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Job Description
Facilitate family-centered community-based medical homes for children with special needs. Facilitate timely access to the PCP & services/resources. Build bridges among families, and health, education and social services, promotes continuity of care. Supply & provide access to referrals, information and education for families across systems. Maximize effective efficient and innovative use of existing resources. Pre-screen, obtain consent and interview families of children with special health needs. Maintain a data base of children with special health care needs (CSHCN) in the practice.
Present to pediatric/family practice residents the medical home model and care coordination role, emphasizing transition for Youths with special needs, using prepared material from Children’s Special Health Services. Develop, monitor and/or update written care plans. Monitor and update transition checklist provided by CSHS for all transitioning youth on each visit. Supply, coordinate, and promote access to culturally appropriate resources, referrals and information for the education of families across systems. Display and communicate information to practicing physicians and other staff on how to access services and resources for transitioning youth. Promote communication between and among families and health, education, behavioral, and social service providers, emphasizing transitional services. Promote continuity of care for transition processes (which may include transitioning from Early Steps to pre-school, from pre-school to school, youth to adulthood medical services and work programs). Conduct quarterly team meetings to improve medical home capacity. Compile and submit quarterly reports
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