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29.2.12 Clinician-Directed Care Coordination Services
Clinician (physician or APN)-directed care coordination services are a benefit of the CSHCN Services Program.
Clinician-directed care coordination services are a benefit only when provided by a primary care clinician, specialist, or subspecialist who attests that he or she is providing the medical home for the client.
• The medical home is a partnership between the child, the child's family, and the primary care provider (or place where the child receives care).
•The medical home is a care delivery model that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent.
•In providing a medical home for the client, the primary care clinician directs care coordination together with the child or youth and family.
•Care coordination is a family-centered process that links children or youths with special health needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care.
Clinician-directed care coordination services (face-to-face and non-face-to-face) must include the following activities, with permission of the client or family:
•Supervising the development and revision of a client's written care plan (a formal document or contained in the client's progress notes) in partnership with the client, family, and other agreed-upon contributors (and sharing of this care plan with other providers, agencies, and organizations involved in the care of the client)
•Coordinating of care among multiple providers
•Maintaining of a central record or database that contains all pertinent client medical information, including hospitalizations and specialty care
•Assisting the client and family in communicating clinical issues when a client is referred for a consultation or additional care
•Evaluating, interpreting, and managing of consultant recommendations for the client and family in partnership and collaboration with consultants, other providers, the client, and the family
Clinician-directed care coordination services should also include supervision of development and revision of the client's emergency medical plan in partnership with the client, the family, and other providers to be used by emergency medical services (EMS) personnel, utility service companies, schools, other community agencies, and caregivers.
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