AAP Voices Blog

How to Get the Most Out of Patient Care Coordination

It’s a conversation many of us have had. A parent sits down, visibly worn, and tells you their child hasn’t been to school in weeks.

“The school isn’t following his IEP,” she says, referring to the child’s Individualized Educational Program. “They don’t understand him. I can’t keep sending him somewhere that isn’t helping.”

At that moment, we have an opportunity.

Whether we’re addressing chronic absenteeism, asthma, or other health concerns, one thing is clear: when the medical home and the school work together, children do better—both in their health and in their learning. And yet, too often, we’re not truly connected.

Children ages 3–18 spend up to seven hours a day, five days a week, for a majority of the year in school. Compare that to the few visits we may have with them each year, often just 20 to 40 minutes at a time. If we’re not collaborating with schools, we’re missing a huge part of our patients’ daily lives.

I’ve seen this firsthand. As a school physician in my local district in Maine, I’ve heard school nurses talk for years about the same challenge - the need for a consistent, reliable way to share information with healthcare providers.

When I came across a post from Dr. Heidi Schumacher on the Council on School Health (COSH) listserv asking, “Does anyone have a good consent form that works for both healthcare and schools?”—I paid attention. It felt like a question many of us had been quietly asking. And the answer? No one really had one.

That moment stuck with me. Here we were—pediatricians, school health leaders, advocates—committed to working together and we lacked one of the most basic tools to make that possible. A small team including myself; Heidi Schumacher, MD, FAAP; MaryBeth Miotto, MD, MPH, FAAP; and our partner at National Association of School Nurses Kim Stanislo, DNP APRN-CNP, LSN, NCSN, CPNP-PC decided to fill this void.  

What started as an effort to create a single consent form quickly grew into something bigger: the development of a co-branded American Academy of Pediatrics (AAP) and NASN consent form template and Implementation Toolkit to support meaningful communication between the medical home and schools.

From the beginning, we knew a form alone wouldn’t solve the problem. The barriers are real—and sometimes just as importantly, they’re perceived. There’s confusion about privacy rules. Workflows don’t line up. Relationships between schools and healthcare providers may not exist yet. A form can’t fix all of that but it can open the door.

In my own district, I saw what can happen when that door opens. A school nurse reached out with concerns about how to support a medically complex child. At an Individualized Education Program meeting, she worked with the parent to complete both the practice’s Health Insurance Portability and Accountability Act (HIPPA) release and the district’s Family Educational Rights and Privacy Act (FERPA) release, then shared them with the primary care office.

What followed was something both the school nurse and pediatrician described as the best collaboration they had ever experienced for a complex patient. They connected directly. They problem-solved together. They built trust—not only with each other, but with the parent, who no longer had to act as the go-between. For the first time, the family saw the school and the medical home working side by side to support their child.

That’s what this work is about.

The toolkit is designed to make that kind of collaboration easier and more consistent. It offers a clear, family-friendly consent process that works for both healthcare and schools, along with practical guidance on how to use it. But more importantly, it reinforces something we’ve learned along the way: consent is just the starting point. We have to build the process around it.

That means making consent part of routine care—not something we scramble to figure out when things are already falling apart. It means helping families understand why it matters and giving them the chance to say yes. It means schools creating clear paths to receive and use information. And it means pediatricians reaching out—proactively—to connect with school nurses and teams.

When we do that, things start to shift. We see fewer situations where families feel stuck between systems. We see care plans that reflect what is actually happening in the classroom. School teams feel better supported and pediatricians have a clearer picture of the child in front of them. And most importantly, we see kids doing better.

This work isn’t about creating perfect systems. It’s about making progress—together. It’s about recognizing that even though we work in different settings, we are all part of the same care team.

So here’s a simple place to start: If you’re a pediatrician, try it with one patient. Use a shared consent form. Reach out to a school nurse. Start the conversation. If you’re part of a school team, connect with a local practice before there’s a problem to solve. And if you’re in a leadership role, think about how you can support processes—not just forms—that make this kind of collaboration sustainable.

The AAP and NASN consent form template and Implementation Toolkit are a starting point. What matters most is what we do with them. Because when we take that extra step to connect, we don’t just improve communication. We change outcomes for kids for the better.

*The views expressed in this article are those of the author, and not necessarily those of the American Academy of Pediatrics.