Team Washington’s journey map illustrated by ConverSketch

Lead Organization

Washington State Department of Health Children with Special Health Care Needs Program (Title V) and Seattle Children’s Hospital 

Family/Youth Engagement Partner

PAVE (Partnerships for Action, Voices for Empowerment)

Clinical Site

Seattle Children’s Hospital

Project Aims

To improve the transition of care and establish medical homes for children, birth to one year of age, discharged from the hospital with at least one chronic condition and/or functional disability.

Project Description

The CMC CoIIN Washington team designed an intervention to better assist families of CMC infants recently discharged from the hospital. Supplemented with care coordination, a “Roadmap” was established to include community resources, primary care medical homes, nutrition services, early intervention programs, parent peer support, and community resource navigational support as care components. The project is under the leadership of Seattle Children’s Hospital and Partnerships for Action, Voices for Empowerment (PAVE) family leaders.

Focus Area(s)

• Family engagement
• Improved access to care for CMC living in rural communities, including telemedicine
• Improved access to home care services
• Alternative payment methods