Community + UCSF Mount Zion Awards

Mount Zion Health Fund

Clinical and Educational Partnership to Improve Care for Children with Special Health-Care Needs

Proposal Concept: Length = 1-2 page Status: 

In this project, UCSF Otolaryngology-Head and Neck Surgery and Primary-Care Pediatrics will partner with San Francisco Unified School District to develop a robust program to share information, communicate, and collaborate to improve coordinated care for children with special health-care needs.


  • Dylan Chan, MD, PhD, FAAP, Associate Professor, UCSF Department of Otolaryngology-Head and Neck Surgery
  • Jennifer Albon, MD, MDev, FAAP, Clinical Assistant Professor, UCSF Pediatric Primary Care at Mt Zion
  • Jennifer Herges, Special Education Supervisor, San Francisco Unified School District

Contact information

Dylan Chan

2233 Post St., 3rd Floor

San Francisco, CA 94115


Jennifer Albon

2330 Post St., Suite 320

San Francisco, CA 94115


Jennifer Herges

3045 Santiago St.

San Francisco, CA 94116


Project Overview: 

Children with special health-care needs (SHCN), including those who are deaf or hard of hearing (D/HH), require care through both clinical and educational systems. In San Francisco, the majority of children with SHCN receive clinical care through UCSF and educational services through San Francisco Unified School District (SFUSD), the public school district for San Francisco City and County.

However, many systematic barriers exist to efficient, systematic, and equitable collaboration on shared children with SHCN. These barriers are a fundamental threat to the Medical Home model of pediatrics primary care. In this project, we will build on an existing UCSF/SFUSD partnership for children who are D/HH and, using this D/HH partnership as a model, establish a formal, sustainable system of cross-disciplinary care for children with SHCN shared by UCSF MZ Primary-Care Pediatrics and SFUSD. 

List of goals: 

  1. To engage stakeholders to identify barriers to communication and information-sharing between educational and clinical providers and, using stakeholder input, develop specific pragmatic mechanisms to overcome them. 
  2. To establish a Memorandum of Understanding (MOU) between SFUSD and UCSF governing these mechanisms of data sharing, communication, and collaboration;
  3. To implement these mechanisms for specific children whose care is shared between UCSF and SFUSD; and
  4. To measure the impact of these mechanisms on healthcare outcomes.

Specific Aims:

Specific Aim 1: To engage stakeholders in SFUSD and UCSF to elicit specific barriers and opportunities for communication and collaboration on children with SHCNs

Specific Aim 2: To establish the mechanisms identified in Aim 1, complete an MOU between SFUSD and UCSF, and implement the mechanisms for defined populations of shared children.

Project Proposal:

Children with SHCN have their care managed across both clinical and educational systems. Both systems are critical to different aspects of care: clinical systems provide diagnosis and medical management; educational systems provide regular therapies and educational services. These different spheres of care are tightly entwined, with progress or concerns in one informing decisions in the other. However, there is no system of care coordination across clinical and educational settings. In fact, there are specific barriers to communication and collaboration. As a result, educational and clinical providers often struggle to share knowledge and collaborate on care for children with SHCN. This leads to delays in care, frustration for families, and inadequate care for children. Parents can bridge this gap and facilitate care coordination, but parents’ ability to do so is limited, especially for more vulnerable populations.

Through the UCSF Children’s Communication Center (CCC), we have engaged in an ad-hoc partnership for children who are D/HH with the SFUSD D/HH program for 8 years: activities have included:

  • UCSF/SFUSD D/HH provider care coordination meetings
  • UCSF CCC social worker participating in families’ Individualized Education Plan (IEP) and Individualized Family Service Plan (IFSP) meetings at SFUSD
  • SFUSD D/HH liaison participating in families’ clinical visits at UCSF

These activities have been successful in improving care for families that have received this coordination, but it has not been implemented in a systematic way.

In this project, we will use our experience with this ad-hoc partnership in D/HH kids to identify specific barriers to collaboration for these children and, more broadly, all children with SHCN, develop mechanisms to address these barriers, establish an MOU between SFUSD and UCSF to govern these mechanisms, and implement this inclusive system of communication and information sharing between SFUSD and UCSF for families of children with SHCNs served in both systems. We will use the D/HH population as an initial pilot group to establish processes that will support all children with SHCN. In this way, this process will yield a sustainable collaborative model that can persist even after the completion of this project.  

To achieve Specific Aim 1, we will first identify stakeholders within UCSF and SFUSD who regularly work with children with SHCNs and need to communicate with providers outside their respective institutions. This includes, at UCSF: social workers in the Pediatrics and Otolaryngology/Audiology clinics (who regularly serve as liaisons on behalf of families for educational services); clinic staff (who manage communication and documentation); speech-language, physical, and occupational therapists (who have direct overlap with school-based services); and at SFUSD, early intervention providers (including teachers of the deaf and blind), administrators, nurses, and therapists at the district and school-site level. We will conduct structured interviews to elicit their perspectives on the barriers to facile communication on shared children and their “wish list” for strategies to make communication more effective and efficient. We will employ human-centered design (HCD) strategies to identify insights on the barriers experienced by the stakeholders. These insights will be developed into potential interventions, which will be considered and integrated with the specific interventions proposed by the stakeholders themselves.

In previous ad hoc discussions between UCSF CCC and SFUSD D/HH staff, proposed strategies have included 1) regular case-conference meetings on shared students; 2) simplification of the release-of-information (ROI) process; 3) clarification and dissemination of key personnel and contact information across institutions; and 4) providing families with tools to and empower them to manage their childrens’ care.  We anticipate that expanding the scope of this stakeholder input and employing HCD strategies will yield a comprehensive and inclusive set of insights and, subsequently, actionable strategies.  Through the Open Proposal platform, additional suggestions were made for creation of data-sharing portals, and universal or simplified forms.

For Specific Aim 2, a smaller, focused group of stakeholders from UCSF and SFUSD (including project leadership) will prioritize the proposed interventions in terms of 1) impact; 2) generalizability to children with SHCNs; 3) feasibility of implementation within SFUSD/UCSF systems; and 4) sustainability.  We will use the PRISM (Practical Robust Implementation and Sustainability Model) and RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) frameworks to structure stakeholder input, identify organizational needs to achieve sustainable implementation and impact, and specify measurable outcomes to assess the success of these strategies.  We anticipate that some strategies may encounter barriers to development and implementation, including low feasibility/sustainability potential (for example, strategies that require too much ongoing personnel commitment), or unsurmountable compliance barriers (such as free sharing of privileged/protected health or educational information across systems).  Through an iterative process with stakeholders, which will include pilot testing and exploration of specific strategies with the D/HH population, we will ultimately produce a clearly defined set of mechanisms for collaboration that will then be formalized in an MOU between UCSF and SFUSD.  Once this MOU is established, we will implement the collaborative plan for defined populations of children with SHCNs whose care is shared between UCSF and SFUSD. We will then measure implementation outcomes for this collaborative plan to assess whether the plan had the intended reach and impact.  These outcomes will be specific to each strategy within the collaboration plan and will be defined using the output of the RE-AIM framework.  These may include accomplishment of predefined goals and deliverables; repeat qualitative interviews with the initial broad pool of stakeholders and families impacted by these strategies; and quantification of the number of students impacted, quantity and quality of communication across institutions, and timing/delays in care such as establishment of IEPs (within SFUSD) and clinical appointments (within UCSF).

Our timeline for this project is as follows:

Year 1: Broad stakeholder interviews, identification of collaboration strategies for development, discussion, and pilot testing with D/HH programs.

Year 2: Focused stakeholder refinement of collaboration strategies, determination of the final set of collaborative mechanisms, and establishment of an MOU between UCSF and SFUSD

Year 3: Implementation of the collaborative plan and collection/analysis of implementation data.

Anticipated benefit for underserved or vulnerable communities in San Francisco

SFUSD and UCSF care for a highly vulnerable population of children in San Francisco. The UCSF Children’s Communication Center serves ~2,000 children, of which 69% are publicly insured (as a proxy for low-income); 38% are non-English-speaking at home; and 74% are racial/ethnic minorities. UCSF Primary Care Pediatrics serves ~15,000 children, of which 69% are non White/non-Hispanic ad 50% are publicly insured. The ~50,000 children in SFUSD are 53% socioeconomically disadvantaged; 27% English-language learners; and 86% non White/non-Hispanic. These vulnerable populations experience tremendous disparities in outcomes within both health and educational systems; when care is shared between these systems, particularly for children with SHCNs, complexity substantially increases for families and their communication challenges are amplified. 

This project, which will build sustainable mechanisms to facilitate communication and collaboration between UCSF and SFUSD, will directly benefit these underserved and vulnerable populations. For example, if one of the project outcomes is to establish a regular series of case conference meetings between care providers in UCSF and SFUSD, the UCSF and SFUSD care teams for these children will more rapidly and effectively come to consensus about the child’s clinical and educational needs, leading directly to better care and clearer communication to the families.  Furthermore, children who are lost to care in either system will immediately be brought to the system’s attention.  These direct benefits will address two of the most significant challenges for families of children with SHCNs – integrating and reconciling (sometimes conflicting) plans from their clinical and educational teams; and delays or loss to follow-up care in either system. As another example, if we establish a more facile means of data sharing and universal release of information for families across UCSF and SFUSD, the significant barriers of requesting, obtaining, and disseminating information across clinical systems, which are often insurmountable for families with limited literacy, will be reduced.  This will directly benefit these families in their ability to share information among their care teams at UCSF and SFUSD.

In our experience with ad hoc partnership between the UCSF CCC and SFUSD D/HH programs, with similar case conferences and other systematic collaborative efforts, families have repeatedly indicated to our social worker liaison these benefits – they have appreciated any direct and facilitated communication between their UCSF and SFUSD providers and assistance in re-establishing care.

How the project addresses UCSF Mount Zion priorities and compelling San Francisco healthcare needs

Children with SHCNs in San Francisco require closely coordinated care between their clinical and educational providers - this care coordination is a central tenet of the Medical Home model of Primary Care Pediatrics, according to the American Academy of Pediatrics - "an approach to providing comprehensive primary care that facilitates partnerships between patients, clinicians, medical staff, and families... that extends beyond the four walls of a clinical practice [to include[ specialty care, educational services, family support, and more."  SFUSD and UCSF are the single largest providers of this care, and the most important non-clinical partnership that these children have. Because of the absence of structured care coordination between these institutions, however, many inefficiencies and gaps in care exist for these children, leading to poor health and developmental outcomes, a significant threat to the Medical Home model for children in San Francisco cared for at Mt Zion Primary Care Pediatrics. This project will close this gap, therefore addressing a critical and compelling San Francisco healthcare need and UCSF Mt Zion campus priority.

Type and duration of campus-community partnership

The existing partnership between the UCSF CCC and SFUSD D/HH programs has evolved over the past several years, with direct engagement in the form of care coordination conferences and UCSF/SFUSD personnel taking part in activities across institutions for the past 4 years.  In this project, this partnership will expand to encompass UCSF MZ Primary Care Pediatrics and the broader system of care within SFUSD for children with SHCNs, including Home and Hospital and Special Education Services.  The partnership will exist on multiple levels – project leadership includes both UCSF (Drs. Chan and Albon) and SFUSD (Ms. Herges) personnel, and the core project personnel (administrative support at both UCSF and SFUSD, and providers (social work, nursing, and therapist)) will be cross-institutional.  Ultimately, the project will generate an MOU between UCSF and SFUSD covering the communication and collaboration plan which will govern the partnership.  Though the active phase of the partnership, as described in this proposal, will last the duration of the project (three years), the MOU established will sustain the partnership after completion of the project.

How the community partner’s experience and expertise was integrated into proposal development

This proposal grew out of the existing partnership between the UCSF CCC and SFUSD D/HH programs. Through multiple partnership meetings, SFUSD staff, including district administrators, teachers of the deaf, speech-language pathologists, Early Start home- and center-based providers, and classroom teachers provided feedback on barriers to communication and collaboration with UCSF. These barriers, in many instances, were shared by UCSF staff and families. Ms. Herges, the SFUSD lead for this project, has worked as an administrator for D/HH services at SFUSD and has collaborated with the UCSF CCC team for 4 years, especially with Silvia Bellfort-Salinas, UCSF CCC social worker; over this time, Ms. Herges has heard this feedback from SFUSD personnel and integrated these experiences with her direct observations. This SFUSD stakeholder input illustrated the critical need for development of better systems for communication and collaboration as described broadly in this proposal, as well as specific examples of collaboration mechanisms (care conferences, personnel/contact lists, data-sharing agreements) that could be considered.  

Subsequently, through pre-proposal development and the Open Proposal process, additional SFUSD stakeholder input has been solicited to expand the scope of the project to support all children with SHCNs.  Ms. Herges, as head of the Home and Hospital program within SFUSD, brings additional experience and expertise on the educational needs of children with significant medical complexity; district and site nurses were engaged to understand the different populations of children and levels of collaboration to consider; and Jean Robertson, head of Special Education at SFUSD, has provided support and additional high-level insight into feasibility and operational needs of the project. This input has yielded several critical refinements to the project, including highlighting the importance of:

1)    Engaging a broad set of stakeholders in SFUSD at both district and site levels for initial identification of barriers and priorities for collaboration

2)    Considering different populations of children to target and support

3)    Budgetary needs within SFUSD to achieve project goals

This project is designed as a true partnership between UCSF and SFUSD; engagement of a broad set of stakeholders within SFUSD will be critical for the ongoing development and conduct of this project.

Roles of UCSF and Community Partner: UCSF provides clinical care for children with SHCN, including those who are D/HH. For example, for D/HH children, audiologists make the initial diagnosis of hearing loss, monitor hearing, and manage hearing devices (hearing aids and cochlear implants). Speech-language pathologists perform therapy and evaluations for speech/language development in some children. Otolaryngologists manage the medical aspects of hearing. A social worker serves as a liaison for the family as they engage with the educational system. SFUSD, the community partner, provides therapy (PT, OT, speech/language) and educational care for children with SHCN. For example, for D/HH children, classroom teachers, specialized teachers of the deaf, and speech-language pathologists provide services as often as daily for children to support their developmental and educational needs.  These providersparticipate with administrators and educational audiologists to work with families to develop Individualized Education Plans or other related frameworks to support the child’s needs. For children with SHCN they have other arrays of multidisciplinary care in the medical and educational system.

In this project, UCSF staff will be engaged in improving communication and collaboration with educational providers at SFUSD. This will occur in three phases – stakeholder engagement and interviews; development of collaboration mechanisms; and implementation and analysis. The UCSF/SFUSD partnership Program Coordinator, together with a counterpart in SFUSD, will coordinate these tasks, with clinical and educational providers serving in two principal roles: 1) a broad and representative set of stakeholders will be engaged to share their perspectives on needs and potential solutions; 2) a smaller core group of stakeholders (provided funding through this project) will serve as a working group to define and implement the collaboration plan.

Project leaders


  • Dylan Chan – Associate Professor, Otolaryngology-Head and Neck Surgery and Director, Children’s Communication Center (CCC)
  • Jennifer Albon, Clinical Assistant Professor, Pediatrics Primary Care at MZ

Dr. Chan developed the multidisciplinary clinical care program and initial SFUSD partnership for children who are D/HH, which will serve as the initial model for this project. Dr. Albon is a primary-care pediatrician focusing on children with SHCN, who will direct the expansion of this D/HH-focused model to encompass children with SHCN cared for at MZ Primary Care Pediatrics.

There are four key personnel that have specifically been engaged already in a UCSF/SFUSD partnership – UCSF-based social workers (Silvia Bellfort-Salinas (OHNS) and Kristin Flores and Alina Woolford (Pediatrics)); a UCSF-based program coordinator (Jenny Stephans); and an SFUSD-based educational liaison (Jennifer Herges).

These individuals have collaborated ad-hoc to improve communication and collaboration on joint UCSF/SFUSD children. Dr. Chan has also successfully taken a MZHF-funded collaborative project with SFUSD — development of classroom lessons on hearing and noise, taught by UCSF staff in SFUSD 4th-grade classrooms — through this process of program development, MOU establishment with SFUSD, and sustainability after MZHF grant completion.


  • Jennifer Herges – Special Education Supervisor

Ms. Herges is the special education administrator directing care for all children who are D/HH in SFUSD. She also heads the Home and Hospital program within SFUSD which provides instruction to the most medically fragile children with a variety of conditions.  A D/HH individual herself, she has collaborated with Dr. Chan and the CCC for 5 years. She has participated in clinical visits with SFUSD families, served as a liaison with our CCC social worker to discuss specific SFUSD/UCSF cases, and led the SFUSD D/HH team during joint SFUSD/UCSF care conferences. She is ideally positioned in SFUSD to understand and address the barriers to communication and facilitate systems-level changes at SFUSD.

MZHF values

This project embodies the six MZHF values:

  1. Service: This project will directly provide a service to children with SHCN and their families, by facilitating direct collaboration between their clinical and educational providers.
  2. Social justice: By developing a systematic way to support all children with SHCN, we will directly address inequities in healthcare in SF.
  3. Community building: By establishing a regular and facile means of communication and collaboration between SFUSD and UCSF providers, we will build relationships among this community of pediatric healthcare professionals.
  4. Education and Leadership: By facilitating this transfer of information across professional settings, we will provide critical cross-disciplinary education.
  5. Innovation: Direct collaboration across educational and clinical systems is rarely performed, and a major gap in pediatric healthcare. This project seeks to establish a novel system to bridge this gap.
  6. Compassion: Families of children who with SHCN often articulate that a significant challenge is how to navigate the multiple systems of their child’s care. This program addresses this need with compassion and empathy.

Project start date and duration

  • Start date: March 1, 2023
  • End date: February 28, 2026




This is an amazing initiative and would tremendously help shape and strengthen the partnership between our community's schools and clinicians. Easier communication between SFUSD and UCSF would not only support our community's kiddos now, but also pave the way for other partnerships of this kind for the future. Please help support this project!

Thank you for making efforts to reduce barriers for communication and collaboration between UCSF and SFUSD!  I am confident that this partnership will improve care, coordination, and communication for providers and our patients!  I fully support this project!

I fully support this project for the benefit of the children who are jointly served by SFUSD and UCSF. Coordination of care and reducing barriers to this coordination are vital in supporting children with are deaf or hard of hearing reach their individual potential.

As an audiologist and a parent of a child with hearing loss, I strongly support this project! 

Anything that will help deaf/hard of hearing students succeed can only be a good thing. 

What was the origin of the ad hoc partnership between UCSF and SFUSD (i.e., Who initiated the ad hoc partnership and in what ways)?

The importance of community partnerships is boundless.  Our partnership between SFUSD and the Hearing and Communication Clinic at UCSF started 5 years ago.  Two major institutions with which parents interact, the health care system and the public school system, previously functioned as separate entities, and parents had to navigate these two complex systems on their own.  This inequity was addressed through ongoing collaboration between UCSF Hearing and Communication Clinic and San Francisco Unified School District.  Our partnership provided an opportunity for me to be a part of the clinic appointments to help guide parents through the educational system.  We also collaborated on Parent Education Workshops and ASL Classes.  The series of monthly Parent Education workshops provided the ability to support parents with community resources, understanding how to read an IEP and IFSP, advocacy for their child, and navigating the public and private school system.  Through the weekly ASL classes, parents were able to learn functional communication skills to communicate with their Deaf or Hard of Hearing child, providing incidental learning, and foundational language skills.  By means of the workshop series, more students are receiving the services that they require and deserve as parents have the ability to understand the IFSP and IEP documents and request evaluations for services.  Due to knowledge revolving around programs, schools, and placements, more students than in the past attend Deaf and Hard of Hearing magnet sites within SFUSD.  Students are being placed into appropriate programs where they are be able to receive appropriate supports and thrive both socially/emotionally and academically.   

Thank you UCSF! Such an important project to support advocating for D/HH children. Having a background in working in an elementary school, I believe that it is highly critical to continue building out education/resources and support at an early age, so they can build confidence and thrive. Not only that but families with D/HH children always need support and UCSF/SFUSD can help provide that with this project. For those of you who are reading this thread, please help support this project!

As a speech-langauge pathologist in the medical setting, this project has my support! Coordination of care between educational and medical teams is so vital to helping DHH children reach their potential. Support to formalize this partnership will help not only our local SF patients and families but also hopefully serve as a model for other centers. Hearing health care truly takes a village! 

This is such an amazing initiative! Thank you so much, UCSF. I, myself, having a close family member with hearing loss, am a huge advocate of hearing healthcare and fully support this project. I hope that all families with D/HH children receive the support and services they require.  

This would be a great opportunity to bridge the gap and become more collaborative to this highly vulnerable popluation. Starting young removes the future barriers and hurdles and builds confidence!  I couldn't think of a better TEAM to make this happen.  

This has been a grassroots effort that I have had the opportunity to watch develop over the last several years and which has been to the very positive benefit of our patients, providers and the community. To have formal monetary support will allow this program to be more continue to grow and estlabish strong roots will continue to elevate the level of care and coordiantion for our patients!

This is an incredible initiative that has my full support. As a speech-language pathologist in the medical setting and with past experience in the school setting, I know first-hand how critical collaboration is among everyone on the child's care team. Dedicated monetary support would help to reduce the barriers that currently exist to cross-site collaboration and lead to improved outcomes for our DHH children.

Institutional connections foster stronger bonds and communication avenues for the students we are mutually serving so that the students are better provided regarding their needs and access to each of language, social, emotional, personal, identitty, and life development.

As a hard of hearing individual myself, I applaud this effort to organize systems to benefit children and families. 

I support this project, is the link we have been missing to better support our patients/students from the D/HH community. Thank you!

I'm an SFUSD school nurse and I know that reducing barriers to communication between me and medical providers will facilitate our ability to take care of our shared kids. I fully support this project!

United efforts to reduce barriers and increase collaboration and communication are bound to yield positive outcomes for our D/HH students. Many thanks to Dylan Chan, Jen Albon, and Jenny Herges for your committed partnership. 

Great that you are embarking on this partnership. You may want to pilot some potential feasible interventions to see if they would work. (1) Children with medical complexity have school health forms that need completion and updating every year. It would be great if these could be just be signed if there are no changes, or only change the part that needs change, rather than to rewrite the entire set of forms. (2) When IEPs are about to be conducted, can there be a portal or other means for clinicians to provide medical and developmental information? (3) When clinicians need to communicate with nurses or teachers, a central number, or pre-arranged times would be really helpful. I often have to use email which is not secure. When I call, the teachers are teaching, and when teachers call, I'm often seeing patients. Knowing "best times" to communicate will improve efficiency and timely communication. (4) Universal ROI (release of information) would also help! Thank you, again, for all your efforts!

This sounds like a wonderful proposal! - Sabrina Fernandez

At UCSF in Oakland, I have been partnering with OUSD for 3 years, largely working with the school nurses in Oakland, and with a greater Alameda County school nurse group. While it has made for stronger partnership, it has not trasnlated into more consistent back and forth about every patient. Lessons learned from other partnerships would be helpful in your project. I also want to echo Dr Takayama's comments, especially some sort of portal where parents can easily agree to information sharing (with e-signature, click of a button), and clinicians can share information and concerns about students in the district

Thank you, John, Sabrina, and Noemi, for your comments and suggestions. It is clear from your comments and feedback from other SFUSD and UCSF folks that the first step of our project needs to be to directly solicit broad stakeholder input on the communication barriers, and specific strategy ideas such as these.  Noemi - I would love to hear about your experience with OUSD.

This seems like a fantastic and much needed project to improve care coordination for children with special health care needs. As clinicians, we often struggle to determine who to contact to support a particular patient, how to participate in the IEP process, and how we can enhance communication and share important information between the school and clinical setting. Formalizing these processes and educating providers about this relationship will be an important step forward!

This proposal addresses a massive gap in the quality of our care: systematic, regular communication between the medical system and the schools.  As clinicians, we miss essential information, especially for diagnoses like ADHD or learning disabilities, if we don't get timely information from the educational experts who see children every day. As a UCSF clinician at SFGH who cares for many children with special health care needs, I spend hours every month collecting ROIs, sending to SFUSD, tracking down teachers, social workers, and psychologists, and obtaining the right IEP documents to help guide my medical decision-making.   Starting with a specific population is a good idea and I see great potential for generalizing to a larger group of children.  I'd recommend during the stakeholder interviews to talk to parent advocates in groups like Parents for Public Schools or Innovate Public Schools.  Serena Yang at UC Davis might be another good person to talk to: she spoke briefly at a state-wide meeting about her county attempting to create IT solutions for better information-sharing systems.  Melanie Callen is another key informant since her full-time job is to be a liaison between SFGH and the schools.

Thank you for sharing information about your work. I have no comments at this time.