Care Coordination

Care coordination links children and their families with health care and community supports in an effort to achieve good health.

Coordination services may be available from health care and community-based organizations. These services can address medical, social, developmental, behavioral, financial and educational aspects of health. Coordination may include sharing information with different agencies as well as active connection to health care and community services. Children and families are always at the center of the support.

The Medical Home Initiative collaborates with clinical, public health and community organizations across Wisconsin to improve support systems of coordination that promote family-centered practice. We invite you to collaboratively pursue solutions to challenges in systems of coordination that benefit all children and families.

Advancing Family-Centered Care Coordination

The Medical Home Initiative supports Wisconsin health care professionals and Tribal Health Centers to increase knowledge, skills and practices that improve cross-sector coordination of care and community of support for children and youth with special health care needs. There are multiple tools available to help with care coordination such as care maps, care notebooks and shared plans of care (see our Family Engagement page).

2024 Tribal Health Center Learning Community Calls

  • January/February: Individual team calls
  • April 24: Learning Call
  • June/July/August: Individual team calls
  • Oct. 23:  Learning Call

2023 Project Team Map

2023 Learning Community Calls
• January/February: Individual team calls
• April 26: Learning Call
• June/July/August: Individual team calls
• Oct. 18: Learning Call

2022 Project Team Map

2022 Learning Community Calls
• February/March: Individual team calls
• April 27: Learning Call
• July 13: Learning Call | Slides
• September/October: Individual Team calls
• Dec. 7: Learning Call

2021 Project Team Map
2021 Driver Diagram

2021 Learning Community Calls
• Feb. 23: Learning Call
• April/May: Individual team calls
• June 22: Learning Call | Slides
• September: Individual team calls

2020 Project Team Map
2020 Driver Diagram

2020 Learning Community Calls
• Feb. 25: Slides | Recording
• June 23: Slides | Recording
• Oct. 27: Slides | Recording

Care Coordinator Collaborative

Network and learn about what other clinics and organizations are doing regarding referral and coordination processes.

2024 Calls

  • Feb 13: Topic – Youth to Adult Health Care Transition

Clinician & Professional Resources

American Academy of Pediatrics (AAP) Policy Statement
Patient and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth across Multiple Systems.

Boston Children’s Hospital Integrated Care Program
Support the provision of family-centered care coordination with this comprehensive program.

National Resource Center for Patient/Family-Centered Medical Home
Provides practices with care coordination tools to start and sustain the medical home transformation process.

Shared Plan of Care Example
View an example of a Shared Plan of Care from Indiana University’s Riley Children’s Hospital.

Family Resources

C.A.R.E. Medical Home Series for Families
Learn strategies to coordinate and strengthen communication between your child’s health care team and other partners you work with.

National Resource Center for Patient/Family-Centered Medical Home
Find tools and resources to help coordinate your child’s care.

Pediatric Care Plan Template
See an example of a shared plan of care from the American Academy of Pediatrics. Talk to your provider about developing a plan for your child.

Contact Our Staff

Colleen Lane
Program Manager
Medical Home
(608) 442-4177

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Medical Home Minute

Monthly news, events and resources from the Wisconsin Medical Home Initiative.

The Wisconsin Medical Home Initiative is funded by the Wisconsin Department of Health Services’ Title V Children and Youth with Special Health Care Needs Program and the Maternal Child Health Program located in the Division of Public Health.

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