Care Coordination

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)

Advancing care coordination for children and youth with special health care needs

The Wisconsin Medical Home Initiative supports implementation of care coordination quality improvement grants through the Advancing Family-Centered Care Coordination for Children and Youth with Special Health Care Needs Project. Participating Wisconsin pediatric primary care teams are working to advance medical home care provision for children and youth with special health care needs through the use of Shared Plans of Care.

Learn More

Clinician Resources

Family Resources

  • 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
Project Manager
Medical Home
(608) 442-4177

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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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