Special needs navigator
Care coordination: one team that holds the whole picture
A child with complex needs can have six specialists, three therapists, a school team and two insurance plans. Care coordination means Dare2Care keeps those parts talking to each other, so the family is not the only one carrying the plan.
NCQAPatient-Centered Medical HomeWhat it means here
A medical home, in practice
As an NCQA-recognized Patient-Centered Medical Home, Dare2Care Pediatrics is measured on coordination: whether referrals are completed, whether specialist notes come back, whether the care plan is current, and whether families can reach someone who knows the chart. For children with special needs this is the core of the work, not an extra.
Every child with complex needs has a written care plan in the chart that lists diagnoses, medicines, equipment, the specialists and therapists involved, school supports and the family’s goals. It is reviewed at each visit and shared with the family and, with your permission, with the people on the team.
What we coordinate
The parts we keep connected
Specialists
Referrals to neurology, developmental pediatrics, genetics, GI, cardiology and others, with the question written out, records attached, and the notes brought back into the plan.
Therapists
Speech, occupational, physical and behavioral therapy: prescriptions, plans of care signed on time, progress reports read and acted on.
School
Medical documentation for IEP and 504 evaluations, letters for accommodations, health plans for the school nurse, and a phone call when the team needs the doctor’s view.
Insurance and programs
Prior authorizations, letters of medical necessity, and the documentation Katie Beckett, waivers and SSI need, including at renewal.
Equipment and supplies
Orders and paperwork for durable medical equipment, feeding supplies, orthotics and hearing or vision devices, and follow-through when a vendor stalls.
Transitions
Hospital discharges, new diagnoses, moves between schools, and the hand-off to adult care from about age 16.
How it works
From the first visit onward
Step 1: A longer first visit
We read what you bring, listen to what a good day and a hard day look like, and agree on the first priorities. Children who do better in a quiet office can have the first or last appointment of the day.
Step 2: A written care plan
Diagnoses, medicines, equipment, the team, school supports and your goals, in one document you can share. Updated at every visit.
Step 3: One contact
Questions between visits go to a person who knows the plan, through the portal or by phone, rather than to whoever answers.
Step 4: Regular check-ins
Children with complex needs are seen more often than the well-visit schedule, so problems are caught while they are small and paperwork stays current.
Questions
Care coordination questions
Is care coordination billed separately?
The visits are billed as primary care. The coordination between visits is part of being your child’s medical home; there is no separate charge to families for it.
Can you talk directly to my child’s school or therapist?
Yes, with your written permission. A release form at the first visit lets us exchange information with the school, therapists, specialists and program case managers you name.
We already have a case manager through a waiver. Do we still need this?
A waiver case manager coordinates the waiver’s services. We coordinate the medical side and work with that case manager, so the two plans do not conflict.
Do you offer this for children without a diagnosis yet?
Yes. Much of coordination happens before a diagnosis: screening, referrals for evaluation, and keeping the family informed while answers come in.
Bring us the whole picture
Call or text (770) 615-7000 to schedule a first visit. Bring reports from specialists, therapists and the school, and we will build the plan from there.