Identify Children and Youth with Special Health Care Needs

“No practice has been inclined to use rigid screening tools for inclusion of children in their identified population but rather a guided prospective process of informed practitioner identification and family confirmation.”

Source: Building Medical Homes: Improvement Strategies in Primary Care for Children with Special Health Care Needs, Pediatrics, 2004; W. Carl Cooley & Jeanne W. McAllister

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Site last updated:
July 25, 2014

Wisconsin Resources

Wisconsin Early Intervention Referral Guide (PDF)

Early Identification Resources - Wisconsin Early Childhood Collaborating Partners

National Resources

Definition of Children with Special Health Care Needs, American Academy of Pediatrics

AAP Screening Initiatives

  • Developmental Surveillance & Screening Algorithm (link)
  • Identifying Infants and Young Children with Developmental Disorders in the Medical Home. Pediatrics, 2006 (link)

Developmental Behavioral Pediatrics Online

The Commonwealth Fund

Developmental Screening Toolkit

CSHCN Screener (link

Wisconsin Medical Home Teams used a variety of methods to identify children, youth and families to begin implementing new ways of coordinating care. Here is a summary of key strategies for an integrated system of identification and screening in a Medical Home:

  • Identify, categorize complexity, and create a registry of patients with special health care needs, using flu lists, diagnostic lists, and physician recall;
  • Use tools such as The Children with Special Health Care Needs (CSHCN) Screener©, Appointment Scripts and Complexity Tools to help identify families whose children have special needs;
  • The routine use of developmental screening tools are critical to early identification of CYSHCN;
  • Once identified, the patient’s record is flagged electronically, by using colored charts or other systematic reminders, so all practice staff are cued to recognize children with special needs. 

In the video, two physicians discuss their approaches to identifying children and families in the practice who would benefit from more coordinated care. They tested their strategies in small patient groups and expanded the approach using electronic medical record systems.

Medical Home Resources
Providers in Wisconsin can use the Early Identification Checklist to refer families to the Birth to 3 Program.  Developmental screening tools include The Developmental Surveillance and Screening Algorithm, published in Pediatrics in 2006, and links to several national Web sites with training modules.