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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 health care costs.


Click the image below to read about Care Coordination in Louisiana:

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.


Steps for Implementation

This toolkit uses a 3-step framework for integrating or expanding care coordination services. We have created checklists and worksheets to help you work through the steps listed below. Use the toolbar at the top of each page to navigate between steps. You can download and print out all of the blank worksheets ahead of time here. Examples of how to use each document are also available here




Step 1: Assess Your Clinic’s Care Coordination Services

  • Inventory existing care coordination elements
  • Identify opportunities for improvement

Step 2: Develop a Plan for Implementing Your Priority Task and Train Your Team

  • Brainstorm what would be needed to improve the care coordination elements identified in Step 1 to identify your priority task
  • Break your priority task down into smaller steps to identify processes, protocols, and staff needed to implement
  • Create the plan and assign roles and responsibilities
  • Train your team

Step 3: Test New Care Coordination Service/Process/Workflow

  • Plan: Develop a test and make a prediction
  • Do: Conduct the test and collect data
  • Study: Analyze the data and summarize the results
  • Act: Refine changes for the next cycle



Before You Begin

It is essential to have support from clinic leaders before using this toolkit to implement new care coordination services. Ensure clinic leaders understand the project and what the expected outcomes will be. They will need to be willing to follow through on tasks such as authorizing pilot tests/tests of change, establishing new workflows, updating staff job descriptions, and adopting electronic health records (EHR) to support team communication.

Once you have leadership on board, form a small workgroup of 2-5 people from different areas of the clinic (e.g., physicians, nurses, support staff, billing, etc.) to help complete the steps in this toolkit. If you have any questions during implementation, please contact our care coordination experts at 




MOC-4 Credits

This toolkit can be used to receive American Board of Pediatrics Maintenance of Certification 4 (MOC-4) credits. See the Quality Improvement section on the Training and Support page for more information.