:
- Peer and emotional support
- Tips for accessing services
- Referrals to medical and support services
- Connections to other parents with children and youth with special health care needs
- Use this list of contacts for all FHF locations in Louisiana to find the Community Resource Specialist in your region!
Family Resource Center: The Family Resource Center (FRC) assists providers in linking families to resources and services such as early intervention, childcare assistance, insurance, and disability support. You can contact the FRC at BFH-FamilyResourceCenter@la.gov or (504) 896-1340 (Monday - Friday, 8 am - 4 pm).
EarlySteps & Child Search: EarlySteps is the Early Intervention Program for Louisiana families with children 0-3 years old. Anyone can refer a child to EarlySteps. To refer a family, contact the Intake Coordinator at the System Point of Entry Office in your region and complete the referral form on this page under "Resources". Child Search is the Early Intervention Program for Louisiana families with children from birth to 21 years of age with developmental disabilities. Contact information for Child Search can be found in the Regional Resource Guides accessible using the buttons below.
Regional Resource Guides: These guides were created to help providers refer families to relevant services and share resources for children with special healthcare needs, and each regional guide has local contact and referral information for agencies and services. You can use the buttons below to view the regional resource guide for your parish.

Other State Agencies That Provide Care Coordination Services

Medicaid Managed Care Organization (MCO) Care Management: All MCOs provide care coordination services to children with complex health conditions. A child can be given a health needs assessment to see if they qualify.
Office for Citizens with Developmental Disabilities (OCDD): OCDD serves as the Single Point of Entry into the developmental disabilities services system.
Louisiana's Coordinated System of Care (CSoC): CSoC helps ensure that young people in or at risk of out-of-home placement with significant behavioral health challenges can receive the support and services they need.

Family Engagement Resources

Family engagement is an innovative approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. Family-centered care improves patient and family outcomes, increases family and clinician satisfaction, decreases health care costs, and improves effective use of health care resources.

It is important to talk with families about what they should expect from their children, in terms of growth and development, and to remind them to reach out if they have any concerns. These conversations should emphasize realistic timelines and should be culturally relevant to each family. There are resources linked below to share with families to help guide conversations and serve as a helpful take-home tool to keep families engaged in their child’s development regularly.

Resources to Improve Family Engagement

Family Engagement Assessment Tools: Family Voices developed tools to assess family engagement at both the systems level and the individual level.
National Center for Medical Home Implementation (NCMHI) Family Engagement Quality Improvement Project: A quick look at lessons learned from this project with strategies, tips, and resources for implementing family engagement in clinical settings.

Resources to Share with Families

Vroom Mobile App: A science-based mobile app with daily brain-building activities for parents to do with children ages 0-5.
CDC’s Milestone Tracker Mobile App: Caregivers can access and complete developmental milestone checklists, watch videos of milestones in action, and find developmentally appropriate activities through this app.
Developmental Screening Regional Resource Guides: Review these guides with families to help them explore relevant services and resources. Each has local contact and referral information for agencies and services, as well as family-oriented resources such as milestone tracking apps.
Sesame Street in Communities: Activities, videos, and more for families to do with their children.
Youth Engaged 4 Change: Share this with your teen patients to connect them to resources and opportunities that will empower them to make a difference by improving their knowledge and leadership skills.
SmoothMovesYHT.org: A virtual health and transition teen resource that provides a comprehensive overview of transition topics and hosts a library of transition tools and resources.
Louisiana State Bar Association: A guide to Becoming an Adult provides information on voting, driving, housing, parenting, and more.
Louisiana Rehabilitation Services: Find information on job fairs, pre-employment, and vocational rehabilitation to assist with developing a lifetime career.
Exceptional Lives: Easy-to-understand resources for parents and caregivers of children with disabilities that include SSI benefits, health care transition guides, and more