Care Coordination for Children (CC4C)

CC4C (Care Coordination for Children)

An at-risk population-management program, the state’s Care Coordination for Children (CC4C) is designed for children from birth to 5 years old who:

    • Have long-term medical conditions, developmental delays or disabilities, or social or emotional disorders, or who are at risk for any of those
    • Are dealing with challenging levels of stress in their daily lives
    • Are referred by an eligible party

Each child in the program is linked to a CC4C care manager, and also to a specific local medical practice that serves as that child’s medical home, for coordinating roles and responsibilities, and ensuring necessary care is received. CC4C staff work in close collaboration with local partners like Access East to coordinate care-management services, and to access care-management histories, Medicaid claims, and other vital records.

CC4C care managers use risk assessments, and comprehensive health assessments (including The Life Skills Progression) to tailor care to a child’s specific needs. Care plans include how often a care manager will be in contact with a child and the child’s family, with care managers working with families through:

    • Home visits
    • Phone calls
    • Joining families in attending medical visits
    • Other types of contact

CC4C Goals

    • Ensuring that children are raised in healthy, safe, nurturing homes
    • Connecting families to programs, services, and resources that help them meet their health needs
    • Strengthening families through home visits and personal phone calls
    • Providing parent-support programs, when available
    • Aiding parents in being their child’s best advocates
    • Helping children to reach their full potential

Patient Referrals

Referrals can come from a child’s family or medical home, or from a hospital, community organization, or Access East care-management staff. Upon receiving a referral, the CC4C care manager will meet with the family and child to assess whether services would be beneficial.

Referral criteria include:
    • Children with special healthcare needs (chronic physical, developmental, behavioral, or emotional conditions) who require health and related services of a type and amount beyond that generally required by children
    • Children exposed to such severe stress in early childhood as:
        • Extreme poverty in conjunction with continuous family chaos
        • Recurrent physical or emotional abuse
        • Chronic neglect
        • Severe and enduring maternal depression
        • Persistent parental substance abuse
        • Repeated exposure to violence in the community or within the family
    • Children in foster care who need to be linked to a medical home
    • Children in neonatal intensive care needing help transitioning to community care, or care within a medical home
    • Children with certain potentially preventable hospital costs