Care Coordination for Children with Special Healthcare Needs Anticipating Transition: A Program Evaluation

• Published in: Journal of pediatric nursing 2021-11, Vol.61, p.7-14
• Main Authors: Morton, Beth, Damato, Elizabeth G., Ciccarelli, Mary R., Currie, Jackson
• Format: Article
• Language: English
• Subjects: Care coordination; Case management; Children with special healthcare needs; Disabled children; Transition to adult care
• ISSN: 0882-5963; 1532-8449
• DOI: 10.1016/j.pedn.2021.02.024

Nearly 20% of U.S. children have special healthcare needs (CSHCN). Difficulties experienced with navigating the array of services for these children has highlighted the value of care coordination to improve care, reduce costs and increase satisfaction. This study evaluated the services delivered within a care coordination program at a transition consultation center for CSHCN. It also compared the advancement of youth by age group toward graduation criteria. Using a program evaluation method, data were collected via a retrospective chart review. The convenience sample included clinical records from 100 patients aged 11–22 who had a chronic disease or disability. The comparison of services for those with diagnoses of autism spectrum disorder, cerebral palsy and Down syndrome were uniformly high in supporting primary care and health care financing. Medicaid waiver assistance was provided more frequently to younger adolescents while older adolescents more commonly received support in all other graduation criteria, including primary and specialty care, healthcare financing and decision-making supports. Youth served in a transition care coordination program receive a high volume and broad array of services. There are some variations in the types of services by diagnosis and level of support need. Older youth show greater advancement toward graduation criteria. This in-depth chart review provides a valuable description of the activities of care coordinators serving CSHCN enduring transition. It enables development of targeted strategies for building care coordination programming and sets an example for the design of future research studies on this topic. •Care coordination addresses many needs of children with chronic conditions.•A transition-focused clinic improves the experience for child with special needs.•Transition clinics provide comprehensive services to adolescents and emerging adults.•The transition process includes medical, school, legal and insurance concerns.•Older children with disabilities need assistance with obtaining guardianship.