Priority Need: Improve Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN)

 

Strengthening the system of services for children and youth with special health care needs (CYSHCN) was determined as a state priority during the Title V MCH Needs Assessment conducted in 2015. Strategic partnerships with state agencies, community stakeholders, medical providers, and families laid the groundwork to capture the deficits and gaps in the system of services for CYSHCN. National data and statewide assessments further illustrated performance measures for the state which underperformed national averages and highlighted areas of needed improvement for the system of services available to families.

 

Georgia’s Title V MCH Section provides leadership and oversight, technical assistance and trainings, policy development and implementation, and professional development for the Georgia Autism Initiative, Early Intervention– Babies Can’t Wait (BCW), CYSHCN– Children’s Medical Services (CMS), and Early Hearing Detection and Intervention (EHDI) programs. These programs provide critical services and support for children and youth with special health care needs from infancy to young adulthood and their families. Working collaboratively across the CYSHCN programs within MCH provides enhanced opportunities to leverage resources such as subject matter expertise, funding, trainings, and family participation.

 

The Georgia Autism Initiative, BCW, CMS and EHDI programs are family centered and community-based and ensure early screening and diagnosis, access to a medical home and adequate insurance, as well as successful transition from pediatric to adult health care services. Services are offered statewide and administered through local child health programs available in Georgia’s public health districts. Competent nurses, social workers, care coordinators, service coordinators, developmental specialists, early intervention specialists, therapists, and medical providers are responsible for providing direct services to children and youth with special needs and their families.

 

Timely and ongoing screening and access to a continuum of medical care and early intervention services are critical to achieving optimal outcomes for children and youth with special health care needs. MCH Autism, BCW, CMS, and EHDI programs work together to ensure a comprehensive and seamless system of services for families caring for children and youth with special needs.

 

Overview of the CYSHCN Population Domain in Georgia

The largely rural makeup of the state, increasing population that outpaces the growth of the healthcare system, and the approximate one in four children, under the age of 18, living in poverty provides many challenges to offering comprehensive health and social services to Georgia children, youth and their families. According to the 2018-2019 National Survey of Children’s Health, 19.4 percent of children and youth, ages zero to 17, in the state of Georgia have a special health care need and approximately 48.1 percent of those children and youth live under 200 percent of the federal poverty level.

 

To ensure equitable and timely access to comprehensive services, including early screening, linkages to resources, care coordination, and transition planning for rural and underserved communities in the State, it is critical for families, public health, hospital systems, the medical community, and community-based organizations to collaborate and work towards actionable goals.

 

Within Georgia’s MCH programs, those goals include training and workforce development, strengthening family engagement practices, enhancing community partnerships, expanding telehealth services, and responding to the COVID-19 pandemic.

 

Systems of Services Overview

 

Children’s Medical Services (CMS)

The CMS program provides services to families caring for children and youth, birth to 21 years of age, through local programs available in all 18 public health districts. The CMS program partners with primary care providers, pediatric sub-specialists, healthcare vendors, state agencies, and community-based resources to coordinate timely access to health care services and supports for eligible CYSHCN and their families. Services include physical evaluations, diagnostic tests, inpatient/ outpatient hospitalization, medications and other medical treatments, post-op therapy, durable medical equipment, hearing aids related to the child’s eligible condition, as well as genetic counseling.

 

In the reporting year, pediatric specialty care clinics for children and youth living in rural counties were offered where pediatric medical specialist’s services were limited. The CMS program offered specialty clinics in nine public health districts and coordinated services with more than 30 specialty providers for face to face as well as telemedicine clinic visits. During 2020, approximately 327 clinic days were offered, 112 of those provided via telemedicine, and 2,806 children and youth served via the specialty clinics. Specialty clinics types included endocrinology, nephrology, cardiac, chronic lung, genetics, hematology/sickle cell, orthopedic, hearing, neurology, and cystic fibrosis.

 

CMS also serves as the payer of last resort for health care and medical expenses for families that do not qualify for the State’s Medicaid, SCHIP programs, or are without insurance during the time of CMS program enrollment. In addition to filling in the gap with health care coverage, CMS supported CYSHCN and their families by coordinating appointments, identifying resources, and assisting with social supports such as transportation and support groups. Helping CYSHCN and their families feel confident about managing their health care needs and navigating through complex social issues is an important goal for the CMS program.

 

Families enrolled in CMS received care coordination services by nurses and social workers. The COVID-19 pandemic continued to impact families, services, and the MCH workforce. Many CMS care coordinators were responsible for assisting with local COVID-19 activities, which included vaccine administration, COVID-19 testing, contact tracing, and coordination of local emergency call centers.

 

CMS implemented its continuity of operations plan to ensure families had access to essential services. The program focused on maintaining constant communication with enrolled families as well as those that may have been newly referred to the CMS program for services. Annual and six-month care planning, with the family’s verbal consent, was primarily conducted via the phone rather than by home or office visits. The primary focus of care planning addresses current and immediate medical and family support needs, promotion of well child visits and immunizations, and assistance with medications and medical supplies.

 

In the latter part of 2020, the CMS program expanded telehealth services to include care planning and eligibility determination for families. Cisco WebEx, the Department’s secure videoconferencing platform, is accessible to program staff to assist with improved engagement and coordination of services with new and existing families. The MCH program also received funds through AMCHP to support telehealth expansion, which allowed the local CMS programs to request assistance with equipment for families to readily engage with the Cisco WebEx platform and for staff to enhance current equipment with webcam and microphones.

 

Early Intervention

 

Babies Can’t Wait (BCW)

BCW is an early intervention program which provides a coordinated, comprehensive, and integrated system of service for infants and toddlers with special needs, birth to age three, and their families. BCW provides early identification and screening of children with developmental delays and chronic health conditions by using a multidisciplinary evaluation and assessment to determine the scope of services needed. BCW coordinates services to assist the family in developing a plan to improve the developmental potential of infants and toddlers with these health conditions. Early Intervention allows for support and resources to be built to assist family members and caretakers to enhance children’s learning and development throughout everyday learning opportunities.

 

Early intervention services are primarily delivered in the child’s natural environment and were impacted by the COVID-19 pandemic. The BCW program ramped up their teleintervention program capabilities to the 18 public health districts. Prior to the pandemic, BCW was only piloting teleintervention in four public health districts (Waycross, Valdosta, Dublin, and Gainesville). To prepare for the expansion, BCW in partnership with the Office of Telehealth and Telemedicine, equipped and trained 1000+ BCW providers on the WebEx telehealth platform. The telehealth platform along with weekly technical assistance calls, user guides, and resources allowed for an expedited process to prepare BCW providers to begin service coordination, special instruction, speech, physical, and occupational therapy for families via telehealth as a viable service delivery option. Families who did not have the technology to participate in teleintervention were provided services by phone, consistent with Georgia Medicaid and OSEP guidance regarding service provision via alternative means.

 

Georgia Autism Initiative

The Georgia Autism Services Initiative is a service delivery system which improves Georgia’s capacity for early identification, screening, diagnosis, intervention, and transition planning for children and youth, birth to 21 years of age, with Autism Spectrum Disorders (ASD). The Autism initiative achieves its core functions through education and awareness of early screening, linkages to early intervention services, referral for diagnostic evaluations, the promotion of standardized screening practices, addressing parental concerns, and best practices training.

 

The Autism Services Initiative works in collaboration with community partners and academic institutions to improve Georgia’s professional capacity to provide timely screening and diagnostic services for families. This includes an enhanced professional development infrastructure for medical providers, such as pediatricians, family physicians, physician’s assistants, nurse practitioners, and nurse managers. Evidence-based practices, such as academic detailing, is utilized during trainings. The trainings offered to medical providers is comprehensive and includes the following learning objectives: importance of early screening, listening to parental concerns, using screening tools during well-child visits, implementing standardized screening practices, billing for reimbursement, as well as referring children for diagnosis, early intervention, and community supports.

 

In the reporting year, DPH collaborated with Emory Autism Center (EAC). EAC implemented the BCBA Training and Supervision Program which allowed children with autism spectrum disorder to receive behavioral support services from supervised trainees completing their hours required to become Board Certified Behavior Analysts (BCBAs). This initiative has provided field experience for professionals pursuing a behavioral health national certification.

 

Early Hearing Detection and Intervention (EHDI)

Newborn hearing screening, known as the Early Hearing Detection and Intervention (EHDI), is a multi-partner screening and intervention system for children with hearing loss. The EHDI program maintains and supports a comprehensive, coordinated statewide screening and referral system. EHDI includes screening for hearing loss on all newborns in the birthing hospital; referral of those who do not pass the hospital screening for rescreening; referral of those who do not pass the rescreening for diagnostic audiological evaluation; and linkage to appropriate intervention for babies diagnosed with hearing loss.

 

The most crucial period for language development is the first year of life. Without newborn hearing screening, hearing loss is typically not identified until two years of age. Screening all newborns prior to discharge from the hospital or birthing center is essential for the earliest possible identification of hearing loss, and consequently, for language, literacy, communication, and academic potential to be maximized.

 

The state EHDI Coordinator facilitates technical assistance and training on implementing and maintaining a quality newborn hearing screening program to hospitals, primary care physicians, audiologists, early interventionists, and EHDI district staff. The EHDI program works closely with other MCH programs, such as C1st, CYSHCN, Part C, and Home Visiting. Like other MCH programs, the EHDI program is represented at both the state and local level. Each of the 18 health districts has one full time district coordinator with the responsibility of documenting and tracking newborns that do not pass the newborn hearing screen to their outcome. A dedicated follow-up coordinator in every public health district is directly related to improved timeliness of follow-up testing and reduction of loss to follow-up. Local follow-up coordinators typically form relationships with birthing facilities, pediatricians, audiologists, public health staff, and families to help facilitate rescreening, diagnostic evaluation, and enrollment into early intervention.

 

In the reporting year, the COVID-19 pandemic interrupted the system for EHDI. The impact on health care processes and the public health workforce created challenges in ensuring that newborn babies received an initial hearing screen by one month of age and diagnostic services by three months of age. EHDI implemented a Continuity of Operations (COOP) plan that provided guidance to District EHDI Coordinators during the COVID-19 pandemic, outlining essential services relating to 1-3-6 benchmarks, hospital responsibilities, and the importance of tracking available services at the district level. The COOP plan also outlined follow-up, documentation recommendations, and a framework to track cases impacted by COVID-19.

 

District EHDI Coordinators worked hard to educate families on the importance of newborn hearing screening and explored outpatient options to refer families for testing. Many health departments postponed in-home hearing screening and hearing screening clinics until further notice. Of Georgia’s 18 public health districts, seven District EHDI Coordinators were selected to assist with the COVID-19 response in their community, diverting time away from EHDI responsibilities. Other District Coordinators assisted with the COVID-19 response as needed but continued to focus most of their efforts on EHDI coordination and follow-up.

 

Systems Building

 

NPM 12: Transition to Adult Care for All Children

 

During the reporting year, the CMS Program partnered with stakeholders to improve Georgia’s systems of care and improve transitions for CYSHCN.

 

Outreach and awareness activities geared towards youth, families and community stakeholders

In partnership with Parent to Parent of Georgia (P2PGA), youth and parent/caregivers had access to annual workshops on preparing for the transition from pediatric to an adult model of care. The curriculum used to facilitate the workshops were adapted from the Waisman Center and had accompanying workbooks for families and youth to document their transition goals as well as activities to help youth practice independent health care skills such as setting appointments, scheduling transportation, and filling prescriptions. Six workshops in English and Spanish were funded through the contract with P2PGA. Due to COVID-19, most of the workshops were provided to families and youth virtually.

 

To assist with efforts in educating the public on transition, the CMS program revamped the DPH transition from pediatric to adult care webpage. The new webpage has materials targeted towards families, youth/young adults, and professionals with questionnaires and links to feedback surveys incorporated throughout the webpage to assess transition readiness and satisfaction with the transition information presented on the site. There is also the collection of transition materials specifically developed for families and youth. These materials are marketed at annual outreach events such as health fairs, expos, family nights, and conferences and are now hosted on the revamped webpage.

 

The CMS program also partnered with the Adult Disability Medical Healthcare to provide annual trainings to families on how to support the transition needs for youth and young adults with intellectual and developmental disabilities. In response to the COVID-19 pandemic, a virtual discussion was offered to families to provide strategies on how to respond and support their children’s behavioral challenges while at home and away from their normal school routines. The program provided a virtual support group discussion for young adults with developmental disabilities on tips to stay healthy, resources available, how to process thoughts and feelings related to physical distancing, and relieving anxiety due to COVID-19.

 

Training opportunities for health care professionals

Through continued partnerships with the Georgia Academy of Family Physicians and the Georgia Chapter of the American Academy of Pediatrics, the CMS program provided annual health care transition training opportunities to pediatricians, family physicians, and pediatric nurse members. Most of the trainings were offered virtually at the annual fall and summer conference meetings and via webinar.

 

Implementation of health care transition protocols and standards in public and private health care settings

The CMS program’s efforts to enhance transition planning for enrolled families and youth have been an ongoing process. CMS utilized Got Transition’s Six Core Elements of Health Care Transition principles and guidance to update the policies and procedures, which created a roadmap for care coordinators to effectively support youth/young adults and their parent/caregivers. To ensure implementation of the new policies and procedures, the program’s care coordinators received ongoing training, coaching, and monitoring to effectively work with families and youth/young adults with special health care needs.

 

During the reporting period, the program made strides to address identifying adult providers for young adults to transfer to an adult model of care. About 20 percent of the young adults, 18 years of age and older, enrolled for services have transferred to an adult model of care. Identifying adult providers for young adults with special health care needs is a major obstacle as there are not many adult providers available to care for young adults with special health care needs across the state. Resources shared included community clinics, not for profit clinics, federally qualified health centers, Medicaid services for adults, prescription assistance programs, and adult services available in the health departments.

 

The CMS program also supported and provided funding to the Adult Disability Medical Healthcare (ADMH), a non-profit organization that serves adults with intellectual and developmental disabilities. ADMH services are based on the patient centered medical home model that provides coordinated, comprehensive, compassionate care within a framework that focuses on the needs of the patient. The partnership with ADMH began in 2016. During that time, the number of funded transition clinics has increased from three to twelve annually. On an annual basis, more than 120 individuals are served. ADMH is housed within a family physician practice and transition clinics are supported by several disciplines, which includes family physicians, behavioral analyst, clinical social worker, medical assistant, and family/patient advocate. The number of physicians supporting the transition clinic has also grown from two to four physicians, which made an impact in the ability for the clinic to serve more patients.

 

CMS worked closely with ADMH to incorporate telehealth services in their standard of care. DPH provided telehealth technology and training to ADMH. The program is using the technology for program planning and connecting with the behavioral analysts for consultation services. With the impact of COVID-19, the ADMH telehealth services ramped up and the team provided their comprehensive transition clinic visit remotely with patients in their home. ADMH also connected with a psychiatry provider for telehealth consultations to add to their comprehensive visit. ADMH’s capacity to serve the community and individuals with developmental disabilities has grown considerably over the years and their model of care proves to be effective, compassionate, and supportive.

 

Children’s Medical Services

Strengthening the system of care for youth and young adults transitioning from a pediatric to an adult model of care was outlined in the 2020 Title V Needs Assessment as a priority for the state. The strategies outlined within the state action plan not only enhance transition services offered to youth and families enrolled in the state’s CYSHCN program, but also set the stage for statewide transition services transformation across multiple systems of services.

 

The CYSHCN Program works diligently to increase the number of youth and young adults enrolled for services that transition to an adult model of care by:

• ensuring transition policies and procedures are implemented,
• providing ongoing technical assistance to local district CMS programs on engaging and partnering with local adult providers,
• sharing community transition resources and trainings with local district CMS program staff, and
• engaging with youth and families for input and feedback on transition planning and services.

 

In the reporting year, the CYSHCN program continued to monitor and evaluate health care transition planning activities to ensure youth and young adults and their families were satisfied with services and their transition needs were being met. CYSHCN also worked to utilize existing medical condition specific transition planning protocols (i.e. sickle cell, diabetes) in program planning and outreach activities to better prepare youth and young adults who are transferring to an adult provider.

 

Training opportunities and targeted outreach efforts for medical providers and community partners continued on implementing the Six Core Elements of Health Care Transition and a health care transition communications plan was developed to share targeted transition messaging with youth and their families, medical partners, community-based organizations, health plans, and state agencies.

 

The CMS program coordinated pediatric sub-specialty care within nine public health districts and telemedicine clinic services are offered within seven of those clinic sites. More than 3,000 families received clinical services during this reporting period. And more than 700 of those families accessed services via telemedicine. Telemedicine specialty care types includes genetic testing, diagnostics and counseling, sickle cell follow up care, endocrine, pulmonology, pediatric neurosurgery, and nephrology services.

 

DPH’s Office of Telehealth and Telemedicine, in partnership with county health departments, oversee a robust telehealth network which encompasses Georgia’s 159 counties. The telehealth and telemedicine programs aim to improve access to healthcare services, address workforce shortages, and reduce health disparities across Georgia. DPH defines ‘telehealth’ as the use of electronic information and telecommunications to support long-distance clinical health care, health related education, and health administration. DPH defines ‘telemedicine’ as the use of medical information exchange from one site to another via electronic communication to improve the patient’s clinical health status.

 

Partnering with specialists and other telehealth entities has been an important driving force for program expansion. The CMS clinic site serves as the presentation/origination site. The CMS program facilitates reimbursement with appropriate Medicaid telehealth billing codes. All families accessing telemedicine have access to free language assistance services.

 

During the COVID-19 pandemic, CMS implemented its continuity of operations plan, which ceased home visiting services and implemented all care planning activities over the phone. Specialty clinical services also ceased in the early months of 2020 but resumed in May 2020.  Many of the specialty care clinics when resumed were held via telemedicine or telehealth with only a few clinic providers deciding to continue to offer face to face visits for follow up care to patients.

 

The following strategies were applied during the reporting year:

• Develop and implement a health care transition quality improvement and evaluation plan to assess the effectiveness and efficiencies of the Department’s health care transition program activities that impact youth and families.

• During this reporting period, there was a significant increase in the number of young adults that were reported to have transitioned to an adult model of care even though many families reported their lack of willingness to transition during the COVID-19 pandemic. With follow up into the data reported from the local CMS programs, it was identified that the process for collecting data for this measure varied across local programs. There were instances where the reports developed within the local program’s EMR systems did not match the physical medical charts, data was misreported due to a lack of knowledge on what this measure entails, and family and youth input into this measure was not clearly delineated in the care plan and progress notes. Efforts are currently underway to streamline data collection, reporting, and documentation associated with the transition to an adult model of care program measure.

 

Efforts include updating the program data definitions index, developing a tool similar to Got Transition’s registry form to more accurately collect transition data, and incorporating youth and family consensus on their transition to an adult model of care status via the care coordination plan and health care transition goals and action sheet.

 

• Provide technical assistance and guidance on health care transition planning for care coordinators supporting the Title V Children and Youth with Special Health Care Needs program.

• During this reporting period, transition trainings were developed and disseminated to CMS program coordinators who were recently hired, as well as refresher trainings for coordinators who have served in their roles for more than twelve months. The trainings identified areas of program improvement regarding health care transition reporting, data collection, and documentation.

 

• Implement condition specific transition planning protocols for adolescents enrolled in the Title V Children and Youth with Special Health Care Needs program.

• To further support this strategy, the transition program coordinator continued to forge partnerships with condition specific clinics and organizations including the Sickle Cell Foundation of Georgia, Emory Autism Center, and Memorial Health – Hematology and Oncology Clinic across the state to share resources, training opportunities for families and professional development for staff.

 

• Provide educational opportunities for youth and families to increase their knowledge on health care transition planning services and resources.

• The program engaged with community-based organizations, school systems, and academic institutions to promote transition training opportunities for families. Through partnerships with P2PGA and ADMH, annual educational opportunities were provided. With the impact of COVID -19, all the opportunities were held virtually, and participation increased significantly.

 

During the latter part of 2020, the program worked in collaboration with Emory Autism Center and Emory School of Nursing to offer families information on transition planning resources and tools specifically geared towards youth/young adults with ASD. The program partnered with the Henry County School district and their Exceptional Students Education Spring Resource Fair to provide families with health care transition information and resources.  

 

• Establish an advisory group to include youth, families, and providers to support practice improvement efforts for health care transition.

• Plans were made to establish an advisory group and outreach to organizations and clinics that provide transition to adult care services was conducted to learn more about their processes, protocols, and challenges.

 

The transition program coordinator engaged with the Emory Autism Center’s Individualized Transition to Adulthood Plan (ITAP) Advisory Board, Georgia Interagency Transition Council (GITC), and the Department’s Asthma Advisory Board to promote and apply the Six Core Elements of Health Care Transition. The GITC and ITAP collaboration is an opportunity for the program to outreach and partner with representatives within the school districts who are responsible for supporting children and youth who have an Individualized Education Plan. The GITC and ITAP is comprised of transition specialists from the school systems, parent mentors, vocational rehabilitation counselors, legal aid representatives, postsecondary education inclusive specialists, assisted living specialists, and assistive technology specialists. The GITC and ITAP outlined activities to provide more educational workshops for families to assist in their youth’s transition planning process. 

 

• Partner with adolescent health programs within the Department to implement best practices that support health care transition planning for youth and young adults with or without special health care needs.

• DPH’s partnership with the adolescent health program allowed opportunities for engagement with youth who may not have a special health care need. The adolescent health program has several youth councils across multiple public health districts who help to inform health policies and public awareness activities. The CYSHCN program began plans to coordinate several focus groups with the youth council representation to help inform the health care transition communications campaign. 

 

• Develop and implement a health care transition communication plan to share targeted messaging for transitioning youth/young adults with and without special health care needs from pediatric to adult care for audiences to include youth/young adults, families, health plans, medical providers, state agencies, and community partners.

• The goal of the Health Care Transition Communication Campaign is to develop effective marketing strategies to help inform youth, families, state agencies, community partners, health care systems, and health care providers on health care transition education and awareness, policies, services, resources, and tools. The Campaign will utilize representative focus groups from each target audience to assist with developing the strategies, recommendations, tools, electronic and print media for each phase for the Communication Campaign.

• Phase I: Youth Health Care Transition and Health Care Coverage. Develop marketing and communications tools for youth/young adults to understand the importance of taking charge of their health care, knowing their health insurance status, how to access health care coverage, and how to access health care if uninsured.

 

• Phase II: Health Care Transition Linkages to Resources and Services for Families. Develop marketing and communication tools for parent/caregivers to increase their awareness of the services and resources available to assist in their long-term planning and supports for their youth/young adult.

 

• Phase III: Health Care Transition Practice Tools for Physicians. Develop marketing and communications tools for pediatric and adult medical providers to begin operationalizing transition protocols for the adolescent well child visit. Also develop tools to help collect, assess, and disseminate information on providers that are implementing transition protocols, require technical assistance, and resources for their patients.

 

• Phase IV: Health Care Transition Tools for Health Plans and Care Management Organizations. Develop marketing and communications strategies and recommendations for health plans to utilize for youth engagement for maintaining coverage through 26 years of age, promote youth independence, and appropriate linkages for adult providers and health care resources.

 

• Provide continuing education opportunities on the six core elements of health care transition for medical and nursing students, pediatric and adult providers.

• In partnership with the Georgia Academy of Family Physicians (GAFP) and Georgia Chapter of the American Academy of Pediatrics (GA AAP), there were ongoing engagement with pediatricians and family physicians through webinars and virtual conferences, which highlighted transition to adult care best practices and resources. The program continued to provide an annual presentation to students at Emory School of Nursing to promote the role of nurses in the health care transition process.

 

To strengthen efforts to support health care transition practice transformation, the program partnered with six pediatric practices, an adolescent health practitioner, and GA AAP to explore the Six Core Elements of Health Care Transition framework and how it relates to the Bright Futures anticipatory guidance and the adolescent well child visit. These pediatric practices will learn about practical applications, resources, and assessment tools needed to help them improve in one of the identified core elements (Policy, Tracking/Monitoring, Readiness, Planning, Transfer of Care, Transition Completion) of the framework. Practices will receive one on one technical assistance to help them implement their identified transition goals, discuss practice member roles and responsibilities, and address practice challenges and barriers.

 

SPM 2: Improve Access to Specialty Care for CYSHCN (2016-2020)

 

Children’s Medical Services (CMS)

CYSHCN programs partner with health care providers and community-based resources to coordinate pediatric specialty and therapeutic care for CYSHCN and their families. To ensure that children and youth served in rural communities received appropriate and needed specialty medical and therapeutic services, CMS, BCW, and EHDI programs offered access to specialty services.

 

CMS offers specialty clinics in nine local public health district programs, which included face to face and telemedicine. CMS used telehealth and telemedicine to provide developmental and genetic services, asthma management, as well as endocrinology, nephrology, pediatric neurosurgery, pulmonology and sickle cell follow-up care. Families have freedom of choice to use informal or formal interpreters.

 

CMS worked with specialty clinics for over a decade through partnerships with pediatric healthcare systems, university systems, and private specialty providers. With increasing provider shortages, CMS recognized the necessity for more robust telehealth services to meet the needs of children. Telehealth services through CMS were first implemented at a pulmonology clinic in Valdosta, and slowly expanded to other counties. During this reporting period, there were seven district CMS sites capable of providing telemedicine services. The CYSHCN program continues to coordinate clinics with telehealth services and onsite providers. For example, the sickle cell clinic has onsite and telemedicine clinic hours. Only follow up appointments are offered via telemedicine. Initial consultations and diagnosis are only provided when the hematologist is onsite.

 

The sickle cell telemedicine program was established in 2016 through a partnership with Augusta University, the Newborn Screening program, and CMS. The telemedicine program provides follow up care for patients receiving hydroxyurea therapy as well as testing and genetic counseling for abnormal newborn screening results. Telemedicine clinics are scheduled every other month in Dublin, Albany, Valdosta, and Waycross. Utilizing telemedicine improves medical management of hydroxyurea therapy for individuals living with sickle cell disease in rural communities.

 

Since 2017, there have been additional telemedicine services pilot projects that have been established to improve access to audiological and therapeutic services for infants and children with special health care needs. The tele-audiology initiative is a partnership with the state EHDI program, the audiology department at Children’s Healthcare of Atlanta (CHOA), and the Waycross Health District’s EHDI program. The tele-audiology clinic is held once a month and is used to perform diagnostic testing on infants four to six weeks of age that received a referral resulting from the hearing screen performed at the birthing hospital. The tele-audiology clinic will serve one to two patients per month.

 

The tele-intervention pilot project for physical and speech therapy is offered in the Waycross Health District’s BCW program. An opportunity to connect therapy providers with their clients in their home via telemedicine is a breakthrough achievement. The tele-intervention pilot serves five families with physical therapy and four families with Speech language therapy. This pilot is an effort to address the shortage of therapeutic providers available to many families needing early intervention services for infants and toddlers ages birth to three years of age.

 

Current Year: Oct 2020 – Sept 2021

 

Priority Need: Increase the Number of Children, Both With and Without Special Health Care Needs, Who Have a Medical Home

 

NPM 11: Medical Home

Increasing the number of children with and without a medical home was identified as a priority need in the 2020 five-year needs assessment. The American Academy of Pediatrics specifies seven qualities essential to medical home care: accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective care. In the state of Georgia, only 40.3 percent of children and youth with a special health care need accessed care which met the medical home criteria. For children and youth, ages zero to 17, a greater percentage of non-Hispanic White (46.9 percent) reported having access to care within a medical home than non-Hispanic Black (38 percent). Furthermore, it is reported that only 12.4 percent of CYSHCN in Georgia received care in a well-functioning system compared to 14.1 percent of CYSHCN nationwide. The strategies and plans to improve access to a medical home for children and youth with special health care needs center on the following strategies:

• Expand the use of telehealth technology to improve access to audiological and early intervention services for children and youth with special health care needs.
• Facilitate efforts to educate families about telehealth as an option for care.
• Provide ongoing evaluation of the Department’s telehealth network to ensure pediatric specialty services meet the needs of families and patients.
• Develop and implement a quality improvement plan for Title V’s Children and Youth with Special Health Care Needs program to identify opportunities in which telehealth technology may be used to improve medical home access.
• To support medical home access for children and youth with special health care needs residing in rural areas, the Children’s Medical Services program provided access to pediatric specialty clinics in counties where there is limited access to pediatric subspecialists. Through the partnerships with hospital systems, private practice, and academic institutions, the CMS program provides onsite as well as telemedicine clinic services.

 

Priority Need: Improve Systems of Care for CYSHCN

 

NPM 12: Transition to Adult Care for All Children

 

Children’s Medical Services (CMS)

In the current year, strengthening the system of care for youth and young adults transitioning from a pediatric to an adult model of care was outlined in the Title V Needs Assessment as a priority for the State. The strategies outlined within the state action plan will not only enhance transition services offered to youth and families enrolled in the state’s CYSHCN program but also set the stage for statewide transition services transformation across multiple systems of services.

 

The CYSHCN Program works diligently to increase the number of youth and young adults enrolled for services that transition to an adult model of care by ensuring transition policies and procedures are implemented, providing ongoing technical assistance to local district CMS programs on engaging and partnering with local adult providers, sharing community transition resources and trainings with local district CMS program staff, and engaging with youth and families for input and feedback on transition planning and services.

 

The CYSHCN program continues to monitor and evaluate health care transition planning activities to ensure youth and young adults and their families are satisfied with services and their transition needs are being met. CYSHCN is also working to utilize existing medical condition specific transition planning protocols (i.e. sickle cell, diabetes) in program planning and outreach activities to better prepare youth and young adults who are transferring to an adult provider.

 

Continued training opportunities and targeted outreach efforts for medical providers and community partners on implementing the Six Core Elements of Health Care Transition is in progress and a health care transition communications plan was developed to share targeted transition messaging with youth and their families, medical partners, community-based organizations, health plans and state agencies.

 

In the current year, the following strategies continue to be utilized to facilitate transition to adult care for all children:

• Develop and implement a health care transition quality improvement and evaluation plan to assess the effectiveness and efficiencies of the Department’s health care transition program activities that impact youth and families.

• Provide technical assistance and guidance on health care transition planning for care coordinators supporting the Title V Children and Youth with Special Health Care Needs program.

• Implement condition specific transition planning protocols for adolescents enrolled in the Title V Children and Youth with Special Health Care Needs program.

• Provide educational opportunities for youth and families to increase their knowledge on health care transition planning services and resources.

• Establish an advisory group to include youth, families, and providers to support practice improvement efforts for health care transition.

• The program is establishing an advisory group within the current year and is currently outreaching to organizations and clinics that currently provide transition to adult care services to learn more about their processes, protocols and challenges.

• Partner with adolescent health programs within the Department to implement best practices that support health care transition planning for youth and young adults with or without special health care needs.

• Develop and implement a health care transition communication plan to share targeted messaging for transitioning youth/young adults with and without special health care needs from pediatric to adult care for audiences to include youth/young adults, families, health plans, medical providers, state agencies and community partners.

• Provide continuing education opportunities on the six core elements of health care transition for medical and nursing students, pediatric and adult providers.

• In partnership with the Georgia Academy of Family Physicians (GAFP) and Georgia Chapter of the American Academy of Pediatrics (GA AAP), engagement continues with pediatricians and family physicians through webinars and virtual conferences highlighting transition to adult care best practices and resources. The program also continues to provide an annual presentation to students at Emory School of Nursing to promote the role of nurses in the health care transition process.

 

Children’s Medical Services (CMS)

 

Families enrolled in CMS receive care coordination services by nurses and social workers. Beginning in February and March of 2020, the COVID-19 pandemic impacted the state, MCH workforce, and families. Many CMS care coordinators became responsible for assisting with COVID-19 testing sites and local emergency call centers. The remaining CMS staff continued to provide services and supports to families and CYSHCN.

 

CMS implemented its continuity of operations plan to ensure families had access to essential services. The program focused on maintaining constant communication with enrolled families as well as those that may have been newly referred to the CMS program for services. Annual and six-month care planning with the family’s verbal consent is conducted via the phone rather than by home or office visits. The primary focus of the care planning addresses current and immediate medical and family support needs as well as medications and medical supplies. During this time, the program also limited the standard disenrollment, financial eligibility, and cost participation procedures to ensure a continuum of services for families impacted by the state declared public health emergency. Many of the specialty care clinics are held via telemedicine or telehealth with only a few clinic providers deciding to continue to offer face to face visits for follow up care to patients.

 

The CMS program also worked with community partners and Georgia’s Family to Family Health Information Center to provide critical information and resources to families across the state caring for CYSHCN.

 

Early Intervention

 

Babies Can’t Wait (BCW)

Early Intervention, primarily delivered in the child’s natural environment, were impacted by the COVID-19 pandemic. The BCW program ramped up their teleintervention program capabilities to the 18 public health districts. Prior to the pandemic, BCW was only piloting teleintervention in four public health districts (Waycross, Valdosta, Dublin & Gainesville). To prepare for the expansion, BCW in partnership with the Office of Telehealth and Telemedicine, equipped and trained 1,000+ BCW providers on the WebEx telehealth platform. The telehealth platform along with weekly technical assistance calls, user guides and resources allowed for an expedited process to prepare BCW providers to begin service coordination, special instruction, speech, physical and occupational therapy for families via telehealth as a viable service delivery option. Families who do not have the technology to participate in teleintervention were provided services by phone, consistent with Georgia Medicaid and OSEP guidance regarding service provision via alternative means. 

 

Early Hearing Detection and Intervention (EHDI)

EHDI made progress in several key areas over the past year.  Some of the progress includes increasing collaborations and engagement with key stakeholders, completing modifications to the State Electronic Notifiable Disease Surveillance System (SendSS) database used for surveillance and tracking for new data elements, and expanding of the state’s capacity to provide teleaudiology services. 

 

Collaborations and engagement with stakeholders have flourished due in part to the framework for collaborations developed with the passage of legislation. The Official Code of Georgia Annotated (O.C.G.A) § 30-1-5, called the Language and Literacy Initiative, requires that DPH work with the Department of Early Care and Learning (DECAL), and the Department of Education (DOE) to improve educational outcomes of children who are Deaf or hard of hearing (DHH); developing an actionable individualized birth to literacy plan for every child who is DHH in the state from birth through the third grade. The goal of OCGA 30-1-5 as amended by Act 462 is to create an individualized, child-focused system that supports a seamless provision of services for children and families as they move through the seven key transactions necessary for age appropriate language and literacy outcomes. The task force identified seven key transaction points based on best practices that provide guidance for families on their journey from birth to literacy. Georgia children who are DHH will be able to achieve proficient language and literacy skills in significantly greater numbers when every DHH child can complete these transactions in a timely and coordinated manner.

 

Key transaction points include:

1) Newborn hearing screening

2) Diagnostic evaluation

3) Early Hearing Orientation Specialist (EHOS) visit

4) Early Intervention

5) Transition

6) Preschool services

7) School-based services

 

Data from the EHDI program are reported in the first three transaction points and positions. Since August 1, 2018, for each infant identified as DHH, the EHDI program requests a Georgia Testing Identification (GTID) number from DOE to facilitate monitoring progress of children once they transition from infancy and early childhood into DOE services. DOE assigns a GTID to every child enrolled in the Georgia public school system. Once assigned, the GTID remains with the student through high school.  This number allows educators and evaluators to identify and map the progress of every child enrolled in public school. Through the Language and Literacy initiative, DOE is now able to assign GTIDs at the time hearing loss is diagnosed (several years before school entry).  To date, 768 children who are DHH have received a GTID through Georgia EHDI requests. 

 

Collaborations with the newly developed Georgia Mobile Audiology (GMA) program are developing well during the first year of their program. Georgia’s Legislature and DOE recently funded GMA, which launched with limited services in 2020. GMA includes a fully outfitted mobile audiology unit that will travel to rural areas to provide screening, audiological care, early intervention, and hearing aids to children who are DHH.  Two pediatric/educational audiologists and a patient care coordinator will establish a routine schedule in underserved areas in Georgia. The focus of GMA is to provide gap-services in audiology to infants and school children in underserved areas throughout the state.  GMA is working with EHDI to provide outpatient follow up services for infants referred from newborn hearing screening, provide infant hearing assessments, and assist with professional development, training, and in-services for providers.  Discussions with individual districts are underway to capitalize on the services that GMA can provide based on the needs of the individual district. To date, four districts have coordinated with GMA for their services (Fulton, Valdosta, Rome, and Gainesville). 

 

Webinars, grand rounds, presentations, and virtual meetings have also been conducted to engage, educate, and inform stakeholders about the EHDI system and their role in ensuring that infants and families receive timely and appropriate services. Georgia EHDI has two Ear, Nose, and Throat Physicians engaged as Chapter Champions, Dr. Paula Harmon and Dr. Nandini Govil. Three webinars and grand rounds at four hospitals focused on the physician’s role in meeting EHDI benchmarks and promoting language and literacy for infants and young children who are DHH.  Webinars on using the audiology portal in SendSS have been conducted for audiologists in collaboration with GMA and the Georgia Pediatric Audiology Network (GPAN), and monthly teleconferences have been held with district EHDI coordinators to provide technical assistance and provide district updates on state EHDI activities.

 

Over the last year of the project, Georgia EHDI has worked with Information Technology (IT) to make numerous updates and modifications to the EHDI module within the SendSS database. The changes made facilitate reporting and tracking, performing follow up activities, and promote progress towards meeting the 1-3-6 EHDI benchmarks. In addition, the modifications provide a means of documenting program progress towards referring families of infants with confirmed hearing loss for family to family support and for deaf adult to family support.

 

While most babies are still receiving their initial hearing screen prior to hospital discharge, the COVID-19 pandemic has interrupted the follow-up system for EHDI on a widespread basis, particularly in non-metropolitan regions of the state. The impact on health care processes and the public health workforce has created challenges in ensuring that newborn babies receive an initial hearing screen by one month of age and diagnostic services by three months of age. EHDI implemented a Continuity of Operations (COOP) plan to provide guidance to District EHDI Coordinators during the COVID-19 pandemic, outlining essential services relating to 1-3-6 benchmarks, hospital responsibilities, and the importance of tracking available services at the district level. The COOP plan also outlines follow-up and documentation recommendations and provides a framework to track cases impacted by COVID-19.

 

Some of Georgia’s birthing facilities are screening mothers and infants for COVID-19 symptoms, and only conducting hearing screenings on non-symptomatic babies. Symptomatic families are discharged without a hearing screening and may have a future appointment scheduled at time of discharge. Some hospitals postponed newborn hearing screening altogether for varied durations, placing the responsibility of follow up solely on the parents and District EHDI Coordinators, although most have continued to provide all newborn screenings on healthy babies. Other hospitals continued to provide the initial hearing screening but ceased providing outpatient rescreening services.  Families that are discharged from the hospital without a hearing screening, a future appointment, or proper education on the importance of newborn hearing screening are unlikely to follow-up at a later time. In addition, some families have received education on the importance of screening but are electing to postpone testing due to fear of infection. District EHDI Coordinators are working hard to educate families on the importance of newborn hearing screening and are exploring outpatient options to refer families for testing. Many health departments have postponed in-home and health department outpatient hearing screening and hearing clinics until further notice. Of Georgia’s 18 public health districts, all District EHDI Coordinators have assisted with the COVID-19 response in their community, diverting their time away from EHDI responsibilities.

 

In several districts, audiology facilities have implemented a variety of schedules to provide care. Some audiology facilities, primarily in the metro Atlanta area, remain open and continue to provide services. Other facilities have implemented emergency only services or are offering sick/well visits during different parts of the day or implemented alternate schedules, setting a specific amount of time aside each week to conduct screenings on non-symptomatic babies at a specific age. Some facilities postponed testing until further notice. Teletherapy services are also being provided by some facilities, however, the services that are being provided varies by location.

 

Two early intervention programs, Auditory Verbal Center and Georgia Parent-Infant Network for Educational Services (PINES), and two support services, Georgia Hands & Voices (H&V) (family to family support) and the Deaf Mentor program (Deaf/hard of hearing adult to family support) have implemented teleservices for clients and other early intervention programs are conducting staff trainings to provide such services to families. EHDI strives to ensure that families receive the services they need during the pandemic.

 

Challenges: Several persistent challenges remain for Georgia EHDI as the program works to meet the 1-3-6 benchmarks for all infants who are DHH and their families. Loss to documentation/loss to follow up, turn over for staffing, and lack of institutional memory are all challenges Georgia’s EHDI program is experiencing. The public health emergency has impacted the Georgia EHDI program throughout the project period to date. Over past year, four new district EHDI coordinators were hired and over half of the 18 district EHDI coordinators had time allocated by their district to the COVID-19 response, with many still active in that regard.

 

Each of the challenge areas have been addressed by the EHDI program.  For example, to address loss to documentation and loss to follow up, Georgia EHDI worked with IT to automate the follow-up actions delivered to district staff when an infant is born out of the hospital. Once the notifications are received, district staff know to contact families residing in their district to educate them about the importance of newborn hearing screening and inform them about where follow up services are available. Engaging and educating providers is an ongoing strategy to address loss to follow-up and loss to documentation. Activities focused on stakeholder engagement during the project period included in-services, updates at stakeholder meetings, webinars to audiologists and physicians, postings on the Georgia Pediatric Audiology Network (GPAN), and outreach to individual practices to discuss Georgia EHDI policies and procedures. Further information regarding activities for stakeholder engagement is discussed in the third section of the Goals and Objectives section below. Similar activities accompanied each of the challenge areas in EHDI’s response to ensuring that infants who are deaf and hard of hearing and their families receive appropriate and timely follow up services.

 

Related Legislation: The Coronavirus Preparedness and Response Supplemental Appropriations Act as signed into law by the President of the United States on March 6, 2020 allows states broad authority to waive limitations on settings where members are eligible to receive telehealth and where telehealth services can be delivered during the emergency. All members with access to video or telephone communication may receive services in their homes to reduce exposure to themselves and others. Under the emergency declaration and waivers, these services may be provided by professionals regardless of patient location. The services must meet established medical necessity criteria relevant to the procedure or treatment.

 

Qualified providers deliver services from distant sites. During the COVID-19 state of emergency, providers may deliver medically necessary services in various settings including their homes or other settings in which the privacy and confidentiality of the member can be assured. Qualified providers should continue to follow all applicable licensure rules specific to their profession. Services delivered from distant sites will be billed using the provider billing address associated with the enrolled Medicaid practice or facility. Claims must be billed using the associated procedure code, GT modifier and place of service code to indicate telehealth delivery.

 

Systems Building

Developing the system of services for CYSHCN through workforce development, family engagement, community partnerships and telehealth/telemedicine services are critical components of current year efforts to better support the needs of CYSHCN and their families.

 

Workforce Development

The CMS program is committed to improving the partnership with families and has implemented the Family Engagement Learning Community for care coordinators supporting local district programs. The overall goal of the learning community is to shift the local public health district CMS program’s level of engagement further down the continuum from direct consultation to partnership and shared leadership with families enrolled for services.

 

Through an organized and facilitated learning community, the CMS workforce will gain knowledge, skills and resources to effectively prepare families to be partners in the health care decisions for their child. All 18 local public health district CMS programs participated in the twelve-month learning community. The learning community is comprised of four phases:

• Communication Phase: Aims to increase the number of strategies program coordinators use to share information with families and community partners.

 

• Family Activities Phase: Aims to establish and maintain opportunities for families to volunteer and connect with other families in the program.

 

• Advocacy/Leadership Training Phase: Aims to provide training for families on a variety of topics that promote leadership and advocacy skills for CYSHCN.

 

• Advisory Council Phase: Aims to establish a parent led advisory council for CMS that will continue to enhance the program structure and quality of services.

 

The learning community has strengthened community partnerships and increased the number of activities provided for families which include family appreciation, lunch and learns, miracle league baseball games, durable medical equipment fairs and conference attendance.

 

BCW is committed to increasing the percentage of infants and toddlers who are nearer or meet age expectations for positive social-emotional skills including social relationships. For the past several years, BCW providers, including Service Coordinators and Special Instructors, have received training and coaching to implement evidence-based practices for providing positive behavior supports to children identified with behavioral concerns.

 

Since 2015, there have been four Cohorts with more than twelve local BCW programs trained on the Pyramid Model to promote social emotional competence.

• Module One- (Family Coaching) 201 providers trained
• Module Two- (Parents Interacting with Infants) 170 providers trained
• Module Three- (Face-to-face, Train-the-Trainer) 111 providers trained

 

As a result of the Pyramid training, results show improved provider knowledge and confidence in using evidence-based practices. The Self-Assessment survey results show most trained providers use specific evidence-based practices most of the time or always to support parents and caregivers in improving their child’s social emotional skills. Observation results show that most of the providers are using specific evidence-based practices in their practice. Survey results show that families have increased understanding and confidence in their capability to support their child’s social-emotional development.

 

Georgia Autism Initiative, in collaboration with the EAC, implemented the BCBA Training and Supervision Program which allows children with autism spectrum disorder to receive behavioral support services from supervised trainees completing their filed hours required to become BCBAs. This initiative has provided field experience for approximately 12 professionals pursuing a behavioral health national certification. Approximately 200 children have received behavioral support services through this initiative.

 

The EHDI program has implemented two learning communities within the Augusta and Athens health districts to educate providers about the importance of meeting the 1-3-6 EHDI benchmarks (screen for hearing loss before one month of age, diagnose hearing loss before three months of age and enroll in early intervention programs before six months of age) and promoting care coordination in their district. Learning community members include DPH staff, audiologists, family members of children who are deaf or hard of hearing, hospitals, early intervention providers, and medical home providers. Learning Communities are targeting areas for improvement of service provision specific to their district based on the feedback received from the members and from performance measures shared by the state EHDI program.

 

Related legislation: A legislative Social/Emotional study committee that was formed last session finalized its recommendations, suggesting that a multi-agency tasks force be formed to begin working on improving service options for young children with social-emotional needs. DCH made available as of April 1, 2020, reimbursable CPT codes for use by licensed Social Workers and Professional Counselors enabling them to provide and be reimbursed for much needed behavioral health services for young children.

 

As a result of Act 462, it is easier for the EHDI and Part C programs to work more collaboratively with DECAL and the DOE to monitor and strengthen the systems that support early identification, intervention, language development, academic achievement for DHH children across the continuum of service they receive from birth to third grade.

 

Family Engagement

The Parents as Partners project was implemented to enhance and further support the system of care for CYSHCN. The CMS and BCW programs partners with P2P, Georgia’s Family to Family Health Information Center, to implement the Parents as Partners Project. Parents as Partners are parents of a child or youth who has a special health care need and provide support to other parents who have children with special health care needs as well. The Parents as Partners are paid as part-time employees of P2P and support local district child health programs and private pediatric medical practices. Parents as Partners provide information and resources, emotional support, and coordinate free training opportunities for parents served at their site.

 

Since the initiation of the project, there have been 17 Parents as Partners trained and supporting families with children and youth with special health care needs. The most recent Parent Partner was hired to serve a community-based organization supporting the refugee/immigrant population in Clarkston. The partnership with the Refugee Health section provided an opportunity to discuss the early intervention needs of the population and strategies. The Parent Partner along with ongoing stakeholder engagement and training opportunities offers help to better support the refugee/immigrant population.

 

P2P also maintains the Statewide Central Directory database and hotline funded by the CMS and early intervention programs and houses approximately 6,000 resources. The Directory allows users to search for information and referral resources or one on one assistance over the phone for families of children ages birth to 26 with developmental delays, disabilities and chronic health care conditions.

 

EHDI maintains strong collaborative ties with the family to family support program, the Georgia Chapter of H&V. EHDI contracts with H&V to provide support and facilitate care coordination through two of their programs: Guide By Your Side and Advocacy and Support Training. H&V leaders are included on the EHDI stakeholders/ advisory committee at state and district levels, are invited to review educational materials prepared for families, are enlisted to encourage families to seek follow-up services when their baby does not pass the newborn hearing screening, and are funded to attend the annual EHDI meeting sponsored by federal grants.

 

NPM 12: Transition to Adult Care for All Children

 

Health Care Transition Projects

 

During the reporting year, the CMS Program partnered with stakeholders to improve Georgia’s systems of care and improve transitions for CYSHCN.

 

Outreach and awareness activities geared towards youth, families and community stakeholders

In partnership with P2P, youth and parent/caregivers have access to annual workshops on preparing for the transition from pediatric to adult model of care. The curriculum used to facilitate these workshops are adapted from the Waisman Center and has accompanying workbooks for families and youth to document their transition goals as well as activities to help youth practice independent health care skills, such as setting appointments, scheduling transportation and filling prescriptions. Six workshops in English and Spanish are funded through the contract with P2P. Due to COVID-19, only two face to face workshops have been provided to families and youth. A contract extension was approved to allow P2P to facilitate the remaining workshops virtually.     

 

Training opportunities for health care professionals

Through continued partnerships with the Georgia Academy of Family Physicians and the Georgia Chapter of the American Academy of Pediatrics, the CMS program provides annual health care transition training opportunities to pediatricians, family physicians and pediatric nurse members.

 

The following trainings are offered during the current year:

• Transforming Your Health Practice into an Adolescent Centered Medical Home-Family Physicians Fall Conference
• How to Break Up with Your Adolescent Patients Gently- Ground Rounds
• It’s You, Not Them- Grand Rounds
• Demystifying Health Care Transition: The 6-Step Program for Family Physicians- Family Physicians Virtual Summer Conference

• Healthcare Transition for Adolescents and Young Adults with Autism- Family Physician Webinar
• Patient Privacy in Considerations in Family Practice- Family Physicians Webinar
• Achieving Successful Healthcare Transitions Despite a Pandemic- Pediatricians

 

Trainings are offered via face-to-face encounters at the annual fall and summer conference meetings as well as via webinar. During the current year, there will be five training opportunities provided with approximately 300 attendees.

 

Implementation of health care transition protocols and standards in public and private health care settings

The CMS program’s efforts to enhance transition planning for enrolled families and youth continued.  About 74 percent of transition aged youth that participated in the program receive ongoing transition planning and preparation.

 

Improve Access to Specialty Care for CYSHCN

In the current year, CMS partnered with health care providers and community-based resources to coordinate care for CYSHCN and their families. The CMS program used telehealth and telemedicine to provide developmental and genetic services, asthma-management, as well as endocrinology, nephrology, pediatric neurosurgery, pulmonology and sickle cell follow-up care. As the presentation/origination site, the CMS program was able to facilitate reimbursement with appropriate Medicaid telehealth billing codes.

 

CMS has worked with specialty clinics for over a decade through partnerships with pediatric healthcare systems, university systems and private specialty providers. With increasing provider shortages, CMS recognized the necessity for more robust telehealth services to meet the needs of these children. Telehealth services through CMS were first implemented at a pulmonology clinic in Valdosta, in South Georgia, and slowly expanded to other counties throughout the state. During this reporting period, there were seven district CMS sites capable of providing telemedicine services.

 

The EHDI program is also working to address provider shortage issues. A large geographical area of the southern portion of the state does not have access to audiologists with the expertise and instrumentation necessary to perform hearing assessments for infants. In effort to reduce some of the health care disparities, Georgia EHDI and audiologists at CHOA have implemented a tele-audiology program at 2 facilities for providing hearing assessment services for infants under 4 months of age who referred their newborn hearing screening. Waycross and Valdosta health districts now have personnel on site trained to connect babies and their families to the skilled pediatric audiologists at CHOA on monthly schedule.

 

The BCW program’s teleintervention pilot program began more than a year ago in the Waycross health district. Teleintervention offers an opportunity to connect therapy providers with their clients in their home via telemedicine. This pilot project is currently serving families with physical and speech therapy via telehealth. This pilot is an effort to address the shortage of therapeutic providers available to many families needing early intervention services, especially in the rural areas of Georgia. The project continues to focus not only on service delivery availability but also how to incorporate providers into the team structure remotely. With the impact of the COVID-19 pandemic, the pilot teleintervention program has expanded to all providers within the BCW network and to all 18 public health districts. BCW has successfully trained over 1,000 providers to provide teleintervention.