Questions & Answers about Care Coordination

What is Care Coordination?

"Care Coordination is a collaborative process that links children and families to services and resources in a coordinated manner to maximize the potential of children and provide them optimal health care." AAP Policy Statement - Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs
Care coordination is a vital component of the medical home. Building a sense of trust between families and the medical home and responding to their needs in a timely and coordinated manner is essential. Care coordination within a practice will:
  • Facilitate access to services
  • Promote continuity of care
  • Provide families with support
  • Improve health, developmental, educational, vocational, psychosocial and functional outcomes
  • Maximize efficient and effective use of resources

Who are Care Coordinators?

The term "care coordination" is used interchangeably throughout many different systems and organizations. You may hear the terms case manager, service broker or services coordinator. Regardless of the term, the concept of care coordination is to help families link to supports and services to meet their individualized needs.
Care coordinators come from many different professional backgrounds. Examples include medical assistants, nurses, social workers, and clinical office staff. As a result, they may emphasize certain skills over others in their daily work. Clinical experience is important to understand the needs of patients and providers as the care coordinator supports both. However, the care coordinator’s greatest assets are knowledge of community resources and good communication skills.

What are the benefits of having a designated care coordinator in a medical home?

  • Maximizes the opportunity to get to know the families and provides the opportunity for someone in the practice to become an "expert" in community resources and government programs
  • Promotes coordination of specialty and ancillary services by having a designated person in the practice for specialists, hospitals and home health agencies to call
  • Provides the opportunity to learn from families and to pass along what has been learned to other families within the practice

How does a practice identify children and youth and families with special health care needs?

The definition of a child with special health care needs by the Maternal and Child Health Bureau is as follows:
"Children with special health care needs are those who have or are at elevated risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount not usually required by children."
Other considerations may include:
  • An expected duration of the condition
  • Presence of functional limitations
  • A need for increased use of services or devices
Identification of CYSHCN within the Medical Home will facilitate planning care and referrals to needed services. Additionally, the identified child and family can be followed for the purpose of monitoring and improving the quality of their health care.
The National Center of Medical Home Initiatives for Children with Special Needs has additional information to help in Identifying Children with Special Needs (PDF Document 21 KB)

Who uses care coordinators in their agencies?

Care coordinators work throughout the healthcare arena in many different ways. Their expertise depends on their professional background and organization type.
Here are examples of various work settings of a care coordinator:
  • Medical Home - Work with the primary care physicians and family advocates to facilitate access to services, promote continuity of care, provide families support, improve functional outcomes and maximize efficient and effective use of resources.
  • Healthcare Payer or Insurance - Validates eligibility for insurance and benefits limitations, exclusions, co-payments and deductibles. May assist with exploring other alternative funding programs.
  • Home Health Agencies - Explore options and other available services within the agency and determine stability or readiness for the next level of care or discharge. Provide community resources and patient education.
  • Hospital-based Care Coordinators /Discharge Planners - Function as an integral part of the healthcare team and work collaboratively with other care coordinators, the family and other providers on details for discharge.
  • Government for Administration of Programs - Determine eligibility for government programs, work closely with the family, other health care providers and the care coordinators in meeting the needs of the child and family. Authorize services and provide referrals and resources.

What are some examples of day-to-day activities a care coordinator may perform?

Each care coordinator participates in some of the following tasks, depending on his or her skill set and the organizational needs. Here are many of the day-to-day activities that might be part of a care coordinator’s job description:
  • Meeting, calling, and emailing with families and Medical Home care team members to identify their needs and seek information and solutions to their problems
  • Handling prescription refills, coordinating home care services and medical equipment and supplies
  • Coordinating procedures such as surgeries, dental work, lab draws, and immunizations to minimize pain and sedation risks for the child
  • Coordinating coverage with insurance and/or Medicaid
  • Assisting with obtaining prior authorization for services, equipment and supplies
  • Assessing needs, developing and implementing the care plan for patients and evaluating effectiveness of interventions. A care plan helps the family and multiple providers communicate about the patient’s condition, diagnoses, upcoming interventions, care preferences, etc. See Assessment, Plans of Care, Implementation, and Evaluation, below
  • Assisting families and providing tools (binders, forms, care plans) to help with organizing and tracking medical information about their child
  • Assisting the Medical Home Team to track important information about patients and identify gaps in services
  • Providing referrals and resources and contacting community service providers as well as medical and surgical specialists
  • Helping coordinate with school programs. Some care coordinators attend and provide input at Individual Education Plans (IEP) meetings
  • Advocating for families (see Advocacy, below)
  • Conducting home visits when feasible
  • Helping with transition issues
  • Linking families with other families for support
  • Assisting non-English speaking families or recent immigrants and refugees navigate the health care system
  • Working with quality improvement efforts and data management in the clinic
See some sample Care Coordinator job descriptions:

Authors

Contributing Author: Mindy Tueller, MS - 1/2015
Reviewing Authors: Alfred Romeo, RN, Ph.D. - 4/2008
Barbara Ward, RN BS - 11/2006
Content Last Updated: 11/2017