Recommendations for Children and Youth with Special Health Care Needs (CYSHCN)

Publication Date: April 1, 2020
Last Updated: March 14, 2022


1. Follow Bright Futures recommendations and guidance for CYSHCN and their families. Recommendations include the promotion of health and wellness as well as timely assessments of child social-emotional health, parental and/or caregiver depression, and SDH.

2. Use practice transformation strategies, such as quality improvement, patient registries, and previsit planning, to promote psychosocial screening and assessment, referrals, and follow-up among CYSHCN and their families. A good resource is the AAP Practice Transformation site (https:// www. aap. org/ en- us/ professional- resources/ practice- Transformation/ Pages/ practicetransformation. aspx).

3. Use team-based care strategies, care protocols, and dedicated care coordinators (if available) to recognize psychosocial protective factors and ameliorate risk factors. This strategy may involve collocation, consultation, comanagement, and/or integration with behavioral health specialists as part of medical home and specialty care teams.

4. Consider strategies for working with child care and school staff to monitor progress, reduce absences, and improve learning experiences and academic performance for CYSHCN.

5. Advocate for flexible payment redesign with Medicaid and other insurers. Payment redesign may better support wellness and chronic care management for CYSHCN and their families. Flexible payment redesign may include payments for mental health treatment, care coordination, and collocation or comanagement with behavioral health and other specialists or disciplines.

6. Promote evidence-based interventions and strategies in the medical home and subspecialty settings to support psychosocial development of CYSHCN, parenting competencies, and family resilience.

7. Advocate for research on adaptions of existing psychosocial screening tools and interventions for CYSHCN.

8. Advocate for community-based resources and strategies to address SDH and the reduction of disparities for CYSHCN and their families.

9. Pediatric providers and state AAP chapters can partner with Title V Maternal and Child Health CYSHCN programs in supporting implementation of the Association of Maternal and Child Health Program’s Standards for Systems of Care for CYSHCN. These standards include increasing access for CYSHCN to quality medical homes, ease of use of community services, and transitioning across the life span.



Recommendations for Children and Youth with Special Health Care Needs (CYSHCN)

Authoring Organization