“Screening, identification, and assessment of a child’s needs provides the foundation for effective, high-quality care coordination. Assessment is a continuous process that reflects ongoing conversations with CYSHCN and families about their needs, preferences, and priorities.”[11] The standards within Domain 1 support the comprehensive identification of children and families in need of care coordination by screening for a variety of factors. With the family’s consent, the results are shared with care team members to guide service delivery. Below are strategies, resources, and examples to consider for implementing the standards in this domain.

• Determine factors to include in the care coordination screening and assessment process and identify gaps and correlating tools. It is important to consider the range of factors that can be included in the screening process. Any gaps that stakeholders identify may be supplemented by implementing a validated screener and/or adding a module to an existing assessment tool. While some factors may be screened across all CYSHCN, others may be implemented within a particular setting or for a specific subpopulation. When applicable, consider how the screening process can leverage existing data to reduce the burden on families, who have reported that the frequency of screenings through various providers can be onerous.

Screening and Assessment Factors and Tools

The following table includes several areas of needs and strengths to consider in the screening and assessment process and examples of corresponding tools. When interested in screening for a particular need or strength for care coordination purposes and considering tools to implement, stakeholders can draw from this list and others. This list is not exhaustive. Additional tools can be found at Bright Futures Toolkit: Links to Commonly Used Screening Instruments and Tools; Mental Health Screening and Assessment Tools for Primary Care: Decision Support for Clinicians; and Social Needs Screening Tools Comparison Table (Pediatric Settings).

*These tools screen and assess across multiple factors, which may simplify the screening process. Given the challenges for providers in adopting any tool, it is important to consider the utility and feasibility of implementation.

• Conduct an inventory of screening tools used across the care coordination system, streamline where possible, and adapt as needed. The use of consistent screening and assessment tools can reduce the number of data points to track across the system and support collaboration across providers. At the same time, certain tools may be best suited for specific settings and program purposes. Developing an inventory of tools currently in use can help inform the selection of any new screeners based on what has already been implemented, when applicable. Care coordination systems may also find it useful to adapt screening and assessment tools to best fit their needs.
  • For example, in Virginia, all children that receive Children’s Service Act (CSA) services are assessed annually using the Child and Adolescent Needs and Strengths (CANS) tool. [12] CSA serves children with behavioral issues who are in or at risk of placement in residential care, foster care services, and/or a private school education program. As such, Virginia has adapted the CANS tool by expanding a module on trauma and adding a module on child welfare.[13]
• Tailor screening and assessment processes to meet the needs of families. Allowing for options regarding when, where, and how screening and assessment are conducted provides flexibility for families to determine the process that best meets their needs. For example, the care coordination system may set a standard to screen families during a well-child visit and also offer the option for families to self-administer the screening at home. This approach recognizes that while there may be a benefit to providers conducting in-person screening and assessment, families may prefer a more flexible screening process due to time constraints and other barriers to completing the form in a provider’s office. See the following resources to support family-centered screening processes:
  • “A Strengths-Based Approach to Screening Families for Health-Related Social Needs”
  • “Social Determinants of Health: Guide to Social Needs Screening”
  • “Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians”
• Establish processes for sharing screening and assessment results, including consent processes. Developing or enhancing a consent process, along with data-sharing agreements, can allow for screening and assessment information to be shared across providers when appropriate. Ideally, the consent form serves as a single document where families can select and authorize which providers their information can be shared with. Storing results electronically can enable families to promptly access them and can facilitate sharing with other providers as appropriate and in compliance with privacy regulations.
  • See the Confidentiality Toolkit,[14] a resource developed from the Administration for Children and Families’ Interoperability Initiative to support human services programs in sharing data across systems and navigating privacy considerations in the process.
• Use screening and assessment results to guide the intensity of care coordination services and facilitate referrals. Consider developing a standard process for matching the intensity of care coordination services to a child’s level of risk for adverse outcomes, as identified through the screening and assessment process. This may include the use of an algorithm (e.g., 3M Clinical Risk Groups, Pediatric Medical Complexity Algorithm, etc.) or manual scoring of screening and assessment results to stratify CYSHCN into tiers and match service intensity to need. Additionally, facilitating referrals to services and resources immediately following screening and assessment can build trust with children and their families and support their identified needs.
  • For example, Texas uses the STAR Kids Screening and Assessment Instrument (SK-SAI) for children enrolled in the STAR Kids specialized managed care program for CYSHCN.[15] The results of this assessment help to stratify CYSHCN enrolled in the program into one of three tiers, based on the child’s level of need and the intensity of care coordination services.[16]
  • For example, California’s ACEs Aware initiative provides Medicaid reimbursement for providers that screen children for adverse childhood experiences (ACEs) using the PEARLS tool. The state requires participating providers to complete a training on trauma and requirements for conducting the screening.[17] This training outlines the screening workflow, including the algorithm that informs a child’s risk level and that the clinical response includes linking to appropriate services.

Quality Measures that Align with Domain 1

The table below includes examples of quality measures, drawn from the four tools as described in the Quality Measurement section, that could be considered for measuring progress in implementing the standards within this domain. This list is not exhaustive. See more information in Aligning Quality Measures with the National Care Coordination Standards for Children and Youth with Special Health Care Needs.

“The shared plan of care provides a roadmap and an accountability system for integrating care based on family needs and priorities identified in the assessment and is used in coordinating a child’s care.”[19] The standards within Domain 2 identify the recommended core elements of a shared plan of care and support a family-centered approach to its development and use. Policies, procedures, training, and technology are key to facilitating the effective use of a shared plan of care while complying with privacy regulations. Below are strategies, resources, and examples to consider for implementing the standards in this domain.

• Design and implement a system-wide shared plan of care template, with input from key stakeholders, especially families. Providing a system-wide shared plan of care template can help to ensure that care coordinators and providers recognize a variety of child- and family-serving systems and needs. Incorporating the perspectives of a range of stakeholders and partnering with families and family-led organizations can support the design of a template that recognizes the diverse needs of CYSHCN. These partners are also critical in testing the utility and quality of the shared plan of care template and engaging families in its use.
  • See “Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs,”[20] a report from the Lucile Packard Foundation for Children’s Health, as a resource on creating and operationalizing a shared plan of care with families. A model for designing a shared plan of care in partnership with families is included on page 5 of the report. In the report’s implementation guide,[21] step 5 of the “Ten Steps to the Shared Plan of Care,” provides approaches for identifying needed partners, especially families, and collaborating with them to develop a shared plan of care.

Shared Plan of Care Template

This template, excerpted from “Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs,” outlines key components of a shared plan of care.

• Assess the technological capacity for documenting shared plans of care across providers. Ideally, shared plans of care are documented in an electronic health record (EHR) that is shared across a care team. After establishing the design of the shared plan of care, stakeholders can assess technology across the care coordination system to determine the existing technological capacity, any technology modifications necessary, and processes for providers that cannot access the EHR to access the most up-to-date shared plan of care. In developing these processes, stakeholders can ensure compliance with privacy regulations across child-serving systems and determine how consent processes can be implemented to meet these requirements.
  • For example, Iowa’s Medicaid managed care program implemented a shared plan of care that can be electronically accessed by providers, families, the state, and other care team members through its Pediatric Integrated Health Home Program.[23]
• Implement training to support use of the shared plan of care. Comprehensive training for providers and families can ensure that they are consistently using the shared plan of care to support the needs of CYSHCN. This may include training on how to use, maintain, and update the shared plan of care; how to effectively partner with families and providers; and how to adhere to new or modified workflows.[24] Training around privacy regulations may also help providers address potential misconceptions and support appropriate data sharing. [25]
  • For example, Oregon’s Title V CYSHCN program provides resources for care coordination staff to support the development of shared plans of care, including a website with a variety of tools.[26]^,[27]
  • See “Care Notebook: Documents & Resources to Support Your Child’s Shared Plan of Care,” developed by Family Voices of Wisconsin, a resource designed to support families in working with their care team.
• Identify opportunities to promote and incentivize the use of shared plans of care across the care coordination system. There are a variety of opportunities to promote the implementation of shared plans of care, which may differ across initiatives and programs that support sub-populations of CYSHCN. One opportunity is for Medicaid agencies to require managed care organizations (MCO) to use shared plans of care within their managed care contracts. Medicaid agencies and other payers may also provide financial incentives for providers to use a shared plan of care. Another opportunity is through State Title V CYSHCN programs, which can provide recommendations, oversight, training, and other support to promote the use of a shared plan of care across a variety of providers who serve CYSHCN.^[28]
  • For example, West Virginia’s Title V CYSHCN program has established memoranda of understanding (MOUs) with the state’s Medicaid MCOs. These MOUs outline expectations for serving CYSHCN, including that MCOs must use a shared plan of care for any member with a chronic condition.[29]

Quality Measures that Align with Domain 2

The table below includes examples of quality measures, drawn from the four tools as described in the Quality Measurement section, that could be considered for measuring progress in implementing the standards within this domain. This list is not exhaustive. See more information in Aligning Quality Measures with the National Care Coordination Standards for Children and Youth with Special Health Care Needs.

“Communication between members of the care team is timely, efficient, respectful, and culturally sensitive.”[31] The standards within Domain 3 emphasize that the family is the center of the multidisciplinary care team. While all care team members are able to support a family in accessing services, there is a designated single point of contact for care coordination for each family. Below are strategies, resources, and examples to consider for implementing the standards in this domain.

• Develop a process for identifying and aligning efforts across all care coordinators serving a family. Families of CYSHCN have reported that one of their primary challenges is having to coordinate across numerous care coordinators. To alleviate this challenge, stakeholders can develop standard processes to identify all care coordinators that serve a family and facilitate their alignment. These processes may involve information sharing across the care coordination system to identify partners and initiatives serving each family and developing guidelines for communication across care coordinators. Ideally, this process would include steps for identifying a single care coordinator (or another individual) to lead efforts across care coordinators. The shared plan of care can also be used as a tool to align efforts across care coordinators.
  • The Louisiana Office of Public Health’s Children’s Special Health Services, the state’s Title V CYSHCN program, has developed a Care Coordination Toolkit that includes information to support primary care providers in delivering comprehensive care coordination services.[32] This includes guidance on designing roles and workflows across the care team, processes for reporting on care coordination activities, and a Care Coordination/Communication Assessment Tool that providers can use to identify gaps in internal and external communication processes.[33]
• Develop processes for structuring the care team. Care team members and roles will differ depending on the strengths, needs, and preferences of a child and their family. Comprehensive screening and assessment and the shared plan of care can help to identify care team members across medical, behavioral health, social service, and education systems. The family and care coordinator can partner to identify care team members and outline appropriate roles and responsibilities, including determining whether the child is involved in care planning. These roles may include who updates the shared plan of care and which members attend care planning meetings, if any. Standardizing these processes throughout the care coordination system can help to ensure that each family has a full care team with clear roles and that care coordination is family-driven.
  • For example, Virginia’s Medicaid managed care plan for children and adults with complex care needs requires that each enrollee be assigned an interdisciplinary care team (ICT).[34] The managed care contract specifies that certain staff, including the care coordinator, primary care provider, and behavioral health clinician, must have the opportunity to join the ICT. [35] The enrollee can decide whether family members, peer support professionals, advocates, and other support staff are also included on these teams. [36] The contract also requires that the MCO design and submit policies and procedures for ICT communication, including processes for facilitating participation in the ICT and related meetings, aligning with other care coordination teams, connecting to services, and conducting follow-up.[37]

Care Team Member Checklist

This checklist includes potential members of the care team to consider.

• Establish guidelines for communication across the care team. In addition to defining roles and responsibilities for each care team member, clear communication guidelines can support the care team in delivering comprehensive care. This may include identifying a main point of contact for the family while also adhering to a “no wrong door” approach. Communication protocols may outline when the family should contact the care coordinator/care team members, when the care coordinator should contact the family/care team members, and when other care team members should contact the family/care coordinator. Communication guidelines may also include resources to support collaborative care planning, care team meeting facilitation, and strategies to engage providers and families.
  • See these resources: “Guiding Principles for Team-Based Pediatric Care,”[38] “Enhancing Provider Engagement in Practice Improvement: A Conceptual Framework,”[39] and “Engaging Families in Improving the Health Care System for Children with Special Health Care Needs.”[40]

Communication Policy Assessment Tool

This resource, adapted from the Care Coordination Toolkit from the Louisiana Office of Public Health’s Children’s Special Health Services, is an example of a tool that state health policymakers can use to support care coordination providers in assessing and developing comprehensive care coordination communication policies. The rate of policy adoption across providers and programs can also be used as a quality indicator.

• Determine technology and data-sharing needs. A shared platform across the care team can support care management for CYSHCN, closed-loop referrals to community-based services, and notification of change(s) in health status (e.g., hospital admission). The development and use of these platforms may require information-sharing agreements and processes to request a family’s consent to share protected information across providers. Information-sharing agreements may also be implemented to facilitate regular and appropriate communication across the care team while adhering to relevant privacy regulations.
  • See “Community Resource Referral Platforms: A Guide for Health Care Organizations,”[42] which includes considerations for implementing a shared referral platform across health and social service systems.
  • For example, Colorado leveraged a grant from the Administration for Children and Families to improve interoperability of information technology systems across child welfare and behavioral health systems, as well as other health and human services. This project, the Colorado Client Information Sharing System, facilitated data sharing to support direct services, as well as to inform program management and county- and state-level decision-making.[43]

Quality Measures that Align with Domain 3

The table below includes examples of quality measures, drawn from the four tools as described in the Quality Measurement section, that could be considered for measuring progress in implementing the standards within this domain. This list is not exhaustive. See more information in Aligning Quality Measures with the National Care Coordination Standards for Children and Youth with Special Health Care Needs.

“Care coordination includes education, coaching, and training for CYSHCN, families, and care teams. These activities empower children and families and advance their well-being, while at the same time enabling other members of the care team to gain the understanding and insights needed to serve families effectively.”[44] The standards within Domain 4 encourage care coordination systems to provide strengths-based services and supports for families. Below are strategies, resources, and examples to consider for implementing the standards in this domain.

• Train care coordinators and care team members. The care coordination system can provide training for care coordinators and care team members in how to effectively interact with other members of the care team and support families in building skills and self-management. This may include education in strengths-based approaches, methods to clearly communicate complex concepts, and effective strategies to support family engagement. Training can also include the identification of services that support the development of families’ strengths and skills, including peer supports, youth programs, and caregiver support services. Systems may also provide resources, such as facilitation tips and worksheets, to support care coordination staff in these efforts. See the following training tools and resources to support care coordination team members:
  • “Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes”[45]: This curriculum from Boston Children’s Hospital is organized into five modules and can be used to train a variety of audiences in the core concepts of pediatric care coordination.
  • Family Centered Case Management Training for Service Coordinators: This training module from the Texas Department of Health and Human Services is used to support service coordinators in providing family-centered care coordination for Early Childhood Intervention, an initiative to support families of children with developmental and medical needs.
• Establish policies to support education and empowerment for families. A family’s comprehensive understanding of the child’s conditions, needs, and strengths is key to improving self-management and developing related skills. The care coordination system can set policies that guide the care team in providing clear information that considers families’ culture, language, and health literacy levels.
  • See the following resources on family education and empowerment: “Guide to Leveraging Opportunities Between Title V and Medicaid for Promoting Social-Emotional Development”[46] and Strengthening Families and the Protective Factors Framework,[47] which includes action sheets and “Using Protective Factors to Help Identify Relevant Strengths” to support implementation of a strengths-based approach.
  • For example, the Rhode Island Department of Health and Human Services partners with the Rhode Island Parent Information Network, Family Voices, the Neighborhood Health Plan of Rhode Island, and the Rhode Island American Academy of Pediatrics to operate the state’s Pediatric Practice Enhancement Project (PPEP).[48] Through PPEP, family members of CYSHCN are hired as consultants and work directly with pediatric providers to support comprehensive family-centered care coordination.[49] These consultants support families in improving their understanding of the health care system and increasing their sense of empowerment as key decision-makers.[50]
• Support people with lived experience as key members of the care team. Including peer support professionals in care teams can increase cultural sensitivity and improve family engagement. Stakeholders can implement policies that support employment for peer support professionals and family caregivers and equitable compensation for the care coordination they provide. This may include requiring or recommending peer support professionals as part of the care team, reviewing and modifying provider eligibility and rates through Medicaid and other payers as needed, and providing stipends. Increasing access to education, training, and respite services can also support family empowerment.
  • For resources to support the empowerment of family caregivers as members of the care team, see the websitefor Family Voices, a national organization advocating for family participation in health care; Find Your Parent Center, a parent training and information network directory from the Center for Parent Information and Resources; and “Medicaid Funding for Family and Youth Peer Support Programs in the United States.”[51]
  • For example, the Arkansas Department of Human Services provides Medicaid reimbursement for family peer support professionals through the Children’s Services Targeted Case Management state plan amendment.[52] “Parent aides,” parents of CYSHCN, are employed by the state Title V CYSHCN program to provide care coordination services for families. [53] Services include conducting a comprehensive assessment of a child’s needs, developing and monitoring a service plan, and providing service connection and follow-up.[54] To be eligible for the services under this policy, the child must be enrolled with the state’s Title V CYSHCN program, the Supplemental Security Income/Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) Disabled Children Program, or meet certain medical criteria.[55]

Quality Measures that Align with Domain 4

The table below includes examples of quality measures, drawn from the four tools as described in the Quality Measurement section, that could be considered for measuring progress in implementing the standards within this domain. This list is not exhaustive. See more information in Aligning Quality Measures with the National Care Coordination Standards for Children and Youth with Special Health Care Needs.

“The care coordination workforce is well-trained and prepared to serve CYSHCN and their families. All care team members have opportunities to gain the knowledge and understanding needed to perform their roles effectively.”[56] The standards within Domain 5 focus on supporting a diverse care coordination workforce that can provide high-quality care coordination services for CYSHCN. Below are strategies, resources, and examples to consider for implementing the standards in this domain.

• Provide training and clear expectations for care coordination staff. Care coordination systems can serve a crucial role in providing ongoing training, resources, and support for care coordination staff. Stakeholders can develop guidance for recommended criteria for care coordinators to meet or work toward. This guidance can help establish consistent expectations for care coordinators, while also allowing flexibility for care coordination programs to hire staff that meet the specific needs of the families they serve. These competencies may be leveraged in job descriptions and throughout the hiring process and may help guide orientation and ongoing training topics.
  • For example, the Kansas Title V CYSHCN program developed the Holistic Care Coordination Implementation Toolkit, which outlines guidance for providers in implementing high-quality care coordination programs that are organized by and align with the National Care Coordination Standards for CYSHCN. Kansas is also providing technical assistance through a Project ECHO Series and a Community of Practice to support implementation.[57]
  • See the OPIP Quality Improvement Tools & Strategies, a webpage developed by the Oregon Pediatric Improvement Partnership at Oregon Health & Science University, for a variety of resources to support pediatric care coordination providers.

Care Coordinator Responsibilities

The following table includes potential responsibilities that state health policymakers and providers could draw from to develop job descriptions, guidance, requirements, and other resources for care coordination programs. This list is organized by the six domains in the National Care Coordination Standards for CYSHCN. This list is not exhaustive. See these sample job descriptions for additional examples of care coordinator responsibilities and competencies: Practice Based Care Coordination Job Description[58], Pediatric Nurse Case Manager, Special Needs Program[59], and Care Coordinator Sample Job Description.[60]

• Prioritize the hiring of care coordinators with lived experience and those that expand the cultural, racial, ethnic, and linguistic diversity of care coordination staff. Stakeholders can support a diverse workforce by increasing care coordination-related training and educational opportunities for people with lived experience and those with diverse cultural, racial, ethnic, and linguistic backgrounds. Additionally, stakeholders can consider identifying and modifying licensing regulations that may serve as barriers to employment as a care coordinator. These strategies can be coupled with enhanced plans to recruit diverse staff across the care coordination system and cultural competency and implicit bias training for existing staff, management, and leadership to improve hiring practices.[62]
  • See Think Cultural Health and The EveryONE Project Implicit Bias Resources for resources to support care coordinators in providing culturally appropriate services and reducing biases.
• Develop caseload ratios that allow care coordinators to maintain high-quality service delivery. The care coordination system can establish a method of standardizing caseload ratios across care coordinators while also allowing flexibility for providers to adjust the method to best fit their needs. One approach is to use an acuity scoring tool that accounts for the required intensity of care coordination services, the complexity of the case, and other capacity considerations to inform caseload assignment.
  • For example, Georgia’s Department of Behavioral Health and Developmental Disabilities, in partnership with the Georgia Department of Community Health and its MCOs, contract with behavioral health provider organizations to provide intensive care coordination for children and youth with complex behavioral health needs.[63] Georgia sets a caseload ratio of one care coordinator for every 10 families. The state requires care coordinators to have a bachelor’s degree but allows experience to substitute for this.[64] Training for care coordinators includes cultural competency, trauma-informed care, and partnering with families.[65]
• Establish policies for reviewing data to assess the care coordinator and care team performance. System-level guidelines that outline key data points to track and recommend data review processes can support care coordination program management. Guidelines may also include recommendations regarding the frequency of data review and report-out, when and how to make appropriate adjustments, and technology capacity and needs. Potential data points may include:
  • The number of cases for each care coordinator
  • The complexity of each care coordinator’s caseload
  • The intensity of care coordination services required from each care coordinator’s caseload
  • The time required for care coordinators to provide services, including travel time
  • Care coordination activities and services
  • Outcomes from care coordination activities and services
  • Care coordinator staff turnover
  • Child and family feedback on care coordination services

Quality Measures that Align with Domain 5

The table below includes examples of quality measures, drawn from the four tools as described in the Quality Measurement section, that could be considered for measuring progress in implementing the standards within this domain. This list is not exhaustive. See more information in Aligning Quality Measures with the National Care Coordination Standards for Children and Youth with Special Health Care Needs.

“Care transitions refer to the transfer of care between and within medical, behavioral health, social service, education, and justice systems. Emphasis is placed on preparing youth for transitions from pediatric to adult care and promoting independence in the transition to adulthood. Advance preparation and careful integration of services following transitions are essential to a successful transition process.”[66] Below are strategies, resources, and examples to consider for implementing the standards in Domain 6.

• Develop policies to proactively identify and plan for upcoming transitions. Care coordination systems can identify key data points to monitor that may indicate an upcoming transition. Transition policies may outline how these data points are tracked, monitored, and flagged, as well as steps in the transition planning and care transfer process. For example, for the transition from pediatric to adult care, a transition policy may identify the age at which planning for the transition begins, processes for tracking age, how it is flagged that a child has reached the age to begin transition planning, steps for transition planning, and how care is transferred to adult providers. These policies may also include special considerations for transfer of care between providers or to other care settings, such as a child entering or exiting school, inpatient care, or a congregate care setting. See the following resources:
  • Got Transition: This website from The National Alliance to Advance Adolescent Health serves as a resource center on health care transition.
  • Assessment of Health Care Transition Activities in Care Coordination Programs:[67] This worksheet from Got Transition supports care coordination programs in assessing their care transition policies and activities.
  • Transition Planning: This page from the Got Transition website provides resources specific to transition planning, which is Element Four of Got Transition’s Six Core Elements of Health Care Transition.
  • Implementation Guide for Transition Planning:[68] This guide from Got Transition can support the implementation of policies and programs to identify of and plan for upcoming youth transitions.
  • “Health Care Transition in State Title V Programs: A Review of 2018 Block Grant Applications and Recommendations for 2020”:[69] This resource reviews care transition strategies that state Title V agencies reported in their 2018 applications/2016 annual reports and highlights key state examples.
  • As an example, Texas Health and Human Services sets contractual requirements for Medicaid MCOs to support care transitions for CYSHCN enrolled in the STAR Kids health plan, which serves children with disabilities up to age 20.[70] The contract requires that the MCO employ transition specialists who work with care coordinators to plan for adolescents’ transition to adult-serving health plans and providers beginning at age 15.[71] The specialized plan’s handbook lists recommended activities to support this transition, organized by age.[72]
• Provide training and resources to care coordination staff to support effective transitions. The care coordination system can provide training for care coordination staff and the care team to ensure clarity of roles and responsibilities related to transition planning. Transition readiness assessments, transition planning tools, and transfer packets can support CYSHCN and their families in effectively transitioning between providers.[73] Providing standardized tools and training across the care coordination system can help to ensure that care coordination providers are equipped with resources to support CYSHCN and their families.
  • See Education & Training for Health Care Professionals, Health Care Transition Curricula, a resource developed by Florida Health and Transition Services to support the education of care coordination team members on health care transitions.
• Develop processes for tracking care transition activities. Tracking care transition activities and outcomes supports accountability, as well as providing clear communication and information sharing to facilitate a warm hand-off to the new provider(s). These activities and/or the result of the care transfer can be documented in the shared plan of care to ensure that the care team is aware of new provider contacts.
  • For example, the Kentucky Department for Public Health administers the state’s Title V CYSHCN program through the Office for Children with Special Health Care Needs (OCSHCN). OCSHCN has developed a series of five checklists, organized by age, with key questions for families of CYSHCN to track and identify care transition considerations, including potential new services and supports.[74] OCSHCN has also developed a transition policy statement for transition-age youth, administers a transition readiness assessment, and employs a transition administrator who conducts regular follow-up for young adults who have recently aged out of youth services.[75]

Quality Measures that Align with Domain 6

The table below includes examples of quality measures, drawn from the four tools as described in the Quality Measurement section, that could be considered for measuring progress in implementing the standards within this domain. This list is not exhaustive. See more information in Aligning Quality Measures with the National Care Coordination Standards for Children and Youth with Special Health Care Needs.