Medically Complex Children and Youth Guidebook

Special Health Care Needs (SHCN) Service Coordinators (SC) provide HCY case management activities for fee-for-service participants. These activities/responsibilities include, but are not limited to, the following: 

• Gather medical and insurance information to determine eligibility for the HCY Program.
• Talk with the participant, parent(s) and/or responsible party(ies) about their current medical treatment. 
• Complete a comprehensive assessment of needs for the participant, parent(s) and/or responsible party(ies) including but not limited to identifying needs/goals and making referrals to meet those needs/goals, as appropriate. 
• Develop a service plan by identifying the goals of the participant, parent(s) and/or responsible party(ies) and determine the services, funding sources, and outcomes needed in order to reach these goals. 
• Complete necessary paperwork to obtain services and document the information in the SHCN Information System as per policy/procedure.
• Evaluate if referrals are needed to resources to other programs or agencies outside of SHCN, and assist in accessing these services such as therapies, child care, counseling, medical equipment and supplies, financial assistance, and transportation. (Note: SCs are not permitted to transport participant, parent(s) and/or responsible party(ies)). 
• Assist the participant, parent(s) and/or responsible party(ies) in accessing a medical home as needed or desired. 
• Organize and participate in team conferences with the participant, parent(s) and/or responsible party(ies).
• When made aware of participant hospitalization, discuss hospital discharge planning with the participant, parent(s) and/or responsible party(ies). Document their concerns, expected outcomes and priorities and collaborate with hospital case managers, discharge staff and provider agency(ies) to coordinate necessary supportive services. 
• Review the plan of care with the participant, parent(s) and/or responsible party(ies) for ongoing needs, make changes as necessary, and discuss participant, parent(s) and/or responsible party(ies) satisfaction and compliance with services. 
• Monitor the participant’s receipt of authorized HCY services, evaluate any identified barriers to receiving services and collaborate with the participant and/or responsible party(ies) to address barriers, including assessment of eligibility for additional services and/or resources and the need for referral(s).
• Routinely discuss transition planning with the participant, parent(s) and/or responsible party(ies) and document their concerns, expected outcomes and priorities. Participate in discussions with the Regional Coordinator (RC) and Program Manager (PM) as well as other agency representatives to design an achievable plan that supports the participant, parent(s) and/or responsible party(ies) to achieve the best possible outcomes consistent with the situation.
• Adjust supports and services based on changing needs of program participants. 

Service Coordination Process 

Service coordination is a culturally competent, collaborative, proactive, and comprehensive health care process designed to help each participant, parent(s) and/or responsible party(ies) achieve the best possible health and greatest degree of independence. 

The primary mechanisms of Service coordination are: 

• Individualized Assessment 
• Planning 
• Implementation 
• Monitoring 
• Assist with Barrier Removal 
• Transitioning