The Commonwealth Fund released a brief examining five states’ organized care coordination and referral programs for children with early developmental delays, complex medical conditions, and difficulty navigating the health care system.  The authors analyzed programs that refer children and their families to appropriate community or state programs, coordinate their care, offer support and follow-up to ensure that they receive needed services, and serve as a feedback loop for primary care physicians. 

From the abstract:

There are few organized systems of referral and care coordination for children and families identified with early developmental delays, complex medical conditions, and difficulties negotiating the medical and related support systems, but some promising models are emerging. This report summarizes lessons from programs in five states that refer families to appropriate community or state programs, help coordinate their care, provide support and follow-up to ensure they receive needed services, and provide a feedback loop to primary care providers. Common features of successful programs include: maximizing efficiencies through shared resources, leveraging and partnering with other organizations, in-depth involvement with pediatric practice staff, appropriate training and tools, flexible program design, measurement and evaluation, and a holistic approach to care.

Full Report: Systems of Care Coordination for Children: Lessons Learned Across State Models (PDF | 702 KB)

Commonwealth Fund. (2010). Systems of care coordination for children: lessons learned across state models. Silow-Carrol, S. and Hagelow, G.