Care Coordination
Care coordinators are an essential component of the Medical Home team. In this section of the Medical Home Portal, new and experienced care coordinators will find information, ideas, and resources to provide optimal care coordination in the Medical Home setting. Because the work of care coordinators varies in different settings, you may find some pieces are more applicable to your job than others. Periodically refer back to this section of the Medical Home Portal to consider expanding aspects of care coordination as you broaden your professional role.
Periodically refer back to this section of the Medical Home Portal to consider expanding aspects of care coordination as you broaden your professional role.
The Care Coordination Process
The care coordination process includes identifying the target population, assessing needs, planning care, implementing the care plan, and then evaluating options and services to meet the child and family's individual needs.
- Identifying the Target Population
- Assessing Needs
- Care Planning
- Implementation
- Evaluation
Identifying the Target Population
- Children who are newly diagnosed with special health care needs
- Families of CYSHCN who recently have moved into the state or to a different area of the state
- A child with a progressive condition that requires multiple interventions, hospitalizations, or interferes with attendance at school
- Families with multiple agencies involved in the care of their child o Families with limited financial resources
- Children who have a parent who is developmentally delayed, has a severe physical or mental condition, or a demonstrated lack of knowledge and skill needed to care for their child
- A child who has been abused or neglected
Assessing Needs
157 KB) is an example of a family
and patient needs assessment form. The Utah Pediatric Care Coordination Information Checklist ( 171 KB) is another.
Care Planning
Once the assessment is complete, the family and Medical Home team can work together to discuss goals and steps needed to reach those desired outcomes, and determine who will do each of these steps and when they should be done. Information from the assessment may be incorporated into 1-3 documents that can be easily shared with the family as well as other care providers. The purpose is to quickly summarize key information relevant to the child’s current and future health. Written components may include a Medical Summary, a Working Care Plan, and/or an Emergency Treatment Plan. These documents may be shared in print versions as well as electronically. Talk with the family about their preferences for how this information is stored and shared. You can also help the family develop a care notebook to keep these and other documents organized.
Examples
The Medical Summary
| Components of a Medical Summary | |
|---|---|
| Demographics and emergency contact information | Allergies |
| Principal diagnosis | Transportation/equipment needs |
| Health history | Assets and challenges unique to the individual child |
| Current problem list | Other information the family wants caregivers to know about their child |
| Medications | Needs from family perspective |
| Current providers/specialists/services | Needs from medical personnel perspective |
| School placement and services | Strengths of the family and child |
| Cultural, ethnic and religious beliefs | Goals |
| Current therapies | Needs from family and medical perspective |
Working Care Plan
| A prioritized list of needs, concerns and desired outcomes | |
| Medical, educational and social information pertinent to the identified need, concern or desired outcome | |
| A plan/intervention for each need, concern or desired outcome | |
| The person(s) responsible for each intervention | |
| The due date for the intervention to be completed and/or re-evaluated |
-
Pre-Visit Focus Sheet (
38 KB)
-
Working Care Plan ( 39 KB)
-
NICHQ Medical Home Learning Collaborative - Actionable Plan of Care ( 27 KB)
-
Hitchcock Clinic - Concord Pediatric Care Plan ( 37 KB)
-
Gifford Medical Care Plan Part 1 ( 79 KB)
-
Gifford Medical Care Plan Part 2 ( 96 KB)
-
Family-Centered Care Assessment for Families (FCCA-F) ( 242 KB)
-
Utah Pediatric Shared Plan of Care template ( 72 KB)
Emergency Treatment Plans
51 KB) and Sample Seizure Action Plan (University of Utah) ( 67 KB)
Implementation
The next step is to implement the care plan. Hopefully while you developed the Working Care Plan, you listed discrete tasks, timeframes to complete these tasks, and names of the people who will carry out these tasks. The care coordinator organizes and assists the family with resources, referrals, and coordination of care with specialty physicians, schools, and other agencies. The care coordinator also assists the primary care provider in tasks necessary to implement the care plan.
Evaluation
Periodically reevaluate the plan of care and address new needs. Keeping the medical summary updated involves a continual process of reassessing by gathering information and input from a variety of sources. Again, family-centered care is critical to the ongoing success of all aspects of their child’s care, and the child and family should be paramount to this process.
Resources
Information & Support
Key resources include government insurance and benefits programs, advocacy groups, professional organizations.