Care Coordination Toolkit

This toolkit is designed to support practices with improving or expanding care coordination services at the clinic level. It uses a step-wise quality improvement framework designed to maximize clinic capacity and make the implementation of care coordination services efficient and effective. It was created for primary care practices but can also be used by other health care or social service professionals. 

This toolkit provides teams with the information needed to develop and implement improvement targets for care coordination services for any family requesting linkage to services. A practice can determine care coordination service goals based on a practice’s technology, staffing, and spatial capacity. The toolkit is intended to be customizable and will help you assess, plan, and implement services at your own pace. You can also access the printable version of the toolkit here.

Pediatric Care Coordination

A pediatric medical home is a family-centered approach to providing comprehensive, coordinated primary care services from birth through the transition to adulthood. The American Academy of Pediatrics (AAP) and National Standards for Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN) endorse care in a medical home as the gold standard for ensuring holistic and coordinated health care for pediatric populations. Care coordination is a core element of the pediatric medical home. 

The CYSHCN National System Standards defines care coordination as patient and family-centered, assessment-driven, team-based activities designed to meet the needs of children. It addresses medical, social, developmental, behavioral, educational, and financial needs to achieve optimal health and wellness outcomes and efficient delivery of health-related services within and across systems. It is a core component of federal and state efforts to improve health outcomes, reduce caregiver and patient burden, eliminate redundancies, and decrease healthcare costs. 

Children and Youth with Special Health Care Needs (CYSHCN)

The CYSHCN National System Standards define children and youth with special health care needs as those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. CYSHCN may also be referred to as high-needs pediatric patients, patients with complex health needs, etc., but we will use the acronym “CYSHCN” throughout this toolkit.

Many children require care from multiple providers. System navigation alone can create barriers to the timely receipt of support services necessary to ensure optimal child health. Coordinated care involves gathering the people and resources needed to effectively care for a patient, and managing the exchange of information across those systems providing different aspects of care. This allows patients to receive a more comprehensive level of care that better addresses their needs.

Each member of a child’s care team should have well-defined roles and responsibilities that focus on their area of expertise. Families should be made aware of what each health care professional is focused on regarding their child’s care. Ideally, each child will have an individualized plan of care that is based on a thorough understanding of their health and family situation and shared amongst the providers on the care coordination team and the family. The plan should be reviewed and updated regularly to keep up with changes in the child’s condition.