Care Coordination - CYSHN

Care Coordination in Minnesota

Care coordination is an essential component of integrated care, which is the "seamless provision of health care services, from the perspective of the patient and family, across the entire care continuum." Most recent data on care coordination from the 2016 National Survey of Children's Health shows that 13.5% of families of Children and Youth with Special Health Needs (CYSHN) in Minnesota that needed effective coordination did not receive it. This suggests opportunity for improvement in ensuring families receive appropriate, comprehensive care coordination services.

Care coordination is an important function of the patient and family-centered medical home, and care teams can provide optimal coordination and integration of services needed by the child and family. Relationships between the health care provider, the care coordination team, and the patient and family facilitate effective information sharing, goal setting, care planning and follow-up support.

Grants have been awarded to five clinics to implement quality improvement projects aimed at improving care coordination for children and youth with special health needs. The five clinics receiving grants are as follows:

  1. Children's Minnesota - Minneapolis/St. Paul, MN: implementing a project aimed to improve the process of transition to adult health care for youth living with Sickle Cell Disease.
  2. Essentia Health - Duluth, MN: implementing a project aimed at both increasing the capacity of support staff to be integrated into the Care Coordination Program, and improving transition of adolescents to adult care.
  3. Lakewood Health System - Staples, MN: implementing a project aimed at identifying high risk and special needs youth and helping them navigate the complex health care system and transitioning to and from home when specialty care is needed.
  4. Unity Family Health Care - Little Falls, MN: implementing a project aimed at care planning and community resource connections for children with Asthma and ADHD diagnoses.
  5. West Side Community Health Services - St. Paul, MN: implementing a project aimed at developing processes that assure effective coordination with community resources.

Grant Period December 1, 2017 - May 31, 2019

Providing care coordination is both challenging and rewarding. Please join us in building a community of practice for all who provide care coordination for children & youth.

We are developing a statewide list of people that are actively working in this area. This list will improve access to others to build and support your networking community.

Who should register:

  • Care Coordinators, Care Navigators, Health Coaches at Primary Care Clinics: Family Practice, Pediatrics, Med-Peds
  • Care Coordinators at Specialty Care Clinics
  • School Nurses, Public Health Nurses
  • Case Managers: county, non-profit, school, etc.
  • Social Workers, Waiver Case Managers

Anyone... providing care coordination activities and wanting to network with others!


You will receive a follow-up email, inviting you to access a MDH SharePoint site: Community of Practice: Care Coordination for the Pediatric Population.

This site will have a master list of those registered, ability to post and share resources with a discussion board. Per feedback given at the kick-off session, we are planning to convene 2-3 times a year via webinar and in person once a year.

First Webinar is June 27, 2018, 12 - 1 PM

You are Not Alone: Establishing Community Partnerships

The kick-off session was held on April 4, 2108. The morning was spent reviewing the context of care coordination for the pediatric population and defining Community of Practice. A highlight of the morning included a panel presentation Strategies for Success - Care Coordination Spotlights. PPTs and handouts will be posted on the SharePoint site.

Any questions please contact us at

In Minnesota, a systems mapping process, which gathered input from stakeholders from across the state, was undertaken to assess strengths, challenges, gaps, and redundancies that are occurring around care coordination.

Background Information:

Children and youth with special health needs and their families often need a wide variety of medical, psychosocial, educational, and support services. Without effective care coordination, CYSHN can receive fragmented or duplicative services - ultimately receiving less than optimal care and causing unnecessary stress and frustration for families. In order to improve care coordination for CYSHCN, stakeholders need to have a better understanding of current cross-system care coordination efforts.

What did we do in Minnesota?

During 2015 - 2016, we conducted a series of regional meetings across the state with stakeholders involved in providing or receiving care coordination. The specific objectives for these regional meetings included:

  • Discuss greatest opportunities and challenges in coordinating care;
  • Gain understanding of the complexity of care coordination from the family's perspective;
  • Complete system mapping to identify current organizations and initiatives supporting the care coordination system, identify current gaps and redundancies in the system, and guide systems improvement efforts;
  • Develop and prioritize recommendations to improve care coordination;
  • Brainstorm ideas on ways each participant can improve how they practice care coordination;
  • Discuss and plan for ways that care coordinators can collaborate and/or continue working with each other to improve care coordination in their region.

What were our findings?

Regional and state-level findings from our systems assessment are included in the reports linked below: