Care coordination: A vital component of the medical home

The medical home initiative has been working hard on aligning organizations from early identification to care coordination for children and youth with special health care needs (CYSHCN). Read below to learn more about our work around care coordination.

A need for networking
In 2022, the medical home initiative met with care coordinators across eight health systems to identify what kind of support and resources they needed in their practice. One key takeaway from conversations was the vast number of roles coordinating care for CYSHCN, beyond the title of care coordinator. All of these roles require knowledge of resources, often beyond their experience, and desired a broader network to support those connections for families.

In response to the feedback, we created the Care Coordinators Collaborative, where a network of partners in Wisconsin who are coordinating care have a place to build connections with one another and collaborate on the work they are doing. We acknowledge that the way care coordination is designed and structured is often by diagnosis or a group of people, so we wanted to create a space for collaboration that offers broad topics to a variety of different coordinators.

Connecting care coordinators
The Care Coordinators Collaborative is a 45-minute learning session promoting peer learning and support for those who help coordinate the care of children and youth. This is a space for anyone who is coordinating care to build connections, develop contacts, exchange expert advice and learn about resources, supports and tools that have been used locally and statewide, that other professionals can adapt into their own work. Each session is about a different topic with varying resources, highlighted by experts throughout Wisconsin.

Our latest Care Coordinators Collaborative was around the topic of home visiting, and we hosted an expert from the Direct Assistance for Dads (DAD) Project through the City of Milwaukee Health Department. This expert highlighted the role of home visitors, what the DAD Project is, the work they are doing, resources the DAD Project uses when talking with fathers and families and how other communities can engage with fathers. Other topics for past Care Coordinators Collaborative sessions include supporting youth to adult health care transition, cross sector alignment to improve food security and dental health for CYSHCN.

In 2024, we were able to engage with 108 health professionals from a variety of different organizations, including public and state health departments, health insurance, hospitals, clinics and more.

To stay connected on upcoming care coordinator collaborative sessions, sign up for our medical home newsletter. You can also connect with Program Manager, Anna VerKuilen, MP via email with topics of interest or to learn more about our care coordination work!