Care Coord. Publications   Training on Care Coord.   Related Health Topics

• Job Descriptions
• Toolkits
• Training
• Sample Forms

Job Descriptions
Practice Based Care Coordination Job Description

• Social Work, Case Management, Public Benefits & Resource expertise
• Tasks primarily social, not medical

Practice Based Care Coordination Job Description

• Parent Consultant - will be a parent of a child with SHCN, preferably with experience and / or comfort working in a medical setting.

Tertiary Care Center Special Needs Consultation and Care Coordination Program

• Pediatric Nurse Case Manager
• General Summary: Utilizing the case management process, this position is responsible for providing care coordination services to a group of complex, special needs pediatric patients and their families across the continuum of care. The case manager assesses, plans, implements, coordinates and evaluates the plan of care in partnership with the family and other members of the health care team

Toolkits
Care Coordination Toolkit: Proper Use of Coordination of Care Codes with Children with Special Health Care Needs (CSHCN). This toolkit provides information on billing for the coordination of care with descriptions of individual codes, proper documentation, and an easy to follow billing slip. Toolkit

Appendices Included:

1. Identification of CYSHCN: Tools and Strategies
   How to Label / Flag the Chart: Tools and Strategies
2. Forms
3. How to Negotiate with Public and Private Insurers: Tools and Strategies
4. Selected Vignettes

Forms from the toolkit are available in word and excel formats

• Physician Management Billing Form
• Care Coordination Measurement Tool
• Billing Office Form

Developed by the Center for Infants and Children with Special Needs at Cincinnati Children’s Hospital Medical Center & The National Center of Medical Home Initiatives for Children with Special Needs.

Tools for Enhancing Care Coordination Adobe PDF
The Physician's Guide to Caring for Children with Disabilities and Chronic Conditions, edited by Drs. Robert E. Nickel and Larry W. Desch, provides valuable tools and information on the complexities of providing comprehensive care coordination for children with special health care needs (CSHCN).

These tools include Coordination of Care Summaries, which should prove valuable in facilitating collaborative communication among the family, the primary care physician and the sub specialists:

• Situational Stressors and Family Risks Assessment
• Effect of Child's Disability on Family Members Interview
• Family and Physician Management Plan Summary for Children and Adolescents with Cerebral Palsy
• Family and Physician Management Plan Summary for Children and Adolescents with Meningomyelocele
• Family and Physician Management Plan Summary for Children and Adolescents with Cleft Lip and Palate
• Family and Physician Management Plan Summary for Children and Adolescents with Seizure Disorder
• Family and Physician Management Plan Summary for Children and Adolescents with Traumatic Brain Injury
• Family and Physician Management Plan Summary for Children and Adolescents with Down Syndrome
• Family and Physician Management Plan Summary for Children and Adolescents with Developmental Delay or Mental Retardation
• Medication Record
• Primary Care Family Assessment
• Craniofacial Disorders Psychosocial Screening Form
• Seizure Record

New Community Tools for Improving Child Health: A Pediatrician's Guide to Local Associations by John L. McKnight and Carol A. Pandak
Pediatricians are becoming increasingly aware of the importance of non-medical determinants in the healthy development of children. This booklet offers a guide to how pediatricians and others can mobilize the resources and leaders of local community associations to improve child health. The authors see these associations as "powerful new tools" that can be used to plan and implement child health projects for the community and to provide information to local citizens. The booklet contains a project worksheet to plan how to involve associations in such projects and to spell out tasks for various groups to augment these efforts. It also provides a typology of associations and offers specific steps to locate them within the community. Download the booklet.

New Knowledge Path to Help Service Providers and Families Locate Community-Based Services
Knowledge Path: Locating Community-Based Services to Support Children and Families is an electronic guide for service providers and families to help them find resources within their communities to address child and family needs.

The knowledge path was produced by the MCH Library, in collaboration with the National Technical Assistance Center for Children's Mental Health at Georgetown University. It contains information on (and links to) Web sites and electronic publications; toll-free telephone lines; and databases. Topics include education and special needs, mental health and well-being, family support, parent education, child care and early education, health and wellness, and financial support. The knowledge path is available at:
http://www.mchlibrary.info/KnowledgePaths/kp_community.html.

From The Arc of the United States "COMMUNITY FOR ALL" TOOL KIT
This tool kit was developed at the request of volunteers, advocates, self-advocates, and professionals concerned that the remarkable progress made towards the inclusion of people with cognitive, intellectual and developmental disabilities (our constituents) into the fabric and mainstream of community life in America was at risk. In some places in the United States there are those who would not only continue to deny people currently in public and private institutions freedom and opportunity through continued institutionalization but who also want to expand the role of institutions in the lives of our constituents.

A full copy of the Tool Kit can be downloaded or printed. It is a large document and may take a considerable amount of time to download. You can order a complete copy of the Tool Kit including a CD with all documents. See the order form below.

NOTES: Some portions of this Tool Kit can either be found on the Web or will link to external files; where possible, links to these external sites and documents are included.

Copy of Tool Kit - PDF (15 mb):
http://thechp.syr.edu/toolkit/Community_for_All_Toolkit_Version1.1.pdf
Order Form for Tool Kit - PDF
http://thechp.syr.edu/toolkit/Communit_for_All_ToolKit_OrderForm.pdf
Web site for Tool Kit: http://thechp.syr.edu/toolkit/

Bridges to Excellence: Rewarding Quality Across the Healthcare System
...payments for care should be redesigned to encourage providers to make positive changes to their care processes. Ideally, this shift will begin with purchasers and insurers, and filter down through the delivery system to help encourage improvements at all levels. From the Institute of Medicine (IOM) report entitled " Crossing the Quality Chasm."

In response to this challenge, a group of employers, physicians, health plans and patients has come together to create Bridges to Excellence.

• Providing tools, information and support to consumers of health care services,
• Conducting research with respect to existing health care provider reimbursement models,
• Developing reimbursement models that encourage the recognition of health care providers who demonstrate that they have implemented comprehensive solutions in the management of patients and deliver safe, timely, effective, efficient, equitable and patient-centered care which is based on adherence to quality guidelines and outcomes achievement.

For more information on these tools and models click here.

Training

Educating Practices in Community Integrated Care (EPIC IC) - Care Coordination Presentation

Learning Objectives:
1.Understand:
Care Coordination Process/Tasks
Care Coordination roles at the practice and individual levels
2.Determine first steps of a practice care coordination program
3. Identify tools to facilitate the process

EPIC IC is a collaborative effort of the Pennsylvania Department of Health Division of Special Health Careprograms (DOH Title V), family organizations (Family Voices, Parent to Parent), and the PA Chapter of the AAP. EPIC IC Medical Home project is based on the Educating Physicians In their Communities (EPIC) model. The EPIC IC is a statewide provider education program using office based change as the key to improving the care provided to CSHCN.

Listserv Request: Looking for Care Coordinator Curriculums/Training programs. This includes community case managers as well as office and community-based care coordinators.

Responses to this request were posted August 22, 2003 to the medical home bulletin board. This page provides information on past questions posted on the Medical Home LISTSERV. Responses are provided by physicians, allied health professionals and parents of children with special needs.

Sample Forms and Additional Resources

The Care Coordination Process: Questions and Answers | Family Involvement | Assessment| Plans of Care/Implementation/Evaluation | Resources | Advocacy | Funding www.medhomeportal.org/about/aboutCare.cfm

How to Make Best Use of Resource Information Questions and Topics
In a well child visit, here are a list of questions and topics providers should be asking families to assess if they have any needs with home health, durable medical equipment, day care, respite, insurance/financing, school, etc. Utilize local/state resource guides for information to offer families and patients. For local and state specific resources you can go to your state page "Family Corner" by clicking here.

Sample Forms from the Training Curriculum Module: Comprehensive, Coordinated, Collaborative Care are available by clicking here.

Last updated October 17, 2005