Care Coordination Toolkit | Louisiana Department of Health
Source: http://dhh.louisiana.gov/bureau-of-family-health/care-coordination-toolkit
Archived: 2026-04-23 17:30
Care Coordination Toolkit | Louisiana Department of Health
For Providers
Care Coordination Toolkit
Care Coordination Toolkit
Pediatric Care Coordination
A pediatric medical home is a family-centered approach to providing comprehensive, coordinated primary care services from birth through the transition to adulthood. The American Academy of Pediatrics (AAP) and
National Standards for Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN)
endorse care in a medical home as the gold standard for ensuring holistic and coordinated health care for pediatric populations. Care coordination is a core element of the pediatric medical home.
The CYSHCN National System Standards define care coordination as patient and family-centered, assessment-driven, team-based activities designed to meet the needs of children. It addresses medical, social, developmental, behavioral, educational, and financial needs to achieve optimal health and wellness outcomes and efficient delivery of health-related services within and across systems. It is a core component of federal and state efforts to improve health outcomes, reduce caregiver and patient burden, eliminate redundancies, and decrease healthcare costs.
Children and Youth with Special Health Care Needs (CYSHCN)
The CYSHCN National System Standards define children and youth with special health care needs as those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. CYSHCN may also be referred to as high-needs pediatric patients, patients with complex health needs, etc., but we will use the acronym “CYSHCN” throughout this toolkit.
Many children require care from multiple providers. System navigation alone can create barriers to the timely receipt of support services necessary to ensure optimal child health. Coordinated care involves gathering the people and resources needed to effectively care for a patient, and managing the exchange of information across those systems providing different aspects of care. This allows patients to receive a more comprehensive level of care that better addresses their needs.
Each member of a child’s care team should have well-defined roles and responsibilities that focus on their area of expertise. Families should be made aware of what each health care professional is focused on regarding their child’s care. Ideally, each child will have an individualized plan of care that is based on a thorough understanding of their health and family situation and shared amongst the providers on the care coordination team and the family. The plan should be reviewed and updated regularly to keep up with changes in the child’s condition.
Steps for Implementation
This toolkit uses a 3-step framework for integrating or expanding care coordination services. We have created checklists and worksheets to help you work through the steps listed below. Use the toolbar at the top of each page to navigate between steps.
You can download and print out all of the blank worksheets and examples ahead of time below
.
Step 1: Assess Your Clinic’s Care Coordination Services
Inventory existing care coordination elements
Identify opportunities for improvement
Step 2: Develop a Plan for Implementing Your Priority Task and Train Your Team
Brainstorm what would be needed to improve the care coordination elements identified in Step 1 to identify your priority task
Break your priority task down into smaller steps to identify processes, protocols, and staff needed to implement
Create the plan and assign roles and responsibilities
Train your team
Step 3: Test New Care Coordination Service/Process/Workflow
Plan
: Develop a test and make a prediction
Do
: Conduct the test and collect data
Study
: Analyze the data and summarize the results
Act:
Refine changes for the next cycle
Before You Begin
It is essential to have support from clinic leaders before using this toolkit to implement new care coordination services. Ensure clinic leaders understand the project and what the expected outcomes will be. They will need to be willing to follow through on tasks such as authorizing pilot tests/tests of change, establishing new workflows, updating staff job descriptions, and adopting electronic health records (EHR) to support team communication.
Once you have leadership on board, form a small workgroup of 2-5 people from different areas of the clinic (e.g., physicians, nurses, support staff, billing, etc.) to help complete the steps in this toolkit. If you have any questions during implementation, please contact our care coordination experts at
[email protected]
.
MOC-4 Credits
This toolkit can be used to receive American Board of Pediatrics Maintenance of Certification 4 (MOC-4) credits.
See the Quality Improvement section on the
Training and Support
page for more information.
Funding
This web-based resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $12,947,060.00, with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the U.S. Government. For more information, please visit
HRSA.gov (opens in a new tab)
.
Surgeon General
Evelyn Griffin, MD
Secretary
Bruce D. Greenstein
Powered by
Cicero Government
For Providers
Care Coordination Toolkit
Care Coordination Toolkit
Pediatric Care Coordination
A pediatric medical home is a family-centered approach to providing comprehensive, coordinated primary care services from birth through the transition to adulthood. The American Academy of Pediatrics (AAP) and
National Standards for Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN)
endorse care in a medical home as the gold standard for ensuring holistic and coordinated health care for pediatric populations. Care coordination is a core element of the pediatric medical home.
The CYSHCN National System Standards define care coordination as patient and family-centered, assessment-driven, team-based activities designed to meet the needs of children. It addresses medical, social, developmental, behavioral, educational, and financial needs to achieve optimal health and wellness outcomes and efficient delivery of health-related services within and across systems. It is a core component of federal and state efforts to improve health outcomes, reduce caregiver and patient burden, eliminate redundancies, and decrease healthcare costs.
Children and Youth with Special Health Care Needs (CYSHCN)
The CYSHCN National System Standards define children and youth with special health care needs as those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. CYSHCN may also be referred to as high-needs pediatric patients, patients with complex health needs, etc., but we will use the acronym “CYSHCN” throughout this toolkit.
Many children require care from multiple providers. System navigation alone can create barriers to the timely receipt of support services necessary to ensure optimal child health. Coordinated care involves gathering the people and resources needed to effectively care for a patient, and managing the exchange of information across those systems providing different aspects of care. This allows patients to receive a more comprehensive level of care that better addresses their needs.
Each member of a child’s care team should have well-defined roles and responsibilities that focus on their area of expertise. Families should be made aware of what each health care professional is focused on regarding their child’s care. Ideally, each child will have an individualized plan of care that is based on a thorough understanding of their health and family situation and shared amongst the providers on the care coordination team and the family. The plan should be reviewed and updated regularly to keep up with changes in the child’s condition.
Steps for Implementation
This toolkit uses a 3-step framework for integrating or expanding care coordination services. We have created checklists and worksheets to help you work through the steps listed below. Use the toolbar at the top of each page to navigate between steps.
You can download and print out all of the blank worksheets and examples ahead of time below
.
Step 1: Assess Your Clinic’s Care Coordination Services
Inventory existing care coordination elements
Identify opportunities for improvement
Step 2: Develop a Plan for Implementing Your Priority Task and Train Your Team
Brainstorm what would be needed to improve the care coordination elements identified in Step 1 to identify your priority task
Break your priority task down into smaller steps to identify processes, protocols, and staff needed to implement
Create the plan and assign roles and responsibilities
Train your team
Step 3: Test New Care Coordination Service/Process/Workflow
Plan
: Develop a test and make a prediction
Do
: Conduct the test and collect data
Study
: Analyze the data and summarize the results
Act:
Refine changes for the next cycle
Before You Begin
It is essential to have support from clinic leaders before using this toolkit to implement new care coordination services. Ensure clinic leaders understand the project and what the expected outcomes will be. They will need to be willing to follow through on tasks such as authorizing pilot tests/tests of change, establishing new workflows, updating staff job descriptions, and adopting electronic health records (EHR) to support team communication.
Once you have leadership on board, form a small workgroup of 2-5 people from different areas of the clinic (e.g., physicians, nurses, support staff, billing, etc.) to help complete the steps in this toolkit. If you have any questions during implementation, please contact our care coordination experts at
[email protected]
.
MOC-4 Credits
This toolkit can be used to receive American Board of Pediatrics Maintenance of Certification 4 (MOC-4) credits.
See the Quality Improvement section on the
Training and Support
page for more information.
Funding
This web-based resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $12,947,060.00, with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the U.S. Government. For more information, please visit
HRSA.gov (opens in a new tab)
.
Surgeon General
Evelyn Griffin, MD
Secretary
Bruce D. Greenstein
Powered by
Cicero Government