5Cs photo

More than one million children in California have a special health care need, and many of these children and families face severe challenges. Health care and other support services may be poorly coordinated, and families are left to navigate the fragmented and confusing system on their own. These challenges are magnified for children of color, low-income families, and those living in rural areas.

Since 2013, we have been funding the California Community Care Coordination Collaborative (5Cs) with the goal of improving local systems of care for children and families. The learning collaborative comprises county coalitions with representatives from the California Children’s Services Program, Regional Centers, Family Resource Centers, Early Start, as well as pediatricians, public health nurses, and special education and mental health professionals.

The coalitions meet locally and their leaders take part in the statewide California Community Care Coordination Collaborative (5Cs). The 5Cs provides a structured opportunity for the coalitions to learn from one another, identify areas of shared need, discuss emerging challenges and connect with others engaged in improving the quality of services for children with special health care needs in California.

Through this work, we have been surprised by the lack of communication and interaction across agencies serving these children. The model of local coalitions, along with a statewide learning collaborative, seems to help in developing and sharing inter-agency solutions to improve this situation and address care coordination. In 2015 we expanded the program to fund new counties and build on the initial phase.

Phase II Coalitions (2015-16):

The Alameda County California Children’s Services (CCS)/Behavioral Health Services Integrated Care Coordination Project, under the direction of the Alameda County Health Care Services Agency, is improving access to behavioral health services for CCS-enrolled children and enhancing the coordination of their care among key community service providers.

The Seven Cs Project, under the direction of the Public Health Division of Contra Costa Health Services, is piloting the use of a CSHCN service system coordinator to facilitate inter-agency meetings and direct case reviews of challenging cases.

The Orange County Care Coordination Collaborative for Kids, led by Help Me Grow Orange County, is assessing CSHCN needs in the county and pilot testing a process to identify, track and review cases of families of CSHCN to help connect them to services and increase communication between providers.

The San Joaquin County 5Cs Project, led by the Family Resource Network, is establishing a health navigator within each agency serving children with special health care needs (CSHCN) and their families in the county, and expanding formal and informal workgroups into a formal network to improve care coordination for CSHCN ages 0 to 20.

The San Mateo County Care Coordination Learning Community, led by Community Gatepath, is developing care coordination policy and practice recommendations and working with First 5 San Mateo to expand care coordination services for a San Mateo County Health System Clinic.

The Ventura County VC-Pact, under the direction of the County of Ventura Public Health Department, is improving their screening and referral protocol for children with special health care needs. The group is developing a tool to screen for potential chronic health needs that will be used during intake of children and youth into Child Welfare Services and the County Probation Agency. Once this tool is piloted and refined, it will be used in other child-serving agencies in the county.


Tools Developed by 5Cs Member Coalitions

Memorandum of Understanding – sample from San Joaquin County

Steering Committee Expectations – sample from Alameda County

Evaluation Plan – sample from Orange County

Job Description for CSHCN Service System Coordinator – sample from Contra Costa County

Authorization to Exchange Confidential Information – sample from Contra Costa County

Confidentiality Agreement Sign-In Sheet for Interagency Meeting – sample from Contra Costa County

Protected Health Information Chart for Interagency Meeting – sample from Orange County

Acuity Screening Tool – sample from Orange County

Acuity Screening Tool Frequently Asked Questions – sample from Orange County

Process for System Level Care Coordinator – sample from Orange County

Assessment and Referral Form – sample from Kern County

Protocol for Case Review – sample from Orange County

Flow Chart for Assessment and Referral – sample from San Mateo County  

Community Pediatrics Poster Session of the American Academy of Pediatrics (AAP) National Conference, 2015: Multiagency Collaboration to Improve Care Coordination: A County-Level Case Study of Children with Special Health Care Needs – presented by Orange County

Other Care Coordination Tools

Medical Home Care Coordination Measurement Tool

Care Coordination Measures Atlas

Key Literature

Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems

Beyond the Medical Home: Coordinating Care for Children

Care Coordination and Unmet Specialty Care Among Children with Special Health Care Needs

Care Coordination for California’s Children and Youth with Special Health Care Needs: Building Blocks from Other States

Benefits of Care Coordination for Children with Complex Disease: A Pilot Medical Home Project in a Resident Teaching Clinic

Care Coordination: A Multidisciplinary Framework

Care Coordination Definition and Principles: Massachusetts Consortium for CSHCN

Financing Models and Payment Strategies for Care Coordination

Improving Care Coordination: Early Lessons and Recommendations from 5 States

Policies for Care Coordination Across Systems

Reducing Care Fragmentation: A Toolkit for Coordinating Care

Systems of Care Coordination For Children: Lessons Learned Across State Models

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