Care Coordination

This section provides definitions and information about concepts that are common to the care of children with special health care needs. Additional information, resources and tools can be found by following the links in each section.

According to the American Academy of Pediatrics, care coordination is a process that links children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care. Often, care coordination is complicated because there is no single entry point to multiple systems of care, and complex criteria determine the availability of funding and services among public and private payers. Economic and socio-cultural barriers to coordination of care exist and affect families and health care professionals. In their important role of providing a medical home for all children, primary care procedure have a vital role in the process of care coordination, in concert with the family (source: American Academy of Pediatrics). In addition to the medical home, other programs, services and providers may also provide or participate in the care coordination process. At times, a family may have more than one care coordinator with whom they work. Often, the family coordinates the work of the various care coordinators, and enhanced communication between and among them can help assure smooth services for the child and family.

Other terms may be used to describe care coordination, such as service coordination, case management, and care management.

Generally, the care coordination process includes the following steps:

  • Assessing and Identifying Needs - Identification of family strengths and needs is the first step in the care coordination process. A care coordinator may use some kind of formal assessment tool to learn more about the child and family, or may simply Developing a Plan of Care - After identifying the strengths and needs of the child and family, the care coordinator and the family work together to develop a plan of care that includes goals and action steps. Together they will determine who carries out which of the action steps.
  • Implementation - The individuals identified during the planning process implement the plan. Each checks with the other to assure that progress is being made, or to identify barriers to needed services. The care coordinator provides resources, information, referrals and supports to the family, in collaboration with other providers of care.
  • Evaluation – At specified intervals, the care coordinator, family, and other providers of care check with each other to assure that the child and family are receiving needed services. If barriers are identified, or if new needs arise, the plan is revised as needed.


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The Center for Children with Special Needs, Care Coordination Toolkit
While developed for families that live in the State of Washington, this website includes valuable resources in coordinating services for children with special health care needs.

Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs
This policy statement from the American Academy of Pediatrics defines care coordination, and discusses the roles of parents and providers, the components of care coordination and recommendations.

Care Coordination Toolkit: Proper Use of Coordination of Care Codes with Children with Special Health Care Needs
This toolkit offers information to providers to assist in billing for care coordination services.
Care Coordination Toolkit document (pdf)

A Critical Analysis of Care Coordination Strategies for Children with Special Health Care Needs
This policy brief, by Wise and colleagues, provides information about care coordination for children with special health care needs.

Tools for Coordinating Care: Toolkits and Guides
This website provides numerous tools to assist in the coordination of care for children with special health care needs.

National Center for Cultural Competency