Care coordination in primary care

Abstract

Families embarking on the journey of ASD evaluation and treatment face a complex road ahead, and the Primary Care Clinician (PCC) can play a key role in navigating that journey successfully in the context of the medical home. Given the high frequency atwhich children visit their PCCs in early childhood, PCCs participate in early identification through developmental surveillance and screening and provide referrals for children who require further evaluation. Throughout childhood, PCCs facilitate crucial linkages to community resources and specialty providers while also providing routine preventive care to children with Autism Spectrum Disorder (ASD). To varying degrees, PCCs provide direct care for co-occurring medical or mental conditions and assist families in securing treatment services. To execute this role effectively, modifications to the medical home may be necessary. This chapter provides an overview of the knowledge, processes, and skills necessary to provide comprehensive care coordination for children with ASD in the medical home setting.