Specifications include, but are not limited to: The provision of services that enhance the system of care with community-based care coordination services for children with medical complexity and Children with Special Health Care Needs (CSHCN) that incorporate the following components: Screening, identification, and assessment of a child’s needs to provide the foundation for effective, high-quality care coordination. Shared plan of care to provide a roadmap and an accountability system for integrating care based on family needs and priorities identified in the assessment. Team-based communication between members of the team that is timely, efficient, respectful, and culturally sensitive. Education, coaching, and training for CSHCN, families and care teams to empower CSHCN and their families and advance their well-being. Training and supervision of care team members. Health care transition planning across the systems of care for CSHCN and their families.
