Advancing Family-Centered Care Coordination for Children and Youth with Special Health Care Needs using a Shared Plan of Care

Since 2016, over 20 Wisconsin clinics have participated in Shared Plan of Care (SPoC) pilot projects. Clinics have piloted this work with families of children diagnosed with chronic health or behavioral health needs including Attention-Deficit/Hyperactivity Disorder (ADHD), Juvenile Rheumatoid Arthritis (JRA), medically complex children, and those transitioning from pediatric to adult health care. Clinic teams report “This has streamlined communication between primary providers and other health care providers and mental health counselors.” Many of the families report that their child’s needs have been met and have shared that “[I] feel having the shared plan has helped me to understand, communicate and determine what is best for my child…”

Children’s Health Alliance of Wisconsin’s Medical Home Initiative is releasing a Request for Applications for quality improvement projects in Wisconsin medical practices serving children and youth with special health care needs. Funding for projects is provided through a grant from the Wisconsin Department of Health Services, Division of Public Health, Bureau of Community Health Promotion, Family Health Section, Children and Youth with Special Health Care Needs Program.

Teams will use a quality improvement approach to accelerate their learning. Based on available funds up to $125,000, organizations may choose to apply for a grant in an amount up to $25,000. Project teams are required to pilot and implement use of a shared plan of care with children with special health care needs while engaging youth and family in the QI activities. Teams will participate in a statewide learning community where they will learn and share with one another.

Pediatricians who can attest to meaningful participation in the project are eligible for 25 Maintenance of Certification (MOC) Part 4 credits through the American Board of Pediatrics upon project completion.

Completed Applications are due by Dec. 2, 2019:

  • Access the 2020 project proposal guidance
  • Access the online application to submit your proposal
  • Download a one-page summary of the grant opportunity
  • Register for the Oct. 28 (12-1 p.m.) information call (register by Oct. 24)

For additional information, visit or contact Colleen Lane (