Care Coordination
Mission Statement
The Care Coordination (CC) Team at The Children’s Clinic works with families and children with complex medical needs to get the right services and information. This might mean coordinating services or helping with communication when many different providers are involved in a child’s care.
Patients who need Care Coordination are chosen based on social situations, chronic health problems, and medical conditions that need care from different specialists. The CC team helps connect patients and families with their doctors and other healthcare team members and may offer coaching, track tests and referrals, help with transitions in care, and support ongoing communication between teams. The CC writes care plans for patients which become part of their electronic health record.
En Español:
En TCC, la Coordinación de Cuidados juega un papel esencial para asegurarse de que los pacientes con necesidades de cuidado complejas reciban coordinación de servicios y comunicación para apoyar la integración del cuidado y mejorar el mantenimiento y apoyo de la salud. TCC cree que la Coordinación de Cuidados ayuda a evitar que las enfermedades empeoren y otras complicaciones de salud.
Los pacientes son identificados para la Coordinación de Cuidados según determinantes sociales, condiciones crónicas de salud y diagnósticos médicos que requieren cuidado con varios subespecialistas pediátricos. La Coordinación de Cuidados se convierte entonces en un enlace entre los pacientes/familias, la práctica del proveedor y otros miembros del equipo de cuidados, ofreciendo orientación, seguimiento de pruebas y referencias, transiciones en el cuidado y comunicaciones continuas con equipos de cuidados internos y externos. El equipo de Coordinación de Cuidados desarrolla planes de cuidado por escrito para los pacientes identificados e incorpora esa información en el expediente electrónico de salud de TCC.
Autism Spectrum Disorder:
Family Echo: https://autismcarenetwork.org/family-echo-autism/
A series of 75-minute session that will help you understand and manage challenging behaviors, building supports, etc.
Help Is in your Hands: https://www.helpisinyourhands.org/course
- Based on Early Start Denver Model caregiver-coaching
- Free and empirically supported strategies parents use at home to increase social interactions and communication
- Accessible on a cell phone
Mirror Me – Reciprocal Imitation Training https://mirrormeonline.org/
- Free online modules that teach caregivers Reciprocal Imitation Training (RIT is an evidence-based naturalistic developmental behavior intervention (NDBI) that teaches generalized, spontaneous imitation to young children with autism spectrum disorder (ASD) within a social-communicative context)
- Play-based intervention to improve social, communication, and imitation skills
Triad Families First Program: https://vkc.vumc.org/vkc/triad/fam/
- Free online modules that teach caregivers Reciprocal Imitation Training (RIT is an evidence-based naturalistic developmental behavior intervention (NDBI) that teaches generalized, spontaneous imitation to young children with autism spectrum disorder (ASD) within a social-communicative context)
- Play-based intervention to improve social, communication, and imitation skills
ADEPT (Autism Distance Education Parent Training Program) https://health.ucdavis.edu/mindinstitute/centers/cedd/adept.html
- Interactive, self-paced, online learning modules
- Teach parents applied behavioral analysis (ABA) tools to teach functional skills
Autism Empowerment https://www.autismempowerment.org/
RDIconnect – Program to teach parents how to guide their child and succeed in reciprocal relationships. https://www.rdiconnect.com/
Seattle Children’s Hospital – Conversations about Autism YouTube Series https://www.youtube.com/playlist?list=PLjvfRtcMhn4PB0NTW0RlvsMJGu1Csnn5s
Autism Acceptance https://autismacceptance.com/
Autism Society of Oregon has some great options for virtual and in-person support groups https://autismsocietyoregon.org/support-groups-virtual-meetings/
Autism Society of Oregon – Spanish https://autismsocietyoregon.org/en-espanol/
Project Impact Training:
- Project Impact is a parent-coaching program at OHSU for families with children who have autism, suspected autism or other social communication challenges. The program works to improve children’s skills in:
- Communicating
- Playing
- Imitating
- Interacting with others
- Families have 10 to 12 one-hour visits with an occupational therapist, speech-language pathologist or social worker. Visits can take place:
- At Doernbecher Children’s Hospital or Doernbecher’s Cornell West clinic in Beaverton.
- In a virtual visit with a secure online link.
- Project Impact uses ideas from applied behavior analysis therapy but is not ABA therapy.
- To take part in the program, ask your child’s doctor for a referral.
Cerebral Palsy:
United Cerebral Palsy https://ucp.org/
- Leading source of information on cerebral and palsy and a pivotal advocate for the rights of persons with any disability.
American Academy for Cerebral Palsy and Developmental Medicine https://www.aacpdm.org/
- Provides multidisciplinary scientific education for health professionals and promote excellence in research and services for the benefit of people with cerebral palsy and childhood-onset disabilities.
CP Family Network: https://cpfamilynetwork.org/
Down Syndrome:
Karen Gaffney Foundation: https://karengaffneyfoundation.org/
- Dedicated to championing the journey to full inclusion in families, schools, communities and the workplace for people with Down syndrome or other developmental disabilities.
National Association for Down Syndrome: https://www.nads.org/
- Information, support, and advocacy
Gigi’s Play House https://gigisplayhouse.org/portland/
- Provides programming & support for individuals with Down syndrome & their families.
Down Syndrome Network of Oregon https://dsno.org/
- Local resource for Down syndrome support and offers a range of community-based programs to build an outstanding support organization for families, friends and individuals with Down syndrome
Northwest Down Syndrome Association https://www.nwdsa.org/
