Care Coordination: Weaving the Net Before They Fall 

Care coordination for children and adolescents is not just about medical appointments. It is about rebuilding continuity and safety in the lives of youth who have rarely known either. When a 13-year-old girl who survived trafficking finally finds a stable foster placement, she needs a trauma-informed therapist, a pediatrician trained in complex care, a case manager, and often a judge—all to be on the same page. When a 16-year-old boy with autism is discharged from a psychiatric facility after a violent outburst tied to unaddressed trauma, he needs a care coordinator who understands his triggers, his medications, his educational needs, and his housing instability.

Without coordination, these children are trapped in a cycle of institutional care, missed appointments, emergency room visits, and missed developmental milestones. With care coordination, these same youth can experience healing, connection, and the possibility of thriving. 

Managed Care: Reinvesting in Better Outcomes 

For Medicaid systems, managed care offers a structure for reinvestment. Instead of pouring money into high-cost crisis care, states and managed care organizations (MCOs) can redirect funds into prevention, continuity, and community-based services that stabilize children before they spiral. 
 
By embedding care coordination into managed care, states avoid unnecessary emergency room utilization, repeated psychiatric hospitalizations, foster care disruptions, and long-term institutional placements. The cost savings are measurable, but the human impact is even more profound. 
 
And for children and teens with disabilities or chronic health needs tied to trauma, these investments become bridges to possibility, not pipelines to despair. 

The Role of 1115 Waivers: Innovation for the Invisible 

1115 Waivers give states a platform to innovate for populations that traditional Medicaid structures often miss—especially youth with complex trauma and disability. Waiver-funded pilots can test models that integrate behavioral health and primary care, expand school-based services, and fund trusted adults like peer mentors or culturally specific navigators. 
 
States can also use these waivers to fund upstream interventions: mobile crisis teams for children, youth-specific housing supports, respite care for family caregivers, and training for pediatric providers in trauma-informed approaches. 

Five Innovations Needed Now for Poor Youth

with Trauma and Disability 

• Trauma-Informed Pediatric Behavioral Health Integration
  Children and teens need behavioral health care embedded in every space they enter—schools, clinics, and homes. Trauma-informed, co-located pediatric care reduces stigma and makes healing routine, not exceptional.

• School-Based Care Coordinators
  Many youth only touch the system through school. Embedding care coordinators or social workers within schools allows for early identification, ongoing support, and seamless connections to Medicaid and waiver-funded services.

• Youth-Centered Peer Navigators
  Survivors of violence and trauma often respond best to peers who’ve “been there.” Investing in trained, lived-experience youth navigators can bridge trust gaps between systems and the children they serve.

• Safe Transition Services for Reentry and Housing-Insecure Youth
  Homeless youth, justice-involved teens, and children aging out of foster care need wraparound services at moments of transition. Medicaid can fund transitional housing, case management, and health services through waiver authorities.

• Parent and Caregiver Support
  Caregivers of children with disabilities and trauma histories are at high risk of burnout. Waivers can fund respite care, parent training, and mental health services to sustain families and prevent placement disruptions. 

Building a System Worthy of Their Healing 

At the heart of care coordination is not paperwork—it’s presence. It is the commitment to walk alongside children and teenagers through fractured systems and into whole lives. Managed care brings structure and sustainability. The 1115 Waiver brings flexibility and innovation. Together, they create a lifeline for poor children and teenagers who have experienced more harm than any child should have.

We are a care coordination entity, and this is our work: not only to reduce state spending, but to raise the ceiling of what’s possible for every child with complex needs. By aligning FQHCs, hospitals, schools, and community partners, we transform the system from one of reaction to one of relationship.

Because every child deserves a coordinated village—not a broken system.