Coordinating Care

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About Medical HomeFor ProvidersFor Youth & Families

A medical home is an approach to providing primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.  In a medical home, the primary care team develops a trusting relationship with the family and works as a partner to assure that all of the child’s needs are met.

Through its medical home initiatives, ICAAP works with individual physicians, primary care practices, and community and state agencies to support the dissemination and implementation of the medical home model, with a focus on improving services for children with special health care needs.

Coordinating Care Between Early Intervention and the Primary Care Medical Home: About the Program

Screening young children for developmental delay is of limited value when families lack ready access to EI services. When such services are available, information about them must be incorporated into the child’s health care plan if the services are to be effective and supported during regular doctor visits. In many communities, collaboration between medical practices and Early Intervention (EI) programs is in need of improvement.

Coordinating Care Between Early Intervention and the Primary Care Medical Home aims to overcome barriers to referral and care coordination for children eligible for EI services by improving communication among primary care practices, Child and Family Connections staff, and families.  This training program addresses barriers and obstacles on both the primary care and EI sides of the referral process that contribute to poor care coordination for children with developmental problems. The program includes two trainings: one for primary care providers and one for EI staff.  By participating in the trainings, health care providers and EI staff will save time and share information to provide higher quality care; parents will be more satisfied with the care they receive through their primary care medical homes; and children will receive more timely and coordinated services that will help improve health and developmental outcomes.   You can access training resources by clicking here.

The Coordinating Care program is funded by The Commonwealth Fund (2008 to 2011) in collaboration with Advocate Health Care’s Healthy Steps for Young Children Program and the EI Bureau and is part of the larger Enhancing Developmentally Oriented Primary Care (EDOPC) project.  EDOPC is a statewide, comprehensive effort to increase primary care providers’ use of validated tools for developmental, social-emotional, and maternal depression screening. More information on EDOPC is available at

The primary care training is available as a one-hour CME in-service or as a webinar version accessible here  If you are interested in participating in the Coordinating Care training, please contact Jodie Bargeron ( or 312/733-1026).

Featured Resources

Illinois Special Needs Provider Directory

The Illinois Provider Directory for Children, Youth and Young Adults with Special Health Care Needs is a free online resource that connects individuals with special health care needs with skilled health care providers. Search for providers or sign up to be listed in the directory by visiting

Coordinating Care Trainings for National and Statewide Audiences

The Coordinating Care Project recently launched a series of four trainings for Early Interventionists, Part C Coordinators, and other early childhood providers. There are separate trainings for Illinois EI staff and for national Part C staff. The Illinois trainings are approved for EI credit. To learn more about the trainings, including which are best for you, click here.

Practice Resources

Follow the links below to view an annotated list of resources.

Policy Statements 

Background Information

Implementation and Referral Resources

Sample Early Intervention Forms

Developmental Screening Tools

Reimbursement and Coding

Early Intervention Public Education Materials

Special Education Resources

Prioritization of Urgency of Needs for Services (PUNS)


For more information about ICAAP’s medical home initiatives, please contact:

Kathy Sanabria, MBA, PMP
Associate Executive Director, Programs
Illinois Chapter, American Academy of Pediatrics
1400 W Hubbard, Suite 100
Chicago, IL 60642
Phone: 312/733-1026 ext 208
Fax: 312/733-1791