Medical Home Partnerships-Children and Youth with Special Health Care Needs (CYSHCN)

WCYSHCN people

Promoting quality care for children and youth with special health care needs in Wisconsin.


NEW Care Coordination and a Medical Home training Modules

Care Coordination is the process that helps connect children and families with appropriate services in a coordinated way to achieve good health.

Family Voices of Wisconsin and the Wisconsin Medical Home Initiative have partnered to develope a three-part training on Care Coordination and the Medical Home. The modules are helpful for families who have typcially developing children and for those who have children and youth with special health care needs.

Coordinated Care in a Medical Home

Children and youth with special health care needs (CYSHCN) often require more medical care, mental health services or education services than other children. They may be enrolled in multiple state and federal programs for their specific needs, including Medicaid, Social Security Income, early intervention and more. As a result of complex conditions and many providers, families may need help coordinating this care.

A medical home is a comprehensive way of providing health care to children and youth. Medical homes are most commonly composed of primary care clinicians (such as pediatricians, family physicians, pediatric nurse practitioners and physician assistants), care team members, and family members. In a medical home, care is coordinated based on family priorities. It is also accessible, continuous, comprehensive, compassionate and culturally effective. There is growing evidence that care provided within the medical home supports the Institute for Healthcare Improvement's Triple Aim, including improved patient and family experience, overall improvement in population health and, for certain patient populations, reduced cost of care.

The CYSHCN Program works to assure that children have a primary care provider who serves as a medical home, providing comprehensive, family-centered care and helping to coordinate the families' medical and non-medical needs within their community. The Regional Centers provide support and technical assistance to families and providers in strategies to strengthen medical homes.

Wisconsin Medical Home Initiative

The Wisconsin Department of Health Services' Title V Children and Youth with Special Health Care Needs Program (CYSHCN) and Maternal and Child Health Program, located in the Division of Public Health, provides funding for the Wisconsin Medical Home Initiative (WisMHI). WisMHI, an initiative of the Children's Health Alliance of Wisconsin, promotes children’s health and development through its direct support to primary care clinicians and families. Training, technical assistance and resources are provided to support medical home implementation with a focus on developmental screening, behavioral health integration and family partnership.

Wisconsin State Plan to Serve More Children and Youth within Medical Homes (including those with special health care needs)

The Wisconsin CYSHCN Program received notification of funding for a 3-year grant project titled the Wisconsin CYSHCN Medical Home Systems  Integration Project beginning September 1, 2014. Funded by the federal Maternal and Child Health Bureau of the Health Resources and Services Administration, this project aims to increase the number of CYSHCN served within a medical home by 20% or approximately 17,735 more CYSHCN by September 2017. The most recent National Survey of CSHCN (2009-2010) estimated approximately 200,000 Wisconsin children have special health care needs, and 44% of them receive care within a medical home. Care within a medical home is typically provided by a primary care clinician and his or her care team, in partnership with parents. Health care outcomes and family satisfaction are consistently higher for children served within medical homes.

The state plan was written to outline steps to achieve more children receiving care within medical homes, along with associated measures to track their accomplishment. The Department of Health Services (including Public Health and Medicaid) and statewide health care and community resource professional leadership met four times from January to July 2015 to identify strategies to be considered for inclusion in the state plan. In addition, guidance was offered from the National Academy on State Health Policy, National Improvement Partnership Network, and the Wisconsin Maternal Child Health Bureau needs assessment process. The plan identifies three strategic areas: Understanding and Promotion of Medical Homes; Performance and Quality; and Financing. Strategies target families, clinicians and systems in an effort to achieve the goal of serving more children within a medical home.

Wisconsin State Plan (P-01149) (PDF,  6.5 MB)

National Medical Home Resources

National Center for Medical Home Initiatives for Children and Youth with Special Health Care Needs
American Academy of Pediatrics

Patient-Centered Primary Care Collaborative

American Academy of Family Physicians


Center for Medical Home Improvement

Wisconsin Public Health Information and Referral (24 hours a day/7 days a week)

Wisconsin First Step
Information and links to services for children and youth with special needs, their families and providers. Call 800-642-7837 to speak with a parent specialist. Information is available on services such as Birth to 3 early intervention, financial assistance, parent networking and support, home health care, therapy services, Regional Centers and more.

Maternal and Child Health (MCH) Hotline
Information and links to services for pregnant and postpartum women and children. Call 800-722-2295 for information on BadgerCare Plus, WIC, HealthCheck, maternal depression, Medicaid Prenatal Care Coordination, family planning, developmental screenings, and more.

Last Revised: January 30, 2017