Continuity of care through nursing case management of the chronically ill child

In the care of the chronically ill or disabled child, continuity of care between hospital and home must be prompt and continuous. In our myelomeningocele clinic, continuity of care is maintained through a nursing case management system. Our definition of case management is derived from the definition of service coordination made by the Ohio State Bureau for Children with Medical Handicaps. The service coordinator is a CNS who works for health care coordination by bringing together all health care services that are needed for a child with a disabling condition. We describe the aspects of that care coordination, including a thorough definition of our nursing case management process.