​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Coordinated care is an integral part of health care provisio​​​​n in a medical home. ​​​​​​

The process of coordinating care involves the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.” ​

Optimal outcomes for children and youth, especially those with special health care needs, require interfacing among multiple care systems and individuals, including the following: medical, social, and behavioral professionals; the educational system; payers; medical equipment providers; home care agencies; advocacy groups; needed supportive therapies/services; and families. 

Coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care, and improvement in the patient/family experience of care.​

Brad Thompson, MA, Licensed Counselor | The Hali Project

​Coordinated care is not something that occurs solely within the walls of a medical practice. Efficient communication and coordination with appropriate community services and other providers or clinicians can optimize health outcomes and decrease fragmented care.​​​​​​

 Characteristics of Coordinated Care

Your practice provides coordinated care across all settings if it:

  • ​Has a care plan (paper or electronic), which is developed with families and specifies who will perform tasks to coordinate care and identifies patient subpopulations that will benefit from linkages to needed services and resources
  • Designated a team member to oversee the functions of coordinating care for patients and families
  • Provides support and education materials for situations and conditions common to children and youth, particularly those with special health care needs
  • Provides assistance to families in connecting with needed services
  • Has reliable policies and procedures to communicate with other clinicians (particularly to ensure that referrals are completed and documented)
  • Has and maintains a list of community resources
  • Communicates and coordinates regularly with other sectors that influence child health and well-being such as: education, child care, and any other system/agency as warranted

 Tools & Resources

Care Coordination Fact Sheet
One-page fact sheet which defines care coordination characteristics, functions, and competencies for professionals providing health care services.

Family Centered Care Coordination Questionnaire
One-page family questionnaire which practices can use to collect information about family concerns, needs, and preference in the care that their child receives within the practice.

New Patient Referr​al/Consultation Information Form
One-page customizable form for primary care clinicians to provide comprehensive information about patients to specialists during the referral process.

Co-Management Letter and Agreement
Three-page customizable form which allows primary care clinicians to establish a care coordination/co-management agreement with specialists.

Community Resource List​​
One-page list of resources which can be used by practices to educate patients and refer to community services as appropriate.

Further Links:

Patient- and Family- Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems
This policy statement, written by the American Academy of Pediatrics Council on Children with Disabilities and the National Center for Medical Home Project Advisory Committee, outlines essential partnerships and activities necessary for effective care coordination in pediatric care.

Making the Grade: How to Coordinate and Collaborate with Schools
Developed by Bright Futures, this resource provides pediatric clinicians with tips on how to connect and collaborate with schools in order to promote optimal care for pediatric patients.

Got Transition/Center for Health Care Transition Improvement
Coordinated and cohesive transition from pediatric to adult care is an essential part of medical home and care coordination. This National Center provides tools, resources, literature, and technical assistance for practices looking to improve the care they provide to pediatric patients as they transition to adult care.

Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs
This white paper and implementation guide, published by the Lucile Packard Foundation for Children’s Health, explains the importance of a comprehensive and individualized plan of care designed to implement effective care coordination.

Building Your Care Notebook
This collection of resources allows families and clinicians to keep track of their child's health care clinicians, community resources, medications, and other materials necessary for family-centered coordinated care.​

 Tools and Resources from the American Academy of Pediatrics

EQIPP: Medical Home

The American Academy of Pediatrics offers an EQIPP course, Medical Home, which guides users through the detailed quality improvement process necessary to undergo the pediatric medical home transformation.​