Care Coordination

Raising a child is a joy and has its challenges.  If your child has special health care needs, that job is even more complex.  Navigating the system to ensure your child’s and family’s needs are met can be frustrating and overwhelming.

We are here to partner with families of children and youth with special health care needs to connect and coordinate services which may assist your child's development.

Our services include:

1. Referral to resources and support services
2. Connecting families to Medicaid, CHIP, Supplemental Security Income and/or health insurance
3. Assisting families with organizational needs:
• Establishing a Care Notebook of the child’s specific needs by organizing doctor’s appointments, medications, school plans and resources; and community resources.
4. Helping families to complete the Ages and Stages Questionnaires.
• Reviewing results with parents and assisting with concerns as well as highlighting successes.
• Making referrals to appropriate developmental resources as applicable.
5. Working with families to understand the transition to adulthood process:
• Providing transition-related information, resources, and referral for children with special needs ideally beginning around 12-14 years of age.
• Working with youth throughout the transition period, regardless of age.
6. Exploring housing and financial issues and solutions.
7. Working through behavioral health issues.
8. Helping families understand and work through educational needs, concerns, and plans.
9. Helping families create realistic care plans that include:
• Health care goals
• Life goals
• Family self-sufficiency goals
• Educational developmental goals
• Behavioral/Mental health components
• Transition to adulthood activities
• Evaluating progress toward completing those goals.
10. Follow up and monitoring of care plans

Your values and beliefs are important to us.  You determine what, when, and how we help you.  Some families may only need a few tips or resources.  Other families may need more intensive coordination for an extended period of time.

Privacy and confidentiality are paramount as we work together.

Medical Home

Children with special health care needs benefit from a medical home: a source of ongoing routine health care in their community where providers and families work as partners to meet the needs of children and families. A medical home assists in the early identification of special health care needs; provides ongoing primary care; and coordinates with a broad range of other specialty, ancillary, and related services.

Every child should have an opportunity for a medical home. A medical home, in simple terms, is the center of a child’s medical and non-medical care.  Ideally, the medical home “…is a cultivated partnership between the patient, family, and primary provider in cooperation with specialists and support from the community.”  “The patient/family is the focal point….and the medical home is built around this center.” It provides “accessible, continuous, comprehensive, family centered, coordinated, compassionate and culturally effective care.” (HRSA; AAP)

Utah Medical Home Portal
http://www.medicalhomeportal.org/

National Center for Medical Home Implementation
https://medicalhomeinfo.aap.org/Pages/default.aspx

SPARK for Autism

Transition to Adulthood

It is important to address needs pertaining to your youth transitioning into the adult world.  This can include issues such as independence, education, employment, housing, and health care.  Planning can start as early as 12-14 years of age.  Our care coordination team can help you with navigating this process.

Transition Action Guide

For Providers

Our multidisciplinary care coordination team offers a variety of services to help patients and families navigate care for children with special needs. We serve patients from birth to young adulthood. Our focus is to partner with these families and promote a patient and family driven care plan that is closely aligned with the patient’s primary care provider or Medical Home. Once the family is referred to us, we are happy to assist them over the phone and, when possible, meet with them in person to:

• Assist with Medicaid eligibility, benefits and services and SSI eligibilty and determination.
• Coordinate medical, educational, social, behavioral health, specialty and support services and resources.

Services are provided at no cost to the patient/family and the health care provider

Our team of care coordinators would be happy to meet with you to discuss ways we can partner with your office to expand your ability to provide comprehensive care management to children with special health care needs in your practice. While we do not arrange prior authorization for services and/or provide medication management, we are able to ensure ongoing and consistent care management and follow-up for the special needs population within your practice.

Please call us at (801) 273-2988 to discuss ways we can help you..

To make a referral to our program please use one of the following methods:

• Call us at (801) 273-2988
• Email us at integrated.services@utah.gov
• Fax referral to (801) 272-3502 - Care Coordination Referral Form

Forms

• Authorization to Disclose Health Information to Health Clinics of Utah
• Authorization to Disclose Health Information to Other Providers
• Care Cordination Referral
• Consent to Telehealth
• Notice of Privacy Practices