Health Manager Orientation Guide

A Coordinated Approach to Services

A comprehensive and coordinated family-centered system of services for CSHCN includes:

  • Collaboration between stakeholders in the child’s care, including the child’s family, health care and service providers, and Head Start staff
  • Coordinated health services and supports

The Maternal and Child Health Bureau found six indicators of a family-centered system of care:

  1. Children are screened early and continuously.
  2. Children receive a medical home model of care that is patient-centered, coordinated, comprehensive, and ongoing.
  3. Community-based services are organized so families can use them easily.
  4. CSHCN receive services necessary to make transitions to adult life, including health care.
  5. Families have adequate insurance and funding to pay for services they need.
  6. Families of CSHCN are partners in decision-making at all levels of care, from direct care to the organizations that serve them.

A mother and daughter with another woman taking notes. The Head Start program design addresses the challenges and inequities CSHCN and their families have in getting health care and services. Internally, this involves coordinating other service areas and staff where needed. Externally, it includes collaborating with families, health care providers, and community services. As staff become aware of a known or suspected special health care need, the program may need to delay enrollment to allow time for individualized planning and accommodations. The health manager can reassure the family that although the program may need more time to get information and properly train staff responsible for their child, the program will work closely with the family and be ready to care for the child as quickly and safely as possible.

Program Coordination

The care of CSHCN in Head Start programs is not limited to health services. Depending on the health condition, accommodations, and services needed, health managers may need to work with others in the program, such as nutrition managers, disabilities coordinators, teaching staff, and family services coordinators. Some CSHCN may be eligible for services under the Individuals with Disabilities Education Act and have an Individual Family Service Plan (IFSP) or Individual Education Plan (IEP). That said, not every child with special health care needs has a disability.


Individualized health care planning begins with the family. As the child’s primary caregiver and advocate, the family knows their child best. The family is usually the first stop for information about a child’s known or suspected health care needs. They can share any concerns about understanding, skills, and self-efficacy related to their child’s special health care needs. If the family is facing barriers in caring for their child, the program can work with them to find supports. The family can also help staff connect with their child’s health care providers.

Health Care Providers

The child’s health care providers should be able to give detailed instructions about assessments and services the child may need. The health care provider team can include the primary health care provider, medical home, and medical specialists. Ongoing, three-way communication between the family, Head Start staff, and these health care providers is essential. The American Academy of Pediatrics describes this as a family-centered medical home approach, where families are recognized as the child’s primary caregiver and essential partners in their child’s health care planning.

Community Services and Supports

Community services and support include specialized health service providers, such as occupational and physical therapy as well as Part C and Part B providers for children who qualify with a disability. They also include other community agencies, programs, or foundations that offer support, education, and resources for specific health conditions, such as diabetes, epilepsy, and asthma.

Tips and Strategies for a Coordinated Approach to Special Health Care Services

  • Use internal meetings that support cross-service area planning, such as case management and interdisciplinary team meetings, to help with coordination.
  • For children with several individualized plans, such as an IHP, IEP, and IFSP, make sure to coordinate all plans wherever possible. Also check that each plan refers to the others.
  • Include IHPs as part of transition planning from an Early Head Start program to a Head Start program, from a Head Start program to kindergarten, and when transferring classrooms or teachers.
  • Identify one or two primary contact people at the child’s health care provider office, such as the nurse, office manager, case manager, or health educator, to help manage communication among the providers, the Head Start program, and the family.
  • Become familiar with community-based programs and organizations for specific health conditions. They can be valuable sources of support, education, and resources for families and staff.
  • Invite health care providers, service providers, community-based programs and organizations, and families of CSHCN to participate on your HSAC. Make sure your HSAC membership is best suited to support your program’s health needs.

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