Care coordination has been shown to improve patient, family and health system outcomes. This page contains resources and recommendations on how to improve care coordination for chronic condition management in schools.

 

What is pediatric care coordination? Pediatric care coordination is “a patient and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational, and financial needs to achieve optimal health and wellness outcomes (1).”  

Pediatric care coordination has been shown to improve patient, family and health system outcomes, particularly for children and youth with special healthcare needs (1). Why is pediatric care coordination important? The provision of care coordination has been associated with improved patient and family satisfaction, reduced unplanned hospitalizations and emergency department visits, improved school attendance, and decreased healthcare costs (1).  

Education partners are essential to multi-disciplinary care teams, providing instruction and services to students, conducting and sharing health evaluation findings, observing the impact of students’ health conditions on their educational experience and more.  

Given their role in direct care provision and their expertise in both education and healthcare, school nurses often serve as the primary liaisons between school and healthcare teams. Beyond this facilitation role, professional school nurses’ training and scope of practice position them well as leaders of care coordination efforts. The National Association of School Nurses (NASN) identifies school nurse-led care coordination as a key principle of the Framework for 21st Century School Nursing Practice.  

NASN defines school-based care coordination as “the oversight and alignment of multiple evidence-based components and interventions that support the health and well-being of students with chronic conditions (2).”  School nurses regularly lead care coordination efforts for individual students and can also lead the development of a comprehensive system of school-based care coordination.  

Conversations about Care Coordination

Listen to and read about inspiring stories, direct from the field, of successful implementation of care coordination.

 

Care Coordination Tools and Resources

Important Education for School Nurses

These two resources are designed for school nurses to support learning and capacity building for school-based care coordination.

Health Care Coordination in Schools: An Instructional Curriculum for School Nurses
An adaptation of the Pediatric Care Coordination Curriculum (PCCC) specifically for school nurses.
Improving Care Coordination for Students with Chronic Conditions Toolkit
The National Association of School Nurses created this toolkit to support school nurses in leading school-based care coordination efforts.
Last Updated

09/13/2023

Source

American Academy of Pediatrics