Home Visiting Care Coordination program for CYSHN

Background: Children and youth with special health care needs (CYSHN) often have complex needs requiring a range of services. Service and communication fragmentation are barriers to coordinated care. CaCoon is an Oregon public health nurse (PHN) home visiting care coordination program for CYSHN. PHNs conduct a nurse assessment and provide interventions to improve outcomes. The CaCoon program, an AMCHP “Promising Practice,” served 1,528 clients in 7,259 visits in 2010 and 1,586 clients in 7,957 visits in 2011.

Methods: Client data from the statewide data warehouse were analyzed to assess needs, interventions and outcomes achieved. Issues assessed included injury, oral health, tobacco, well child, parenting, chronic conditions, community resources, nutrition, access to care, basic needs, child development, and medical home.

Results: In 2011 96 percent of clients received an assessment for at least one of the twelve issues; of those, 98 percent had a need identified. CaCoon provided interventions to 98 percent of the clients with an identified need; with a low of 60 percent for parental smoking and a high of 99 percent for parental basic needs. During the year, CaCoon met a need for 58 percent of the clients who received an intervention; over two years needs met increased to 74 percent of clients.

Conclusion: CaCoon met the needs of more than half of the clients during one year and 74 percent over two years. CaCoon nursing interventions help CYSHN navigate barriers and link them with the services and resources.