Questions & Answers about 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

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.

• 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

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.

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.

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:

See some sample Care Coordinator job descriptions:

• Practice-based Care Coordinator sample job description ( 28 KB)
• Health Advocate sample job description ( 29 KB)
• Pediatric Patient Care Coordinator sample job description ( 29 KB)