2018 Annual Report

NPM 11: Percent of children with and without special health care needs having a medical home.

Objectives:

• Increase by 2% the number of families who have access to a pediatric clinician with effective medical home practices in place by July 2019.
• Increase by 2% the number of families who have access to patient and family centered care coordination by July 2019.
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Strategies:

• Develop trainings and strategies with the New Mexico (NM) Child Health Improvement project for pediatric providers to improve care integration and cross-provider communications using evidence-based tools such as the shared plan of care.
• Develop strategies with the NM Child Health Improvement project to provide training to pediatric providers on care coordination and how to integrate the Title V Children and Youth with Special Health Care Needs (CYSHCN) care coordinators into their practice.
• Collaborate with the Family to Family Health Information Center to recruit family leaders to provide input to Medicaid and the Managed Care Organizations (MCO) to the overall system of care, specifically care coordination and family-centered care.
• Promote use of the Medical Home portal by primary care providers, families and other interested stakeholders by providing relevant and timely content and community resources to improve the care for CYSHCN and their families.

System of Care for Children and Youth with Special Health Care Needs

The focus of the state action plan is to improve the system of care for Children and Youth with Special Health Care Needs (CYSHCN) with a focus on Medical Home. Children’s Medical Services (CMS) has continued to provide leadership around care coordination that is family-centered and culturally competent for CYSHCN.  According to the National Survey of Children’s Health, in New Mexico while more CYSHCN have at least one health care provider and a place they usually get health care they face significant disparities in other areas of the medical home model. Ninety-seven percent of CYSHCN have health insurance but far more, 61% are insured through public plans such as Medicaid and Indian Health Services where nationally this number is 47%. Twenty-seven percent of CYSHCN had at least on annual visit to an emergency room compared to 18% of children who are not; 31% of CYSHC reported having problems getting health care referrals versus 14% of non-CYSHCN. New Mexico CYSHCN also face greater economic hardship than non-CYSCHN with 54 % of these children living with families with incomes under 200% FPL as opposed to 48% nationally.  

CMS employs licensed medical social workers trained in the provision of care coordination for CYSHCN from birth to age 21 in New Mexico, helping to bridge the gaps in the healthcare system and link families to needed services. This coordination of care across settings leads to an integration of services, which decreases health care costs, reduces fragmentation of care, and improves the experience for the patient and family. In rural areas CMS is seen as the only program that addresses the needs of CYSHCN. The CMS program, with its revenue source from Medicaid billing, focuses efforts on maintaining staffing in all regions of the state and defending the necessity and value of the work the social workers do in their communities. With increased staffing this year, we were able to resume outreach activities to underserved communities in rural frontier areas and within tribal communities and increase the number of our pediatric specialty outreach clinics.

In addition to working on medical homes, CMS social workers and CMS management continued to work to improve three of the core outcomes for all CYSHCN clients.  These outcomes are: 1) families partner in decision making and are satisfied with the services they receive; 2) families of CYSHCN have adequate private and/or public insurance and financing to pay for the services they need; and 3) services for CYSCHN are community based and culturally and linguistically competent. 

Best practice for care coordination of CYSHCN involves collaborative patient and family-centered care. For example, the American Academy of Pediatrics (AAP) identifies the following desirable characteristics of coordinated care within a Medical Home: (1) a plan of care is developed by the physician, child, and family in collaboration with other providers and agencies; (2) all pertinent information about medical care and use of services is accessible to the care team while protecting confidentiality; (3) families are linked to support groups and other resources; and (4) the plan of care is coordinated with educational and community organizations to ensure goals of the care plan are addressed. 

Insurance Coverage and Adequacy

New Mexico has benefited from the Affordable Care Act (ACA) as a Medicaid expansion State. This has helped close the gaps in health care access for youth age 18 and older who had historically transitioned into a system with limited health care financing. In 2018, Medicaid implemented the revised 1115 Waiver and awarded contracts to three managed care organizations (MCOs). Key components of the 1115 Waiver include: care coordination delegation and enhancements, cost sharing, patient-centered medical homes, and integrative behavioral/physical health homes. The Title V program had developed key partnerships with the MCOs several years ago and this provided the perfect opportunity to provide input into policy development around key elements such as care coordination, medical home, and transition.

The interagency workgroup met several times and agreed on recommendations that were formally delivered to Medicaid during the public comment period.  Comments were centered around care coordination for CYSHCN and the need to maintain contractual partnerships with community agencies such as CMS, which has expertise in the provision of care coordination for this population, and utilization of evidenced based practices as cited by the “Got Transition” and the six core elements to assure a successful transition for youth with special health care needs into adulthood. CMS continues to monitor the Medicaid activity, as the MCO a CYSHCN is enrolled in can significantly affect access and ability to have health care needs met.

Although the uninsured rate in NM has dropped significantly with the ACA, approximately ten percent of New Mexicans remain uninsured.  Many, but not all, are undocumented individuals, frequently living in mixed status families.  When a child who is medically eligible for CMS has no health insurance, CMS acts as a very limited “insurer,” paying for needed medical services related to the eligible condition and assisting clients in applying for NM’s High-Risk Insurance Pool. New Mexico utilizes a high-risk pool to address access to health care for uninsured CYSHCN. The pool is subject to political influences and therefore requires continuous monitoring by the Title V program.

In a limited capacity, CMS also acts as secondary insurance to help families who have private insurance but meet program medical and financial eligibility guidelines.  CMS closely monitors the developments at the federal level regarding ACA and its impact on insurance coverage for New Mexico children, especially CYSHCN.

In an effort to demonstrate the value of the program, CMS began a contract with the Center for Development and Disability (CDD) at the University of New Mexico (UNM) to evaluate the effectiveness of the care coordination that is provided to CYSHCN in the state. The purpose of this project was to design and implement an evaluation plan that collects valid, reliable information on the impact that CMS social workers and other CMS staff have on clients and their families served by the program including health-related outcomes and quality of life measures.  The CMS services include, but are not limited to:

• Linking clients to health, psychosocial, and social service-related programs and services;
• Coordinating clinics in various specialties at locations across the state;
• Providing care coordination for clients who interact with multiple health and social service providers to maximize the effective and efficient utilization of health and other services and ensure that clients remain in appropriate programs and services; and
• Assisting YSHCN with medical transition issues.

One important goal of the project with the CDD was to produce information that can be used by CMS staff to promote the program when speaking with senior staff of the Department of Health (DOH); policymakers, including legislators; and funders, including federal agencies and MCOs.  Reports prepared will incorporate results from each project component. Data was sought that addresses the cost-effectiveness of CMS services, including cost-avoidance. At this point, little is known about what data is available that meets the criteria listed above.

The first project component was to assess what relevant data is available, develop an analysis plan based on the best available data which will be approved by CMS, implement the analysis plan, and prepare one or more written and/or oral reports. Another piece of the project was requesting that the CMS staff participate in a study of what the work of care coordination entails.  This time tracking was completed and the results were analyzed and reported to the program. An abstract was submitted and accepted for the annual Association of Maternal and Child Health Program conference and the New Mexico Public Health Association Annual meeting. The presentation was well received at both venues and a second contract will be developed to further analyze the data and outcomes.

In November 2018, the CMS program held a statewide conference for all staff. It had been several years since the program was able to do this and the focus was on skills building and care coordination. Topics included; adverse childhood experiences and resiliency; immigration and legal advocacy; angioma and the common Hispanic mutation; pediatric epilepsy; and structural family therapy. The conference promotes cohesion and a sense of community within the program and an awareness of core Title mission and values.

Access to Specialty Care

Another responsibility of the CMS program is the Newborn Screening program (NBSP). The program screens for 32 conditions, including critical congenital heart defects, congenital hearing loss, and a variety of blood tests for metabolic and hematologic disorders. The program assures that all newborns receive these screens prior to discharge and have access to follow-up and treatment in coordination with the Medical Home.  In 2018, there were several activities designed to improve this coordination and support families.

The Newborn Hearing Screening program was engaged in a multi-year statewide learning community focused on Sandoval County, which consists of rural, urban and tribal communities. The goals of the project were  to: (1) measure improvements in patient/family care consistent with evidenced-based approaches to referral, access to care and care coordination at the local and state level for infants with hearing loss; (2) improve response to child and family health care and community needs consistent with evidenced-based approaches based on tenets of the patient-centered medical home; (3) obtain measurable improvements in parent and family engagement; (4) develop a model for building capacity for quality improvement (QI) within the leadership of the target community and (5) measure positive changes in knowledge, attitudes, and provider practice in the content area of newborn hearing screening, referral to services, and follow-up. This past year the learning community has been successful in recruiting and training participants in the QI process and have engaged in activities that are moving the agenda forward.

The Newborn Genetic Screening program is part of the Mountain States Regional Collaborative and is participating in the second year of Underserved Populations Project (UPP) which was undertaken to develop strategies to increase access to genetic services for individuals in rural, Hispanic, and American Indian communities in the Mountain States. The New Mexico team consists of the Title V program, Trish Thomas from Family Voices, Navajo Nation, Parents Reaching Out, and Dr. Dale Alverson from the University of New Mexico office of Telehealth.

The purpose of the project was to support the outreach efforts of Ms. Sandoval, who interviews families on the Navajo Nation about access to genetic services. These families have children with genetic conditions, and she provides the families with educational materials, services, and community supports so that the team can understand the gaps and opportunities to improve resources and information for families. Ms. Sandoval left the project this year and the team began to expand its membership to include more families as well as genetic specialists from the University of New Mexico Health Sciences Center. With these changes, the focus of the project began to shift to exploring the use of telehealth as a way to improve access to genetic services.

New Mexico is a largely rural state with most pediatric specialists located in Albuquerque at the University of New Mexico Health Sciences Center (UNMHSC). High poverty rates, lack of transportation, and other socio-economic conditions can make accessing specialty care prohibitive for many families outside of the Albuquerque metro area. In partnership with UNMHSC, CMS facilitated over 160 multidisciplinary pediatric specialty clinics in rural areas of the state including cleft palate, nephrology, endocrinology, pulmonary, neurology, and genetics. CMS medical social workers follow CYSHCN through the multidisciplinary pediatric specialty outreach clinics, as well as assuring that specialists’ recommendations are communicated to the local (community-based) primary care providers.  Without these specialty clinics many CYSHCN would not be able to access this care.

Family Partnerships

Parents Reaching Out (PRO) and the NM Title V CYSHCN program are committed to provide support for New Mexico families of children and youth with special health care or education needs, especially those who have challenges accessing current systems. Within our vast state, the aim is to reach all families, especially those who may be isolated due to language, citizenship status, or geographic location. We work with populations that are diverse culturally, ethnically and linguistically, and populations with varying citizenship status residing within the state of New Mexico. The parents and partners with whom we work reflect New Mexico’s demographic makeup, which is majority Hispanic with significant Native American representation.

Organizations with whom we partner include: Education of Parents of Indian Children with Special Needs (EPICS), Hands & Voices, Growing in Beauty (Navajo), the Mescalero Apache Early Childhood Program, and the Asian Family Resource Center. CMS sponsored and participated in the annual PRO and EPICS Family Leadership conferences. Each conference attracts over 400 participants and consists mostly of families who have children with special needs. Participants from across the state come for mutual support and education about a range of topics that support the core outcomes for family professional partnership.

CMS continued its partnership with the state’s lead agency for child welfare, the Children, Youth and Family Department (CYFD).  The CYSHCN/Child Protective Services project aims to provide CYFD staff with an efficient means to improve overall care of children with chronic medical conditions on their caseloads. CMS social workers provide consultation and co-management for this population as they are specially trained in care coordination for children with chronic medical conditions.  In this partnership, the social workers provide the link between specialty care-patient-primary care offices and dental practices in the local communities.

CMS social workers work with the clients until they turn 21, which serves to provide both continuity of care for those CYFD clients who are aging out of their system at 19, as well as intensive work around youth transition in all areas (healthcare, educational and vocational).  The social workers also work with foster families to teach them about the medical needs of the child, how to navigate the specialty healthcare system, and how to assure a medical and dental home. 

New Mexico needs sustained family leadership and advocacy, especially regarding the system of care for CYSHCN.  From feedback received by Parents Reaching Out (PRO), the state family-to-family organization, family members have identified multiple barriers to obtaining the information they need to navigate the complex managed care system. The Title V program supports the existing family networks to be fully prepared, mentored, and connected to meaningful opportunities of program and policy partnership and ensures that the Managed Care Organizations (MCOs) are guided by patient and family voices. In 2018, PRO enlisted CMS to be part of a State Team to address this issue. Through a training grant from Family Voices, the New Mexico team developed a list of advisory/stakeholder committees that should have or do require consumer/family participation and will be utilizing the Family Leadership conference to recruit parents who are interested and prepared for this leadership role.

The ECHO™ financing clinic at the NM Family to Family Health Information Center (F2F) at Parents Reaching Out continued to address health care financing issues and access to care for CYSHCN. This model uses the “hub” and “spoke” approach to addressing health care needs. The “hub” in this case are experts from Medicaid, the MCOs, the disability community, Title V, and others. The “spokes” are care coordinators and families in rural communities who meet in local Public Health offices. This project had staff turnover and was not as robust as in the prior years and CMS will continue to support and encourage the continuation of the project.

Care Coordination

To improve the quality of CMS social worker care coordination for CYSHN and improve integration with the Medical Home, the contract with Envision (ENM) the Child Health Improvement program in the Department of Pediatrics at the University of New Mexico was completed in spring of 2018.  The program hoped to continue this partnership but due to a change of leadership, ENM changed focused and direction and was no longer aligned with the needs of the CMS program. A request for proposals was issued in the fall of 2018 to continue the quality improvement project related to Title V performance measures, and the New Mexico Quality Improvement partnership was selected. Due to lengthy contracting procedures, the contract was not expected to be finalized until late into the fiscal year, delaying this project. The contract will be for three years, so it does give some longevity to the project.

The MCH Epidemiology program continued its partnership with the DOH Asthma Epidemiology program to address unmet needs of children with moderate to severe asthma. The asthma program uses surveillance data to provide MCH Epidemiology with a list of children who have been hospitalized or had an Emergency Department visit due to asthma. The parents are called and asked a series of questions regarding access to a medical home and other services and offered a referral to CMS for care coordination. The program has been successful linking families to local CMS social workers who assess the family’s needs and prioritizes that the child has a Medical Home. An evaluation component will be developed in 2019.

The Birth Defects program continued surveillance and outreach to families with birth defects. With funding for the Zika Virus ending, the DOH in New Mexico Birth Defects program focused on the 12 core Birth Defects.  The program began developing educational materials around each of the diagnoses. Resource and referral information was also developed on topics such as: behavioral health, substance abuse treatment, and pediatric specialty care. The coordinator participated in numerous outreach events across the state over the year to disseminate this information.

The coordination of services will continue with all babies and children (birth to 4 years) identified with a birth defect being referred to CMS.  Contact is being made with families who are not linked to services.  Families identified through Newborn Hearing Screening will also be contacted if the Hearing Screen results indicate further need of services and/or multiple medical diagnosis are identified.  These families are referred to CMS social workers for care coordination and linkage to the Medical Home.

Babies identified with a Neonatal Abstinence Syndrome (NAS) code were reported to the Birth Defects Surveillance program from the birth hospitals in the State.  Even though NAS is not a birth defect, it was added to the birth defects surveillance because of the high prevalence in NM. For example, many babies who are born exposed to substance in utero have a higher incidence of a cardiac condition such as ventricular septal defect.  Submucosal Cleft Palate is another birth defect that can be linked to smoking and potential poly-substance use as well. 

CMS is partnering with CYFD in developing and implementing the state plan for Comprehension Addiction and Recovery Act (CARA) 2018.  This is part of a statewide effort to address the opioid epidemic and involved a multi-agency task force that met monthly to develop the response and assist CYFD to meet the requirements of the program improvement plan. The Birth Defects Coordinator took the lead in developing the Safe Plan of Care template and the training materials that will be used.  

Medical Home Portal

CMS continues to support and promote the use of the Medical Home Portal (MHP) maintained at the University of Utah as a useful resource for families and providers to obtain accurate information on pediatric medical conditions. It also links families to community resources to address psychosocial needs as well. The community resources page is kept up to date in partnership with the University of New Mexico Center for Development and Disability Information Network. The CMS Program Manager participates in the Medical Home Portal Advisory committee that began meeting quarterly to review portal metrics and usefulness and to provide input into additions that would be helpful for New Mexico families.

The MHP got considerable attention this year from the NM Pediatric Society and the Early Childhood Comprehensive Systems-Act Early (ECCS-AE) State Team. These groups decided to embrace the MHP as the “go to” for their respective stakeholders. A New Mexico team was formed to provide input to the MHP staff in Utah. At the annual NM Pediatric Society conference, a brief survey was made available to pediatricians to elicit level of knowledge and interest of the MHP. The results demonstrated enough interest that the Pediatric Society invested resources from an Association of Maternal and Child Health Programs (AMCHP) grant to develop promotional materials that are being distributed to all pediatricians statewide to encourage use of the Portal.

NPM 12: Percent of adolescents with and without special health care needs, ages 12 through 17 who received services to make transitions to adult health care.

Objectives:

• By July 2019, increase by 2% the number of pediatric and pediatric specialty care practices who report that they have a written health care transition policy and/or process to help youth with special health care needs prepare and plan for transition to the adult physical and behavioral health care systems.
• By July 2019, establish a baseline of youth and their parents/guardians in the Title V Children and Youth with Special Health Care Needs (CYSHCN) program, Children’s Medical Services (CMS), who report that they have the knowledge and tools to talk to their doctor about transition and be engaged in the planning process.

Strategies:

• The Title V program will provide training on transition and the Six Core elements to a successful transition to CYSHCN and their families at the annual parent leadership conference sponsored by Parents Reaching Out (PRO) and EPICS (Educating Parents of Indian Children with Special Needs) and with Youth with Special Health Care Needs (YSHCN) in the CMS program.
• Collaborate with the Family to Family Health Information Center to recruit family leaders to provide input to Medicaid and the Managed Care Organizations (MCO) to the overall system of care for CYSHCN around transition to adult health care.
• The Title V program will develop quality improvement projects with the NM Child Health Improvement project to engage pediatric providers to increase their understanding of transition and implement processes into their practices based on the evidenced based model developed by Got Transition.

Transition Training and Quality Improvement

In 2018, Children’s Medical Services (CMS) continued to enhance foundational program activities to improve medical transition for Youth with Special Health Care Needs (YSHCN).  According to the National Survey of Children’s Health 22.2 % of New Mexico YSHCN reported having received services for transition to health care compared to the national average of 12.6%. Since 2002, CMS has had an established transition program for YSHCN. Transition guidelines and transition plans were developed by the CMS Transition Team over several years, and CMS staff in all five regions of the state utilize the Transition Plans. The transition plans have been reviewed by several CMS social workers and YSHCN to assess effectiveness.  The plans have been helpful in raising issues such as employment, secondary school, medical management of their chronic health condition and inspiring youth to think about transition.  They also assist teens in identifying their own needs.

CMS social workers are required to use this plan for transitioning youth aged 14-21, ideally as part of the CMS renewal process.  We recommend that transition planning occur every other year for youth aged 14-17 and that the written plan be updated every year for those 17 and older, at the discretion of the social worker.  The transition plan is designed to be reviewed and discussed in person with the client as a tool for promoting conversation about transition topics.

CMS social workers complete a transition assessment for youth starting at age 14. This assessment addresses youth knowledge and ability to manage their medical condition, use of health care services, daily living activities, what areas they continue to need assistance with or anticipate needing assistance with, living arrangements, transportation, recreation, social relationships, and future education and/or employment planning.

For medical transition, CMS social workers work with the youth to identify adult providers that will assume care from the pediatric providers during the transition process and assist in addressing health care financing.  NM participates in the Affordable Care Act (ACA) Medicaid expansion, and this has been very beneficial to YSHCN who are 18 because it enables many of them to move onto the expansion coverage when they age out of Medicaid/Children’s Health Insurance Program (CHIP). For youth that are not eligible for Medicaid ACA or private insurance, the social workers transition these YSHCN onto the NM High Risk Pool at age 21. The High-Risk Pool offers a low-income premium plan that offers monthly premiums based on a sliding scale fee.

Behavioral health care has been identified as an increasing need for CMS clients, so the transition plan was updated this year to include questions around behavioral health such as depression, substance use, and suicidality. The CMS social workers also participated in a one-day training at the Head-to-Toe Conference, an annual conference for school personnel. The training, called ASPYR (Alliance for Suicide Prevention and Youth Resilience), focused on screening and assessment for suicide, building safety plans, and enhancing youth coping skills. This was in response to a recognition that depression, suicidality, and other mental health disorders can have a great impact on YSHCN, and staff requested assistance in becoming more effective and prepared to manage these issues.

Assisting youth with the transition to an adult health care provider can still be challenging in some areas of the state. CMS social workers have close working relationships with pediatric providers but feel limited in their connections with adult providers. The program continued to work on partnering more closely with the adult providers (either medical home or specialist) through a warm handoff to help bridge the gap between pediatric and adult providers and to improve the transition and transfer process. The goal was to increase satisfaction of the provider, youth, and family with the transition process.  CMS provides training and mentoring for social workers and medical providers to help providers understand the benefits of partnering with the CMS social worker as well as to help the social worker be comfortable in this role. Many communities have family medicine physicians as primary care providers, which can ease the transition process. This focus on individual community needs is the basis of a successful transition.

CMS social workers continued to receive training and support around transition planning with youth. The data system, CACTUS, has integrated the transition assessment and includes a care plan that is co-developed with the social worker and the youth to highlight areas of work that need to be focused on to assist with a successful transition. Regional staff meetings that occur monthly continue the focus on different aspects of transition and social workers earn CEU’s towards their social work licenses by attending these meetings.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

The CMS Management team continues to review the materials from Got Transition, the national center that supports evidenced-based transition methodology and other transition resources, and to incorporate questions and processes into the transition plan. As a best practice, the CMS statewide program manager attends webinars and trainings that are sponsored by Got Transition and shares this information with the CMS Management team. In addition, a CMS all-staff meeting was held in November 2018; transition for YSHCN was included in the curriculum.

CMS has contracted with Envision New Mexico for several years to assist with quality improvement activities and help the program address Title V performance measures. The contract for the third year with Envision was not renewed due to some changes in their leadership and a shift in their priorities and focus. A Request for Proposal (RFP) was issued in the fall of 2018 to continue the work that had been requested and the New Mexico Quality Improvement Partnership (NMQIP) was selected. Unfortunately, due to delays in contracting, the work is not scheduled to be started until May 2019, but this will be a three-year contract so there will be some longevity in the work.

Statewide/Policy Activities

The New Mexico Action Learning Collaborative (ALC) with the Association of Maternal and Child Health Programs (AMCHP) and the National Academy of State Health Policy (NASHP) set a goal in 2017-18 to review the Six Core Elements of Transition (policy, tracking, readiness, planning, transfer, and evaluation) and other state examples and submit recommendations to NM Medicaid during the public input phase of the Medicaid 1115 waiver renewal. The Six Core Elements were integrated into the written comments that were submitted to Medicaid on behalf of the ALC, as transition was a focus of the waiver application.

From this process, transition was identified by the MCOs and Medicaid as an essential component of care that needs to be addressed. The definition of transition in the waiver was quite broad and incorporated transitions such as juvenile justice, transition from hospital to home etc.   It did not specifically include youth transition to adult health care. Our goal was specifically to introduce the concept of medical transition as a best practice for YSHCN.  This is especially important for Medicaid and the MCOs considering that NM has expanded Medicaid benefits and many of these young people will be transitioning their Medicaid eligibility status at age 18. Ultimately, in 2018 the recommendations regarding transition for youth were incorporated into the Managed Care policy manual section 5.7.

CMS also continued to support the work of the Medical Home Portal (MHP) through participation on the advisory committee. The MHP does house information on transition and acts as a resource statewide. The MHP has received a lot of attention this year from early childhood stakeholders and the NM Pediatric Society. This has led to considerable efforts around outreach events in many communities to promote the use of the Medical Home Portal.

Collaboration and training with the Family to Family Health Information Center

A transition track at the annual family leadership conference sponsored by Parents Reaching Out (PRO) the NM Family to Family Health Information Center (F2F) was supported through funding and professional presentations to train families who have children and youth with special health care needs to be advocates for their children and improve understanding of the health care system. A second conference in Las Cruces, in the southwestern part of the state, was sponsored this year as well as the main conference in Albuquerque.  Families throughout New Mexico and some CMS staff members attend this conference.  CMS presented on transition using the Six Core Elements at the PRO conference in Las Cruces this year, which was well received by families in that region.

Transition training is also part of the annual family leadership conference sponsored by EPICS (Education of Parents of Indian Children with Special Needs), a parent organization that is geared towards Native American families. CMS continues to provide funding to EPICS as part of parent leadership training and helps the program serve as a liaison to Native American families in the state. These conferences attract over 400 attendees and includes families with CYSCHN from other Tribes across the country.  EPICS has started a webinar series on transition as well and CMS will continue to maintain partnership and collaboration.

Several years ago, CMS developed a DVD entitled “What Comes Next” which follows three YSCHN through the transition experience and highlights the need for interagency collaboration, which is still relevant today. A curriculum guide accompanies the film and creates a springboard for interaction and discussion with conference participants. The DVD and audience discussion during the presentation continues to raise numerous issues that parents had on issues such as guardianship and the role of their youth’s primary care physician in initiating transition planning. This feedback is helpful in planning subsequent training sessions.

In 2018, CMS again utilized the Project ECHO Health Care Financing clinics to highlight the needs of transitioning youth and elicit feedback on policies and practices that have been effective. The Project ECHO Clinic participants consist of a cross-section of providers and partners across the state including Children, Youth and Families Department, the MCOs, Medicaid, parents, advocates, the Center for Law and Poverty, legislators, medical providers, therapists, early intervention providers, behavioral health providers, among others. CMS social workers and other staff have presented transition-related cases to the ECHO participants to highlight the needs of YSHCN and seek input. There have been some personnel changes at Parents Reaching Out this year which has affected the regular scheduling of these clinics.