Children with Special Health Care Needs (CSHCN) population, account for 30% of spending or $233.5 billion of the costs (Bui et al., 2017). Identifying barriers to care in the CSHCN population can be multi-faceted and complex incorporating high utilization of time, and clinical resources. This project aims to evaluate the impact of care coordination, and utilization on the CSHCN population through a Patient-centered Medical Home, use of embedded case management assessing this population through using the evidence-based Care

Coordination Management Tool (CCMT). CSHCN (N=117) and families were assessed using the CCMT at every interaction from September 1, 2020 – November 30, 2020. All

assessment data was recorded in Driscoll Health Plan (DHP) EPIC electronic medical record (EMR). Eight RNs completed assessments on 117 CSHCN at each encounter. Utilization indicates a decrease of 13% or $280,172.38. Measurement of coordination activities were 41% parent education, 29% communication improvement, 21% investigation of services, 7% authorization, and 1% authorization review. By category, 29% of needs were related to utilization authorizations, 23% related to disease education, 16% referral for community resources, 18% education on Medicaid and 14% related to a behavioral health follow-up.

This project reveals that assigned case managers utilizing a standardized evidence-based tool can impact costs of care, parent satisfaction, and quality of life for the CSHCN patient.

Date of publication

Spring 4-23-2021

Document Type

DNP Scholarly Project



Persistent identifier


Committee members

Dr. Colleen Marzilli, RN, Dr. Fred McCurdy, MBA, Dr. Karl Serrao, MBA


Doctor of Nursing Practice