Care Coordination

Care coordination is the process that links children and their families with needed health care and services, along with other supports and services. A child and family’s needs, goals, and choices are included in a care plan that is shared with all team members.

-Based on Lucile Packard Foundation for Children's Health and the Catalyst Center's paper "The Care Coordination Conundrum"

AAP policy statement, Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems (2014)



  • 2018 Advancing Family Centered Care Coordination for Children and Youth with Special Health Care Needs Project
    The Medical Home Initiative of Children's Health Alliance of Wisconsin is supporting implementation of quality improvement grants designed to support work with Wisconsin pediatric primary care teams to advance medical home care provision for children and youth with special health care needs through the use of a Shared Plan of Care.
  • Building Your Medical Home: Coordinated Care
    This online resource guide from the National Center for Medical Home Implementation provides practices with tools on coordinated care to begin and sustain the medical home transformation process.
  • Care Coordination Curriculum developed by Boston Children's Hospital
    Boston Children’s Hospital developed this curriculum to support the provision of family-centered care coordination activities in pediatric medical homes.
  • Care Coordination Measurement Tool developed by Richard C. Antonelli, MD, MS, FAAP 
    The purpose of this tool is to track the amount of time spent on care coordination activities by different categories of staff on patient levels from simple to complex.
  • Coordinating your Child's Health Care developed by Family Voices of Wisconsin
    A resource health care teams may use to advance parents' understanding of the importance of care coordination and use of shared plan of care within the setting of a medical home.
  • Referral and Release Forms
    Approved by Wisconsin Department of Health Services, these forms are designed to facilitate communication between professionals caring for children with developmental delays and special health care needs. 
  • Wisconsin Care Coordination for Children and Youth Mapping Project
    A strength and gap analysis (mapping exercise) of current care coordination activities that are being implemented in different systems and organizations across the state. Interviews were conducted with a diverse group of systems, providers, and family representatives (July 2017).


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