Children’s Medical Services (CMS) protects and promotes the health and wellbeing of Florida’s children, including children and youth with special health care needs (CYSHCN). CMS’s aim statement is for all of Florida’s children to be safe, healthy, and thriving where they live, learn, and play. In Florida, 46.1 percent of CYSHCN have public health insurance, as compared to 36.4 percent nationwide, with 44.2 percent reporting private insurance, 5.3 percent reporting a combination of public and private insurance and 4.3 percent uninsured. In addition, 11.6 percent of Florida’s CYSHCN report having received care in a well-functioning system representing a four percent increase from Fiscal Year (FY) 18-19 data, with the reported nationwide average of 14.4 percent.

To influence National Outcome Measure (NOM) 17.2, the percent of children with special health care needs, ages 0 through 17, who receive care in a well-functioning system, CMS’s framework includes five main initiatives that are woven into the findings of the annual report in no order. The initiatives include: 1) transform pediatric practices into patient-centered medical homes (PCMH), 2) build capacity of pediatric primary care providers to treat common behavioral health conditions, 3) address community integrated system building in Florida's diverse regions, 4) improve access and quality through contracts with specialty networks that have condition-specific expertise (e.g., diabetes, sickle-cell disease), and 5) collaboratively partner with CMS Health Plan, a medical managed assistance plan for children and youth with chronic or complex special health care needs.

Increased access to medical homes for CYSHCN is a continued priority need and is reflected in National Performance Measure (NPM) 11. Most of the corresponding evidence-based strategy measures (ESMs) and supporting strategies and activities continue to align, and include an intentional focus on workforce, essential public health services, and family partnerships. However, ESM 11.1 will be inactivated as discussed below.

ESM 11.1 was the number of partners serving CYSHCN in Florida receiving education or technical assistance about the PCMH model and related topics that impact CYSHCN. The objective was to increase this unduplicated number annually, with the baseline of 730 stakeholders and this year’s target of 2,340 stakeholders. The intended workforce for this measure had natural attrition, and needed to pivot, to address priority organizational needs. Subsequently, 236 educational or technical assistance activities were completed in 2022. As this measure only reflected a quantity of effort, and did not address quality or effect, including if anyone was better off because of receiving education or technical assistance, this ESM will be inactivated.

With the prevalence of asthma related emergency and hospital visits rising, the Title V CMS program, as a convener, leveraged resources within the Department’s Bureau of Chronic Disease Prevention and facilitated the creation of a workgroup of stakeholders, including specialists and primary care providers. The group developed a one-page asthma weblink resource guide for providers, families, and community partners. The group also constructed an asthma management in action plan for providers, inclusive of a resource guide with evidenced based interventions and a Microsoft PowerPoint slide deck containing valuable provider information. The asthma home visiting program leveraged resources from Simply and Sunshine Medical Managed Assistance (MMA) Plans to expand the home visiting capacity of the program, with 31 client referrals received as of January 2023. In addition, an asthma education pilot program for high-risk, uncontrolled, asthma patients aged 5 through 18 years, was initiated in January 2022. Notably Lakeland, Florida, has been designated as the fourth asthma capital in the United States with the highest incidence of asthma emergency department visits. Dr. Joi Lucas in Lakeland is now currently participating with the asthma coalition pilot program. Dr. Joi Lucas is advancing an initiative with school nurses, the asthma coalition group, pediatric practices, and stakeholders regarding the asthma home visiting program. The asthma pilot program has been extended to December 31, 2023, to obtain more referrals. The Pulmonary Group at Florida State University (FSU) is collaborating with the asthma program to identify resources on strategies for accessing schools regarding their asthma projects. 

Strategy 11.1 includes significant activities which engage several of CMS’ major initiatives and focuses on community integrated system building and improving health care access and quality. An informed strategy for community integrated systems approach includes the integration of multisector service systems focused on the conditions of daily life. CMS developed a framework and partnered with two existing community programs to implement its Regional Network for Access and Quality (RNAQ) pilot model. This model includes core competencies of public health and the Standards for Systems of Care for Children and Youth with Special Health Care Needs, version 2.0., with the goal to improve access and quality for children in their community. While in different stages of early implementation, recent efforts include moving toward collaboration within the two pilot programs. For the upcoming year, both pilot programs have a joint long-term (and across programs) aim to decrease negative health impacts and improve the care provisions to CYSHCN. Results from one of the RNAQ’ s needs assessments indicated a troubling trending increase in their county’s teen suicide rate, exceeding the state rate. Their follow up activity included conducting a specialized training in the assessment and management of youth with depression or suicide risk. This was accomplished with over 330 primary care providers participating virtually. Additional activities included improving primary care providers’ (PCP) ability to manage CYSHCN with behavioral and mental health conditions, with trainings provided to a minimum of 12 PCPs and the expansion of medical-behavioral home concept to three additional practices in their catchment area. These activities were not without reported challenges, including lack of provider engagement, which will be addressed in the upcoming year. A premier aim of the Orlando RNAQ was to increase the identification of needed supports and services with the use of a tool developed by Nemours Children’s Hospital in their Medically Complex Coordination clinic, from a baseline of 0 percent in June 2021 to 50 percent by December 1, 2022. Challenges with information technology/software issues contributed to delays in disseminating the tool electronically as planned. Turnover in staff has subsequently stalled the project. CMS Title V will continue to collaborate and support the Orlando RNAQ in the upcoming year.

In the pursuit of a well-functioning system that serves CYSHCN in Florida, integrated system building work included an intentional focus on health care access and quality. CMS Title V leveraged condition-specific expertise (e.g., diabetes, sickle-cell disease, asthma) with existing specialty network contracts within tertiary care centers across the state. These contracts previously focused on direct care services; however, they were reengineered with the Standards for Systems of Care for Children and Youth with Special Health Care Needs, version 2.0 as a framework. Contract language now includes Title V CYSHCN priorities including implementation of a quality-of-life measurement tool, completion of the CYSHCN single organization assessment tool, and continues quality improvement for identified needs. Our vision includes these individual tertiary-care, condition-specific programs, and organizations across the state, coming together for collective impact as a collaborative of Statewide Networks of Access and Quality (SNAQ). Guiding principles include a learning action network focused on data driven quality improvement (QI) activities that are inclusive of the family voice. The aim is that all CYSHCN, regardless of insurance status and geographical location, have access to a high-quality system of care. Some lessons learned are to move beyond counts and include more results-based accountability reporting to capture not only quantity of effect, but more importantly quality. While CMS works on creating more uniform data collection and robust reporting, active dialogue about the need for these changes is occurring to help facilitate buy-in and readiness toward these changes.

State action plan activity 11.1.a.vi works to engage various provider groups serving CYSHCN through a learning collaborative approach to share best practices, individual and joint quality improvement projects, and focus on activities to strengthen the system of care for CYSHCN and their families. Dedicated to a culture of learning and continuous QI, CMS Title V partnered with the National Institute for Children’s Health Quality (NICHQ) to craft a formal QI initiative across the SNAQ programs and implement a Learning Action Network (LAN). These 32 tertiary-care/academic programs represent seven condition-specific programs (behavioral health, craniofacial, endocrine, chronic kidney disease, hematology-oncology, HIV/AIDS and pulmonary). They partner with peers from other organizations to collaborate on QI projects. LAN objectives are to build and support motivation for QI, facilitate continuous QI, foster collaboration, shared learning, and action toward improvement. Through CMS and NICHQ co-design and co-facilitation, the goal is to maintain a sustainable LAN. The LAN initiative is a catalyst in the transformation of these historically siloed programs, groups, and organizations into a statewide network focused on improving health care access and quality.

QI teams are engaged in training, coaching, and peer-to-peer learning in QI methods through a series of quarterly virtual learning sessions, monthly interprofessional meetings, and “office hours” for one-on-one technical assistance, all supported by an online platform resourced for easy data sharing collaboration amongst stakeholders. QI teams are guided in rapid cycle tests of change for small scale developments through use of Plan Do Study Act and other models for measurable improvement. Results thus far include 32 institutional QI projects, and nine condition-specific SNAQ-wide (i.e., across institutions) projects. Most notably since the inception of the project, inclusion of patient or family leaders in the quality improvement initiative planning, design, and evaluation has risen from a baseline of 10 percent (n=3) to 55 percent (n=17), with the goal of 75 percent by 2025. In the last learning and action cycle, SNAQs received skill-based training on results-based accountability, including the four categories of measurement. Breakout activities have them look at the current QI outcome and process measures that they had developed for their statewide SNAQ project, determining where they fit in the measurement quadrants, and what outcome measures they might consider now or in the future to demonstrate quality of effect represented by the percent of is anyone better off.

The next phase of this project will focus across all 32 SNAQ teams united on quality improvement activities, including quality measurement, that are specific to transitioning of youth from pediatric to adult health care systems including planning, readiness, and verification of successful completion.

As part of the statewide priority initiative to increase access to PCMH and primary care, recognized family partnership is a focused area of inclusion. ESM 11.2 reports the percentage of caregivers of CYSHCN in Florida who always perceive themselves as a partner in their child’s care, with the objective to increase this number by one percent annually from the identified baseline for this reporting year. Utilizing the 2020-2021 National Survey of Children’s Health Data Indicator 4.14 and whether a decision was needed (N=184), 83 percent (n=152) reported they always or usually were included in shared decision-making. CMS also developed an internal survey to disseminate to family partner organizations. This survey was disseminated at a Family Café conference with 67.74 percent (N=63) reporting they worked with their child’s providers in shared decision-making to create shared care plans for their child(ren). Additionally, 56.99 percent of respondents maintained connectivity between care teams by sharing health information across providers (N=63), as well as asking questions regarding their child(ren)’s care (N=63) and listening and following provider medical advice (58.06 percent, N=54). Opportunities for stronger family partnerships within care teams can focus on optimizing the ease and comfort in which family partners are able to acknowledge and raise concerns with current medical recommendations. In this area, only 44.09 percent (N=41) of respondents felt comfortable having these types of discussions with their providers.

Strategies 11.2.1 and 11.2.2 also focus on family partnership. 11.2.1 details the creation of a cohort of CYSHCN caregivers that are educated and equipped to be a family partner in their child’s care, while 11.2.2 aims to leverage work with existing and potential partners to increase opportunities for CYSHCN families to become family partners at the individual, community, and systems level.

The Florida Family Leader Network (FFLN) was envisioned with the aim of elevating and supporting families through networking and leadership skills development. The goal is to produce family leaders educated and equipped to be partners in their child’s care and if interested, advance them to community and systems work. The FFLN holds an annual summit and quarterly learning activities and has over 280 members across the state of Florida and beyond. Survey data from the 2022 summit, with 115 evaluations received out of 147 participants, indicated that 86 percent strongly agreed or agreed that the information learned at the summit will increase their ability to engage as a partner in their child’s care with their primary care provider, an increase of 10 percent from the year prior. In addition, 90 percent reported that the information they learned will increase their ability to be involved as a family partner or leader at the community level, an increase of two percent from the previous year. Likewise, 85 percent reporting an increase in their ability to be involved at a systems level (i.e., regional, state, national, organization or health care system), also a two percent increase from last year.

Specific to the Title V workforce, inclusive of designated Family Leaders, monthly meetings are held to optimize awareness and promote use of materials and information garnered from various partners related to patient/family engagement and partnership, with an aim to enhance provider and stakeholder outreach efforts. A few examples of resources are the Florida’s Family Voices’ state affiliate weekly newsletter, the Family Network on Disabilities monthly newsletter, the Family Voices’ Effective Family Partnerships website resources, and their new Telehealth Toolkit for Families, as well as the American Academy of Pediatrics’ (AAP) Bright Futures resource for preventive care screenings.

In previous year’s work, the statewide family leader researched and provided multiple evidence-informed resources regarding patient and family engagement, with a focus on how it relates to involvement at the clinical level for quality improvement efforts. These resources were then posted on a shared interdisciplinary platform for the SNAQs. In follow up, the statewide family leader developed a Patient and Family Engagement Roadmap or “how to” guide, inclusive of current evidence-informed journal articles, toolkits, and other related resources. The roadmap is for all team participants in the SNAQ LAN and can be utilized in other capacities, on both the provider and caregiver side, for other program initiatives. Aptly, the new Patient and Family Engagement Roadmap was featured in a well-attended Association of Maternal and Child Health Programs (AMCHP) workshop during their annual conference this year and the year before.

The CMS statewide family leader is an AMCHP Family Delegate for Florida and newly alumnus of AMCHP’s Leadership Lab. She participates in a multitude of state and national level health care, disability, and family leadership boards, councils, committees, and workgroups. Within each of these settings, Title V programmatic information, surveys, and resources related to all state initiatives, including those tailored to caregiver and patient provider engagement and partnership are disseminated. Regional family leaders uphold connections with local community groups within their areas and accomplish similar goals. The statewide family leader, as well as all the regional family leaders, are members of the Title V-funded FFLN. As part of their engagement in this network, they share state and national resources related to patient- and family-centered care, behavioral health, health care transition and other topics related to caregiver support and engagement. This continuous activity of multitiered engagement and shared learning affords CMS access to innovative and pioneering resources from formative grassroot organizations, as well as well-established and highly regarded entities. The material and resources shared among partners and colleagues become far-reaching through intentional dissemination to families and other stakeholders.

For NPM 11, CMS partners with the University of Central Florida’s Health Advancing Resources to Change Health Care (UCF HealthARCH), Florida’s only designated National Committee for Quality Assurance (NCQA) partner in quality. UCF HealthARCH provides one-on-one technical assistance and support to pediatric practices regarding PCMH practice transformation, preparing them for NCQA Certification. Over the past six cohorts (2017-2022), 81 practices have received PCMH Recognition, this includes 132 physicians and 88 mid-level providers, with 72 practices in process. The goal is to have 224 PCMH recognized practices by the year 2025.

ESM 11.5 was created to track the percentage of providers in underserved geographic areas that received formal technical assistance through UCF HealthARCH and become designated PCMHs, with the performance objective to increase the percentage of underserved geographic areas that have at least one pediatric practice that is designated as a PCMH by 20 percent at the end of the five-year period. Challenges, referenced below, contributed to not being able to complete the measurement of this objective at the time of this report. However, measurements will occur for subsequent reporting years.

Strategy 11.3.1 is to create a pipeline of providers that are engaged in enhancing their practice sites based on the foundational principles of PCMH. Activities under this strategy included geo-mapping current pediatric PCMH’s services to children and youth with special health care needs (CYSHCN), to identify underserved communities and populations, and to monitor and evaluate the numbers and geographic locations annually. Title V regional specialists conducted outreach to identify practice type, number of providers, PCMH certification, and patients served. This information was then mapped geographically to identify gaps in access to care. Over 56.24 percent of practice type data revealed that 30.56 percent of providers identified as Family Practice and 25.68 percent as Pediatrics. Other practice types included: Internal Medicine (16.79 percent), Federal Qualified Health Centers (13.63 percent), multi-specialty (13.20 percent), and Free or reduced-cost health clinics (0.14 percent). Per capita income was overlayed on the provider map and demonstrated that lower per capita income areas were less populated and had little or no providers. While first generation PCMH maps were created, it was subsequently determined that transitioning to a different mapping software would be more advantageous, providing the ability to overlay various mapping activities such as behavioral health resource maps and adding a vulnerability population index, entitled children’s needs index, has been finalized. The updated maps, using R studio and pulling from active data bases such as Medicaid, have been instrumental in informed decision making. For example, in looking at the National Survey for Children's Health data related to access to a PCMH, there is a gap in black family access as compared to white and Hispanic families. The geo-maps were then used to help ascertain areas with concentrated black populations, and limited PCMH’s. This information aided in the determination of areas where focus groups could be facilitated, with the aim to learn family perspectives on PCMH principles, and provide PCMH education and resource dissemination to those community providers.  

The new geo maps have population characteristics that can be aggregated or separated, along with various layers of provider or resource maps which serves as a valuable visual communication tool for informed decision making. Comprehensive geo-mapping data includes publicly available census tract level data including population characteristics (such as race, poverty status), and a children’s need index (comprised of deficits or limitations such as cognitive, visual, hearing, self-ambulatory, etc.). Additional various maps such as pediatric/family practices, PCMH designation, behavioral health providers, and children’s hospitals or schools can then be overlayed onto the base map. This comprehensive enhanced data set has given the program pause in how it originally intended to measure “underserved geographic area”. Once the definition is reconciled and finalized, the collected PCMH zip code data from those practices that are PCMH accredited, will be added to determine the overall percentage increase of the newly defined underserved area.  

In working to create a pipeline of providers that are interested in PCMH transformation and partnering with UCF HealthARCH, CMS Title V regional specialists provided community educational outreach to 843 providers. For providers that indicated interest, CMS Title V linked them to UCF HealthARCH to complete a PCMH readiness assessment. The readiness assessments are used by UCF HealthARCH to determine appropriateness for one-to-one PCMH transformation assistance. For the last two years, the recruitment phase for the upcoming cohort has proven challenging, even as primary care providers continue to report interest in the initiative. As a result of competing priorities, the state was targeted for PCMH transformation recruitment, and not just underserved geographic areas as originally intended. In addition, for the practice cohorts already engaging with UCF HealthARCH, it has taken longer than usual to successfully complete the PCMH transformation process. As providers achieve their PCMH recognitions and accreditations, their practice locations will be geo-mapped and those in underserved geographic areas will be tracked for the needed data in this area. This year, specialty providers who also perform primary or secondary primary care in underserved areas with desire to achieve PCMH recognition or accreditation, are also being recruited. The engagement of this provider type will help inform future efforts focused on medically complex clinics for CYSHCN. 

The planned implementation of another LAN to support the population health model utilization within UCF HealthARCH’s PCMH practice transformation services was delayed. LAN specifics include utilization of PCMH readiness assessments to gauge appropriateness among PCMH transformation cohort activities, which will either include one-on-one PCMH transformation technical assistance with UCF HealthARCH or participation in the co-facilitated CMS/UCF HealthARCH LAN. The LAN model includes six to eight virtual trainings to introduce and review the six core components needed to become a PCMH. Open “office hours” will be offered as an opportunity for providers to engage and receive additional assistance. Ultimately, the goal of the UCF HealthARCH/CMS LAN is to provide a space where providers can learn from UCF HealthARCH and other participating practices’ experiences. This encourages LAN providers to start working toward PCMH transformation readiness to become aptly able to enter into the next one-on-one PCMH transformation cohort. It is anticipated that provider participation in the LAN model will also shorten their one-on-one PCMH transformation technical assistance, allowing UCF HealthARCH to serve more providers over time.

Cognizant of the increased demand for mental health services, and steadfast in partnership to build a well-functioning system that addresses conditions of daily life and barriers to medical care, CMS realized the dire need to intersect primary care with tenants of behavioral health/mental health management. Continued conversations encouraged UCF HealthARCH to initiate development of a comprehensive report that will detail the benefits of achieving NCQA’s distinction in BH integration within PCMH-recognized practices. In addition, they will develop a one‐page informational flyer for providers that details the BH distinction, particularly the value it adds to comprehensive care for providers and patients, as well as related information for future dissemination.

Transition for CYSHCN continues to be an important inclusion strategy that is embedded in Florida’s CYSHCN Action Plan. ESM 11.4 measures the Percent of youth with special health care needs who report having successfully transitioned from pediatric to adult health care providers/practices. Planning is in place to capture quantitative and qualitative data through survey’s and focus groups at two upcoming annual conferences, as well as with opportunities described below. 

Strategy 11.4 details collaboration with other Title V CYSHCN Programs and internal Department colleagues to identify and implement activities that will increase the numbers of family practice and adult providers that serve young adults with special health care needs. CMS Title V convened a partnership with Got Transition® and the CMS Health Plan, for a 12-month pilot program aimed to increase the percent of 18 to 20-year-old members who transition from a pediatric provider to an adult care provider through a value-based payment model. This small (N=10) test of change incorporated the coordinated exchange of medical information, a plan of care, a joint telehealth visit with the member/family, pediatric and adult care provider, and facilitated integration into adult care. Providers received an enhanced fee-for-service payment with reimbursement at 100 percent of the Medicare fee schedule for both pediatric and adult providers. CMS health plan members received a direct-to-consumer payment incentive of a $25 Visa Prepaid card for attending each scheduled appointment within the first 6 months after the member transitioned to an adult care provider. Outcomes included 87.5 percent of young adults stating they were very satisfied with their experience with their new adult doctor. Provider teams reported one of the values of the pilot program was establishing a good working relationship between offices, which helped make the transition process easier for all parties. Notable challenges included the scheduling of joint telehealth visits which contributed to delays in access and timely transition.   

Recognizing the need and value of purposeful planned transition, the CMS health plan added a dedicated transition care manager to the care management team to provide team support to ensure members have a smooth transition to adulthood, by mitigating disruption in services. The transition care manager supports the care manager and provides training, guidance, as well as monitoring the effectiveness of the transition planning. Last year the transition care manager received 313 referrals to assist members with transition of care.

In a recent CMS survey, 60 percent (n=37) of parents with transition-age-youth with special health care needs reported that their primary care provider was not actively working with their youth to prepare them for adult care. CMS Title V specialists work to provide transition outreach or education activities (N=71), which include the promotion of Got Transition’s Six Core Elements of Healthcare Transition. In addition, all condition-specific (e.g., HIV, Pulmonary, Diabetes) SNAQ program participants are provided transition education. As part of their contract deliverables, all SNAQ programs submit their transition processes and policies for review through the lens of the Six Core Elements of Health Care Transition. Utilizing program evaluation methodology, these processes and policies are benchmarked and scored. Plan-Do-Study-Act cycles, and other quality improvement strategies, allow for score tracking annually and the inclusion of CMS-provided technical assistance to improve scores. It was noted that an area of improvement across all contracts is to assess successful transition after youth have landed safely within the care of an adult provider. Creating an “exit interview” would be sent to the youth after the initial appointment with their new adult-care provider to help assess this measure. Additionally, all SNAQ programs are required to create an aggregated report that provides data regarding utilization of the Got Transition’s Six Core Elements of Health Care Transition 2.0 Tool Kit components. In review of these reports, it was determined that key definitions and standardization would strengthen the quality of data captured. For example, aggregated utilization reports include a headcount of youth who received transition-related services; however, these reports lacked a comparative count to determine what percent of total youth successfully received these services. This current strategy also failed to capture the quality of SNAQ programmatic efforts with transitioning youth, yet alone the effect or extent of services rendered. CMS Title V is working with our SNAQ programs to develop a proper reporting tool that supports standardized data across all SNAQ programs and leverages more meaningful methods for results-based accountability. Standardized data lends itself to the creation and utilization of an electronic data dashboard. Currently, two of the SNAQ programs are focused on health care transition as a quality improvement project and results will be shared with other SNAQ programs for collective learning. Separately, one of CMS’s contract programs include the nationally recognized Jacksonville Health and Transition Services program (JaxHATS), who, through CMS Title V, continue to provide high-quality, CYSHCN-sensitive, clinic services and skill-building strategies to transitioning youth. This year updates to their contract language include the use of a health care transition registry and quality of life survey, to better measure the effort and effect over time.

CMS is transitioning its long-time contracted state transition clearinghouse program, Florida Health, and Transition Services, into a CMS-operated educational portal available through the Florida Department of Health website. Plans include revisions to CMS’s current website to support this vision and enhance public interface, with rebranding of the transition program. In addition, a new youth to adult transition course for professionals has been developed and is ready to be launched in a hosted platform. This project was facilitated by CMS Title V in collaboration with Florida’s Maternal Child Health (MCH) partners and transition experts. Participants can register and take the four course modules in any order they would like. They are asked to complete a post-test for knowledge check. Once they complete all four post-tests and the course evaluation, a certification of completion is provided. There is a course companion guide, a dedicated webpage accessed from the rebranded site, and will house hyperlinks or actual downloads of the resources mentioned throughout the course modules.

One of Florida’s State Performance Measures is to increase access to mental and behavioral health service. This is aligned with NOM 18, which details the percent of children, ages 3 through 17, with a mental/behavioral condition who receive treatment or counseling. There was a decrease in this indicator from the National Survey of Children’s Health Data from 2018-2019 of 52.9 percent, to 2019-2020 of 45.4 percent, and now 2020-2021 of 42.5 percent.

Performance Objective (PO) 1.1. represents the number of Department team members, providers (pediatric, family practice, and adult), families, family partners, and community service providers receiving education or technical assistance about accessing or providing access to behavioral health services. This includes a CMS Title V performance objective to increase the annual target each year. Due to attrition and the need to pivot the remaining Title V specialists to organizational needs, the annual objective target was not reached. In addition, as the measure was a count and did not actively demonstrate effect, this PO will be deactivated.

Strategy 1.1.1 is to identify, evaluate, and enhance education and technical assistance provided to Department team members, providers (pediatric, family medicine, and adult), families, family partners, and community service providers) regarding accessing or providing access to behavioral health services and related topics that impact behavioral health and wellness. Core inclusion areas are family partnership, access to care, essential public health services, and life course/cross-cutting.

This year focused on building capacity of Title V field staff for the Department’s Florida Pediatric Behavioral Health Collaborative. Details will be discussed more fully in the sections below. As a result of the significant growth of this initiative, including the implementation of additional sites and subsequent program contracts, staff received in-depth training on the model as well as the contract’s tasks and deliverables. In addition, significant education was provided to state and community stakeholders to help garner awareness, outreach, and support of this initiative.

PO 1.2 includes the number of traditional and non-traditional providers that have initiated integrating behavioral health services, with the performance objective to increase the number 3 percent annually from baseline. The activities reported includes a summation for the following strategies:

• 1.2.1 Identify, develop, and disseminate resources for change management for traditional and non-traditional providers to begin behavioral health integration;
• 1.2.2 Leverage work with existing and potential partners to increase the accessibility and utilization of needed behavioral health services;
• 1.2.3 Create a pipeline of providers that are engaged in enhancing their practice sites by improving behavioral health awareness, prevention, identification, and treatment.

Activities this year include continued development of behavioral health system mapping through exploration of data sharing partnerships. In addition to PCMH mapping efforts, acquiring additional layers of data from system partners will support the development of interactive geo and heat maps of Florida’s pediatric behavioral health system. Mapping will support future decision making, allocation of resources, and relationship building.

CMS’s major initiative includes the evidenced-based practice of behavioral health integration (BHI) in the pediatric primary care setting. For this strategy, CMS currently contracts with six university and health system partners across the state (University of South Florida [USF], FSU, University of Florida, University of Miami, Florida International University, and most recently Nemours Children’s Health Orlando to operate as regional pediatric mental health access programs, known as Behavioral Health Hubs (BH-Hub). With funding support from HRSA’s 2021 Pediatric Mental Health Care Access (PMHCA) grant, CMS was able to expand access programs from five to seven geographical areas across the state by implementing two new BH-Hubs in areas with identified needs. The grant funding also supported community family focus groups. The qualitative data collected provided insight into families’ perceived barriers and concerns regarding access to quality behavioral health care. This information will be used for community collaborative conversations and to inform strategic planning, implementation, and evaluation of these BH-Hubs. CMS will implement its seventh BH-Hub’s services in the northwest area of the state later this summer.

The development of the BH-Hub model, and subsequent contractual tasks, were based on national guidelines and frameworks such as those supported by the Center of Excellence for Integrated Health Solutions, as well as evidenced-based practices with a strong emphasis on quality improvement activities. The BH-Hubs are responsible for partnering with pediatric primary care providers and other provider types, along with behavioral health networks in their service area. The aim is to improve identification and treatment of children with behavioral health needs by increasing the provider’s knowledge and confidence through skills-building training, technical assistance, and increased access. Expert mental health clinicians support management of behavior health conditions in primary care settings through telehealth. This year over 268 primary care and other provider types enrolled in BH-Hub’s. They received consultation or referral assistance for 1,086 children. For children 0 through 12, 62 percent were from rural or underserved areas. For adolescents, ages 13 through 21, 38.6 percent were from rural or underserved areas. The BH-Hubs provided 20 skill-based trainings to participants whose disciplines included pediatricians, psychiatrists, psychologists, advanced-practice nurses, registered nurses, social workers, and others.

The regional approach of the BH-Hub model allows for a broader range of clients served and is based on the needs and resources of each community. A common core data set was developed for data capture and analysis, both within and across the BH-Hubs, with external, third-party evaluation services provided through a contract with USF. Utilizing HRSA’s PMHCA grant’s updated performance measures, alignment of previous data points across the current BH-HUBs was done with the intent to join all seven BH-Hubs with common core data set visualized for quality improvement purposes via an online dashboard. The seven regional BH-Hubs, and statewide pediatric psychiatric consultation hotline, collectively form a statewide network of pediatric mental health access programs entitled the Florida Pediatric Behavioral Health Collaborative (Collaborative). Facilitated by CMS Title V, the Collaborative convenes quarterly virtual meetings and includes state agency stakeholders such as Department of Children and Families (DCF)/Substance Abuse and Mental Health, Agency for Health Care Administration’s (AHCA’s) Medicaid Program, family representatives from the National Alliance on Mental Illness, and other stakeholders. This venue provides an opportunity for learning and sharing of information to assist with quality improvement, address needs and challenges, including sustainability.

The aim of the Collaborative and its members significantly aligns with the State Health Improvement Plan (SHIP) resulting in consequential efforts toward sustaining a statewide integrated BH system. As a result of the SHIP’s Priority Area Workgroup activities and Florida Medicaid’s addition of language to the procurement process for Medicaid Manage Care Plans, CMS, BH-Hubs, and MMA plans across the state have begun collaborative conversations around system integration sustainability. Exploratory planning began on piloting systematized care coordination efforts, increased reimbursements, and financial incentives for participation in integrated care activities and supporting PCMH practice transformation. CMS is expanding current PCMH practice transformation activities, with partner UCF HealthARCH, to pilot and scale efforts that support PCMH certified providers seeking NCQA’s additional Behavioral Health Designation. The additional transformation efforts will promote stronger integration practices and sustainably including access to financial incentives. CMS, in partnership with the Florida Behavioral Health Association, and Florida Chapter of the American Academy of Pediatrics, will provide BHI education and training this year to pediatric primary care providers and behavioral health through conference and training activities.

PO 1.3 represents the number of activities identified that support families in enhancing mental health protective factors and build resilience, with the performance objective to increase the baseline by 3 annually. Strategy 1.3.1 is to identify, develop, and disseminate resources for traditional and non-traditional providers, as well as community partners, on available activities and resources that enhance mental health protective factors and build resilience in the families they are serving. In addition, Strategy 1.3.2 leverages work with existing and potential partners to increase activities for families that enhance mental health protective factors and build resilience.

In support of Strategy 1.3.2, partnership with FSU’s Center for Prevention and Early Intervention led to the development of projects to promote optimal health and access for all by building clinical capacity in our workforce. This included mental health professionals being trained and supported in a child/parent psychotherapy learning collaborative supportive of a continuum of infant mental health expertise, encompassing trauma and resiliency training, from Infant Mental Health Foundations. The need for more infant mental health training was demonstrated with over 200 professionals trying to register within a week of notice for a class limited to 30. To meet this obvious need and demand, strategic plans, and the acquisition of funding for additional classes is planned for the upcoming year. In addition, CMS staff in the Medical Foster Care (MFC) program and Children’s Multidisciplinary Assessment Teams will receive infant mental health foundation training to support their subsequent work with this population.

CMS Title V established a vetting process for resources that are identified by various team members for potential dissemination. This includes review of resources by a multidisciplinary team, including representatives with lived-family perspective, to review and ensure resources are evidenced-based, current, aligned with core public health essential services, and are relevant to Title V programmatic priorities or emerging needs. The vetting process is completed prior to resource dissemination to community partners. Specific to the priority need of support and enhancing mental health protective factors for Florida families, 49 resources were identified, increased from the baseline of 24, and made available to Title V specialists for dissemination to engaged stakeholders. A variety of mediums were represented in these resources, including articles, infographics, webinars, websites, and audio/visual trainings. Resources originated from regional or state organizations as well as national organizations, such as Bright Futures. Plans include a focus on the identification of more community or state activities or supports, and not just resources.

CMS identified a need to address the shortage of MFC parents required to serve Florida’ most vulnerable foster care children and youth with complex medical needs.   The MFC program is a coordinated effort between CMS, AHCA, and DCF to provide a safe and appropriate family home environment for medical complex foster children. The MFC program provides specialized training and support for foster care parents, who then become MFC parents, providing in-home, family-based, and individualized care for children ages birth to 21 years who have medically complex needs. The goal for children in MFC is to grow and thrive in a nurturing home environment until permanency goals are achieved. CMS identified there was not a net overall increase as MFC parents’ attrition at an equal rate, mostly due to adopting children in the home and focusing on those effort. To help support the need, a legislative budget issue proposal was submitted for consideration of funding for a MFC marking and recruitment campaign. As a result, an annual MFC recruitment budget was awarded, and the program now has a logo that can be used to establish brand identity. A formal marketing campaign will be launched later this summer.