21.3 Referral, CPS Collaboration, Care Coordination, Transition & Follow-Up

Domain III.D is collaboration, referral, and CPS. III.E is care coordination, including special health care needs and transition to adult care. III.F is evaluation and follow-up — the plan you wrote in 21.1–21.2 is not finished until you see what happened and change it. This is not "be nice to consultants." It is how a primary-care PNP keeps a complex child from falling through six unconnected systems.

Quick Answer: Refer when indicated, with a question and a closed loop. Use EI, WIC, PT/OT/speech, school, and behavioral health. Advocate in writing. CPS on reasonable suspicion — no proof required. CSHCN get a medical home. Got Transition: start in early adolescence, portable summary, name an adult clinician. Follow up and modify. Unstable asthma, DKA, and a surgical abdomen are not primary-care problems — dual AC/PC certification does not change that disposition.

Referral: the right door, the right speed

A referral is a clinical decision with a time scale. Emergency problems leave the office (or never belong in the office). Urgent specialty problems get same-week or same-day calls, not a portal message that dies. Elective problems get a named specialty, records attached, and a tracking step so you know the family arrived.

Write the referral as a question, not a shrug: "pathologic murmur with a thrill — please evaluate for structural disease," not "please assume care of a noisy heart." Send growth charts, key labs, immunizations, and what you already tried. Dumping an undifferentiated chart on GI because you are behind is not Domain III.D.

Community resources are referrals too. You are the navigator.

Advocate. Verbal "you should call EI" is weaker than a referral faxed today, a medical-necessity letter for a spacer, formula, wheelchair, or prior authorization, and a school letter that describes function. Title V CSHCN programs, Medicaid waivers, and SSI eligibility are coordination, not extra credit.

CPS collaboration

Every U.S. jurisdiction makes health-care clinicians mandated reporters. Reasonable suspicion of abuse or neglect is the threshold — not courtroom proof, not a confession, not a child-abuse pediatrician's written confirmation, and not parental permission. You do not investigate like a detective; you examine, document facts, protect safety, and report. If the child is in imminent danger, you do not send them home to an unsafe caregiver while the report "processes." Recognition, injury patterns, and documentation live in Chapter 20. Domain III.D tests the collaboration: you report, you share medical information with CPS as the law allows, and you remain the medical home after the report — reporting is not transferring the child's primary care to the agency.

Do not bargain ("I will report next week if the bruise is still there"). Do not outsource the legal duty to the parent ("you should call CPS if you feel ready"). Do not wait for a photograph from the scene.

Special health care needs and the medical home

Children with special health care needs (CSHCN) are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who need health and related services beyond those required by children generally (AAP/MCHB definition). They belong in a medical home: accessible, continuous, comprehensive, coordinated, compassionate, culturally effective.

Coordination looks like a shared care plan the family can carry, an emergency information form (diagnoses, baseline vitals/labs, airway, meds, specialists — AAP/ACEP-style), comanagement with subspecialists so tests are not repeated blindly, and a scheduler who notices the missed neurology visit. Technology-dependent children, sickle cell disease, complex congenital heart disease, autism with aggression, and transplant recipients are still your patients between specialty visits. Fragmented care is how immunization gaps, missed EI, and contradictory medication lists happen.

Transition to adult care (Got Transition)

Adolescents do not age out of the chart on their 18th birthday without a plan. Got Transition (gottransition.org), aligned with the AAP/AAFP/ACP clinical report, uses Six Core Elements:

1. A written transition policy the youth and family hear in early adolescence.
2. Tracking who is in the process.
3. Readiness assessment (youth and caregiver).
4. Transition planning, including a portable medical summary (diagnoses, surgeries, meds, allergies, specialists, baseline studies, accommodations).
5. Transfer of care to an identified adult clinician (PCP and, when needed, adult specialists) with a warm handoff.
6. Transfer completion — confirm the adult visit actually occurred.

Start in early adolescence — often discussed around 12–14 years, earlier when the condition is complex (IDD, CHD, CF, sickle cell, technology dependence). Before 18, discuss decision-making: typical majority, supported decision-making, or guardianship when a youth cannot consent. Insurance cliffs (Medicaid, parent plans) are coordination problems. Confidential adolescent care (Chapter 17) continues until transfer; the portable summary should not ambush a youth's privacy without a plan.

Waiting until the last pediatric visit to say "find an internist" is a failed III.E item.

Follow-up (III.F) and the dual AC vs PC lane

Evaluation and follow-up means a time and a decision rule. Examples you already use: AOM not better in 48–72 hours → re-examine, do not add a random second antibiotic by phone; stimulant start → 2–4 weeks for BP, HR, growth, sleep; SSRI start → days to weeks, not next year's physical; asthma → step up or down from control, not from the sample closet. You own results you ordered. You track referrals. After an ED visit, the medical home reconvenes the plan.

Modify based on response. A plan that failed is data: adherence barrier (21.2), wrong diagnosis, or a problem that has left primary care.

Dual-certified CPNP-PC and CPNP-AC graduates exist; PNCB eligibility even lists dual AC/PC programs. The CPNP-PC exam is a primary-care exam. Holding an acute-care credential does not turn a community clinic into a PICU, an insulin-drip unit, or an OR. When the problem is no longer primary care, you transfer:

• Unstable asthma: hypoxia, poor air movement, marked work of breathing, not reversing with office albuterol — ED/acute care now.
• DKA: vomiting, Kussmaul, altered mental status, acidosis — emergency, not a pump adjustment in the parking lot.
• Surgical abdomen: peritonitis, bilious emesis, ill child with an acute belly — ED/surgery.
• Same idea: anaphylaxis after epinephrine still needs ED observation; status epilepticus; testicular torsion; neonatal fever/sepsis concern.

Clinic vignette. A dual-certified colleague wants to "watch" a silent-chest asthma flare in an unmonitored exam room overnight because they also sat the AC exam. That is not courage and it is not Domain III. It is the wrong setting. Stabilize what you can, activate emergency transfer, and resume medical-home coordination after the hospitalization — action plans, ICS, trigger control, follow-up in days, not a 3-month allergy slot as the only next step.

Exam traps: delaying EI for a diagnosis; needing a confession before CPS; starting transition at age 17 years 11 months; treating dual certification as permission to keep DKA in clinic; writing a perfect referral and never checking whether the family went.