The American Academy of Pediatrics policy statement defines care coordination as:  

“A patient and family centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the caregiving capabilities of families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational, and financial needs to achieve optimal health and wellness outcomes.”*

The Child Neurology Foundation conducted a needs assessment and found that ninety-one percent of families surveyed in our community were their child’s care team leader. However, this is not always manageable, especially in situations where complex care is needed.  In order to achieve care integration, families work with a team to develop a care plan that meets their medical needs as well as their needs in the community.  

*American Academy of Pediatrics Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patients-and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics. 2014; 133(5): e1451-e1460)  

Many different types of people are involved in a child’s care coordination plan. The patients and families are critical components of care coordination and integration.  Other stakeholders can include, but are not limited to, pediatricians and other physicians, pediatric medical subspecialists and pediatric surgical specialists, case managers, community health workers, schools, state agencies, and more. Anyone who can help your child with their health and well-being can be a part of the care plan. 

A care plan… 

• Is developed by a team of people who regularly help meet the child’s and family’s needs 
• Have goals associated with the health and well-being of the child 
• Is patient/family centered 
• Uses assessments to guide decision making 
• Is re-visited frequently and updated to ensure that all needs are being met 
• Involves not just medical professionals but community supports as well 
• Is used to track progress and facilitate communication across teams 
• Takes into account children who are transitioning to adulthood 

Any person can have a care plan. However, care plans are widely used for patients with chronic and complex healthcare needs where multiple supports are needed to maximize a child’s health and well-being.

Studies have found that having care coordination and integration can: 

• Decrease hospital admissions 
• Decrease healthcare costs 
• Provide greater accuracy in prescribing medications 
• Improve patient satisfaction 
• Improve the quality of chronic disease management 
• Provide better access to specialty care 

• National Care Coordination Standards for Children and Youth with Special Health Care Needs (National Academy for State Health Policy) 
• National Resource Center for Patient/Family-Centered Medical Home  (American Academy of Pediatrics) 
• Boston Children’s Hospital’s Multidisciplinary Care Planning Tool 
• Partner for Kids

• Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems (September 2018)
• Pediatric Care Coordination (January 2019)
• Care Coordination Curriculum (Boston Children’s Hospital)
• Care Coordination Toolkit (Louisiana Office of Public Health and CSHS)