Care coordination is a process that links children and their families with health care, supports and services. It emphasizes quality and cost outcomes, and utilizes partnerships to provide the best family-centered care.
Care coordination is based on a Shared Plan of Care, a living document created by parents and their child’s health care providers. A Shared Plan of Care provides a comprehensive view of a child’s needs and treatment, ensuring information is accessible across systems and that activities are documented by a variety of providers.
Key components of a Shared Plan of Care include:
- Medical summary
- Family strengths and preferences
- Negotiated plan of action (including clinical and family goals, actions to address goals, responsible partners, and timelines)
- Other necessary attachments (such as emergency plans, chronic condition protocols, and relevant legal documents such as IEPs or 504 plans)
AAP policy statement: Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems (2014)