Care Coordination - Minnesota Department of Health

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." 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.

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

  1. Essentia Health - Duluth, MN: has been refunded to continue their transition work of partnering with Family Medicine improving transition of adolescents to adult care.
  2. Gillette Children's Specialty Health Care Complex Care Clinic – implementing processes to improve the process of transition to adult health care for youth with complex medical conditions
  3. Wellstone Muscular Dystrophy Clinic, Univ of MN Regents – implementing processes to improve the process of transition to adult health care for youth with neuromuscular conditions.
  4. South Lake Pediatrics – Implementing processes to improve the coordination of care for the early childhood population.

Grant Period June 1, 2019 - October 31, 2020

Announcement: We are happy to announce that we have selected a grantee, ACET, Inc., to facilitate the Pediatric Care Coordination Community of Practice (CoP). ACET will work directly with the Children and Youth with Special Health Needs staff and the CoP Workgroup to facilitate the implementation of the statewide Pediatric Care Coordination CoP where participants can network, collaborate, share, and learn. ACET has extensive experience in facilitating and working with statewide advisory groups and task forces. ACET also works in many care coordination projects, following the best practices in care coordination according to the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), and others identified by care coordinators. ACET's strategies include using many effective tools that center on listening and learning from those across the state.

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!

Register: Community of Practice

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.

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:

Updated Monday, 13-Jul-2020 08:46:00 CDT