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) through: comprehensive programs; a commitment to health equity; and a focus on social determinants of health. 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% of CYSHCN have public health insurance, as compared to 36.4% Nationwide, with 44.2% reporting private insurance, 5.3% reporting a combination of public and private insurance and 4.3% uninsured. In addition, 11.6% of Florida’s CYSHCN report having received care in a well-functioning system representing a 4% increase from 2018-2019 data, with the reported Nationwide average of 14.4%.

 

To influence NOM 17.2, the percent of children with special health care needs (CSHCN), 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, 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 Managed Care Health Plan. 

 

Increased access to medical homes and primary care for CYSHCN is a continued priority need. NPM 11, along with their associated evidenced based or informed strategy measures (ESM), most of the performance objectives continue to align, with the realignment of one.  Supporting strategies and activities work to include an intentional focus on workforce, essential public health services and family partnerships.

 

To address Florida’s populous state and diverse regions, and in alignment with CDC’s Public Health 3.0 framework, CMS is piloting the community integrated system approach, which embeds the evidence-informed practice of public health detailing. Annual regional needs assessments continue identify needs or gaps that impact the health and wellness of CYSHCN. CMS has 7 regional field specialists and 2 family leaders to provide outreach, education, technical assistance, and linkage of resources to community partners, including providers dedicated to providing care to CYSHCN. Due to the impact of the COVID-19 Pandemic, a national public health crisis, travel restrictions continued to be in place requiring CMS Title V field specialists advance their knowledge, skills, and abilities by becoming effective without usual face-to-face outreach methods, and instead, enlisting the use of various virtual means.

 

ESM 11.2 is the number of Florida Department of Health (Department) team members, providers (pediatric, family practice, and adult), families, family partners, and other partners serving CYSHCN in Florida receiving education or technical assistance about the patient-centered medical home model and related topics that impact the health and wellness of CYSHCN. The objective is to increase this unduplicated number annually, with the baseline of 730 stakeholders and this year’s target of 2340 stakeholders. This year, there were 843 encounters of outreach or education specific to PCMH and related topics. Although this measure is a quantity of effort, it demonstrates a part of what the Title V workforce is responsible for. Our workforce during this pilot has had natural attrition and remaining personnel have been shifted to needed management of community integration activities. We acknowledge the potential for decreasing outreach encounters in the years to come and have updated targets to reflect this projected decline. Future planning will continue to consider other opportunities to provide outreach in meaningful ways.

 

PCMH related educational topics previously included Healthcare Transition, Social Determinants of Health, Universal Screening Tools, including Bright Futures, and Health Promotion. This year further expanded stakeholder outreach topics to include COVID-19 resources, obesity, asthma, telehealth, oral health, effective family partnerships, Quality of Life tools, and the Life Course framework. Asthma was a critical topic to include as annual regional needs assessment results continued to identify a concern of increased asthma emergency department visits in many of Florida’s counties. Title V CMS, as a convener, leveraged resources within the Department’s Bureau of Chronic Disease Prevention and facilitated the creation of a workgroup of diverse 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 MS PowerPoint slide deck containing valuable provider information. Asthma home visiting programs were leveraged with plans to engage volunteers for expansion. In addition, an Asthma Education Pilot program for high-risk, uncontrolled, asthma patients aged 5-18 years, was initiated in January 2022 with plans to enroll up to 20 participants. School-based program activities will be considered in the Fall.

 

Strategy 11.1 includes significant activities which engage several of CMS’ major initiatives and focuses on community integrated system building and improving healthcare access and quality. An informed strategy for community integrated systems approach includes the integration of multisector service systems focused on addressing social determinants of health. 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 towards 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 children and youth with special health care needs (CYSHCN). Results from one of the RNAQ’ s needs assessment 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. This was resourced through CMS Title V-provided trainings to a minimum of 12 PCPs between July 1, 2021, and June 30, 2022. 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 Nemours Children’s Hospital Social Determinants of Health (SDOH) tool in their Medically Complex Coordination clinic, from a baseline of 0% in June 2021 to 50% by June 30, 2022.  Challenges with IT/software issues contributed to delays in disseminating the SDOH tool electronically as planned, and CMS Title V will continue to partner and drive action on this project with the Orlando RNAQ in the upcoming year as well.

 

In the pursuit of a well-functioning system that serves CYSHCN in Florida, integrated system building work included an intentional focus on healthcare access and quality. This is best actualized in a major initiative of the Title V Program, facilitated through use of partnerships with the Office of CMSMCP & Specialty Programs. CMS Title V leveraged condition-specific expertise (e.g., diabetes, sickle-cell disease, asthma) found in existing specialty network contracts within tertiary care centers across the state. These care centers were previously focused on direct care services, however, reengineered, and repurposed, experts within these entities were tasked with Title V CYSHCN priorities including implementation of a Quality-of-Life measurement tool, completion of the CYSHCN single organization assessment tool, and continued quality improvement, all through the lens of the Standards for Systems of Care for Children and Youth with Special Health Care Needs, version 2.0. Our vision includes uniting these individual tertiary-care, condition-specific programs, and organizations across the state, into collaborative Statewide Networks of Access and Quality (SNAQs). Guiding principles include family-centered, learning through quality improvement (QI), kid-focused, inclusive, data-driven, systems of care that serve all CYSHCN, regardless of insurance status and location. Some lessons already learned include the need to standardize the reporting of deliverables to ensure data mined is useable and helps illustrate the value of the services provided.  We recognize the superior value of quality-driven data for results-based accountability and have commissioned the development of a reporting guide that outlines uniform data collection & reporting practices.

 

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 strengthening the system of care for CYSHCN and their families. Dedicated to a culture of learning and continuous quality improvement (QI), CMS Title V partnered with the National Institute for Children’s Health Quality (NICHQ) to craft a formal QI initiative within the collaborative SNAQ programs called Learning Action Network (LAN) improvement teams formed within 32 tertiary-care/academic programs, representing seven condition-specific programs (behavioral health, craniofacial, endocrine, chronic kidney disease, hematology-oncology, HIV/AIDS and pulmonary) partnered with peers from other organization to collaborate on condition-specific quality improvement projects. For this second full year of implementation, LAN objectives are to build and support motivation for QI, facilitate continuous QI, foster collaboration, shared learning, and action towards improvement, and through CMS & NICHQ co-design and co-facilitation, maintain a sustainable LAN. The Learning Action Network initiative is a catalyst in the transformation of these historical siloed programs, groups, and organizations into a Statewide Network focused on improving healthcare 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 1:1 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 (PDSA) and other models for measurable improvement. Results thus far include seven condition-specific SNAQ-wide (i.e., across institutions) projects and 32 institutional QI projects. Since the LAN’s inception two years ago, over 150 PDSA cycles have been completed. For the next planned iteration of this continuous QI journey, steps include developing a LAN health equity framework exploring return on investment for impact and exploring impact among health outcomes such as decreased emergency room visits and decreased hospitalizations. Detailed below are SNAQ highlights, including their statewide AIM statements and local project descriptions.

 

Condition-Specific SNAQ Highlights

HIV: Collective Statewide AIM:

• By December 2022, the team will distribute an HIV Health Resource Guide using QR code-based educational videos to at least 70% of adolescent/young adult HIV-population, ages 12-24y/o, so that 50% of the adolescents/youth report feeling satisfaction with their progress toward transitioning from pediatric to adult care.

 

Local QI projects by each system partner:

 

• Adjust programmatic approach to Vitamin D monitoring and supplementation.
• Increase activation and utilization of electronic Health accounts.
• Continued Screening for Hepatitis C project with process improvements.
• Enhance nutrition education by initiating nutrition referral during clinic visits.
• T-cell protective factor education and improving health literacy, specifically with T-cell lab recall.

 

Diabetes: Collective Statewide AIM:

• By June 2022, we will improve diabetes care at school for children in seven counties of Florida by working with school staff to identify their learning needs and codesign a program of training and learning opportunities to increase knowledge, skill level and confidence of school staff.

 

Local QI projects by each system partner:

 

• Improve the sign-up rate for electronic patient portal (my Chart).
• Improve the transition of care among our diabetes patients.
• Improve the percent of education provided to established patients following a hospital admission for DKA.

 

Pulmonary: Collective Statewide AIM:

• By March 2023 we will improve the level of comfort and knowledge base for school nurses/designated personnel who are responsible for delivering asthma care to children at school by 25%. 

 

Local QI projects by each system partner:

 

• Improve Quality of Life (QoL) in Asthma Patients.
• Improve our work in transitioning and expand screening for anxiety and depression.

 

Chronic Complex Kidney Failure Centers (CCKFC): Collective Statewide AIM:

• The CCKFC SNAQ will engage with our families, community partners and other collaborators to reduce the impact of potential barriers experienced during the transplant listing process by developing a resource for families by families to educate and empower them to better navigate the process.

 

Local QI projects by each system partner:

 

• Enhance referral process from external referrals to decrease overall time to listing.
• Improve transition process from pediatric to adult care.
• Track phosphorus levels on patients with ESRD.
• Improve electronic Health Account Activation and Utilization.

 

Hematology/Oncology: Collective Statewide AIM:

 

• By June 2023, the centers participating in the Hematology SNAQ will improve sickle cell transition from pediatric to adult care across our community. We will do that by building provider capacity.
• By June 2022, we will implement six virtual one-hour lectures focused on sickle cell disease and the Got Transition® program with the goal of increasing the knowledge of at least 25% of participants as assessed in pre- and post-testing.

 

Local QI projects by each system partner:

 

• Create and administer a barrier assessment tool looking to decrease patient unmet needs related to social determinants of health.
• Implement needs assessment to improve patient’s readiness for transition from pediatric to adult care.
• Increase families receiving and understanding updated newborn education materials. 
• Standardize and improve safety of the discharge process of newly diagnosed patients with leukemia/lymphoma and patients with an admission of greater than seven days through the implementation of a journey board tool kit.

 

Cleft Lip/Cleft Palate: Collective Statewide AIM:

• Increase access to dental services (specialty dental care, orthodontic care, and prosthodontics) for children with Craniofacial anomalies by July 1, 2026. This is important because it will result in improved health outcomes and quality of life.

 

Local QI Projects by each system partner:

 

• Implement CLEFTQ/FACEQ speech and psychology patient reported outcomes. 
• Improve Psychosocial Risk Assessment and Resource Support for Craniofacial Team Patients.
• Monitor communication evaluation orders from ordering physician to actual speech therapy scheduling.
• Utilize a cognitive screening tool (KBIT2) that identifies children who need to be referred for additional testing.
• Utilize individual Specialty Protocol Handouts with QR code contact cards designed to assist patients, families, and specialty clinics with understanding of the individual plan of care and access to specialty’s contact information.

 

Behavioral Health (BH):  Collective Statewide AIM:

• Increase the level of engagement with integrated care partners (Primary care providers, Behavioral Health Organizations, Patients/Family, or community organizations) by June 30, 2023, in order to improve access for children and youth to Behavioral Healthcare through their primary care providers.

 

Local QI Projects by each system partner:

 

• Variations of supporting increased screenings.
• Variations of supporting increase BH referrals from primary care providers, including streamlined referral submission.
• Increasing effective communication.
• Facilitating and documenting warm handoff.

 

As part of the statewide priority initiative to increase access to patient-centered medical homes (PCMH) and primary care, recognized family partnership is a focused area of inclusion. ESM 11.3 recalls the number of caregivers of CYSHCN in Florida who perceive themselves as a partner in their child’s care, with the objective to increase this number 1% annually from the identified baseline for this reporting year. Utilizing the 2019-2020 National Survey of Children’s Health Data Indicator 4.14 for shared decision-making, 85% of the sample count (N=355), reported always or usually to whether a decision was needed. This data set will be used as a baseline for future reporting. In consideration of more timely data points, CMS developed an internal survey to disseminate to our family partner organizations. This survey was disseminated at a Family Café conference, with 67.74% (N=63) reporting they work with their child’s providers in shared decision-making to create shared care plans for their child(ren).  This same survey was also disseminated at a Title V sponsored Florida Family Leader Network (FFLN) even. FFLN works at all levels of influence, including community, state, and nationally to provide skills-building training to empower advocacy and elevate family partners to family leaders. In comparison to the CMS survey, their survey results indicated that 93.75% of survey participants (N=30) work with their child’s providers in shared decision-making.

 

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.

 

Florida Family Leader Network (FFLN) was fashioned with the aim of elevating and supporting families. The ultimate 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 280 members across the state of Florida and beyond. Survey data from their last summit indicated that 76% of survey participants 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. In addition, 88% reported that the information they learned will increase their ability to be involved as a family partner or leader at the community level, as well as 83% reporting an increase in their ability to be involved at a systems level (I.e., regional, state, national, organization or health care system).

 

Specific to the Title V workforce, inclusive of designated Family Leaders, monthly meetings are held to optimize awareness and promote use of materials & information garnered from various partners related to patient/family engagement & partnership, with an aim to enhance provider & 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.

 

Building on last 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 Statewide Networks of Access and Quality (SNAQs). In follow up, the Statewide Family Leader further 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 our SNAQ Learning Action Network (LAN) and will be utilized in other capacities, on both the provider and caregiver side, in other program initiatives. Aptly, the new Patient and Family Engagement Roadmap was featured in a well-attended Association of Maternal & Child Health Programs (AMCHP) workshop during their annual conference this year.

 

Our CMS Statewide Family Leader is a AMCHP Family Delegate for Florida and newly alumnus of AMCHP’ s Leadership Lab. She participates in a multitude of state and national level healthcare, 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 & 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 Florida Family Leaders Network (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 ground-breaking 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 1:1 technical assistance and support to pediatric practices regarding patient-centered medical home (PCMH) practice transformation, preparing them for NCQA Certification. Over the past five cohorts (2017-2021), 62 practices have received PCMH Recognition. There continues to be 56 practices still in the recognition process, some are delayed as a result of challenges (I.e., staffing vacancies/turnover, competing priorities) due to the national Pandemic. The goal is to have 224 PCMH recognized practices by the year 2025. ESM 11.6 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% at the end of the five-year period. Challenges, referenced below, contributed to not being able 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, with health equity, workforce, and essential public health services as focused inclusion areas. Activities under this strategy included geo-mapping current pediatric PCMH’s services to children and youth with special healthcare 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% of practice type data revealed that 30.56% of providers identified as Family Practice and 25.68% as Pediatrics. Other practice types included: Internal Medicine (16.79%), Federal Qualified Health Centers (13.63%), multi-specialty (13.20%), and Free or reduced-cost health clinics (0.14%). Per capita income was overlayed on the provider map and demonstrated that lower per capita income areas were less populated and also 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 mapping and adding a vulnerability population index, which is currently in production. The updated maps, using R studio, are currently delayed due to challenges in recruitment of the needed skill set to complete, but planned for the upcoming year.

 

In working to create a pipeline of providers that are interested in patient-centered medical home (PCMH) transformation and partnering with the University of Central Florida’s (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 1:1 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 this initiative. Ongoing challenges as a result of the COVID-19 public health crisis, produced hefty competing priorities for providers, reducing the availability of essential resources (i.e., staffing, etc.) for PCMH transformation. As a result, the entire 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 & 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 and 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. 

 

In support of population health model utilization within UCF HealthARCH’ s PCMH practice transformation services, we planned the implementation of another Learning Action Network (LAN), however the start of this initiative was delayed due to the continued impact of the COVID-19 Pandemic on providers.  LAN specifics include utilization of PCMH readiness assessments to gauge appropriateness among PCMH transformation cohort activities, which will either include 1:1 PCMH transformation technical assistance with 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 patient-centered medical home. 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 in order to become aptly able to enter into the next 1:1 PCMH transformation cohort. It is anticipated that provider participation in the LAN model will also shorten their 1:1 PCMH transformation technical assistance, allowing UCF HealthARCH to serve more providers over time.

 

Cognizant of the increase demand for mental health services, and steadfast in partnership to build a well-functioning system that address social determinants of health 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/ white paper 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 Behavioral Health 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 imbedded in Florida’s CYSHCN Action Plan. ESM 11.4 was intended to address the known transition barrier of the number of Adult Care Providers/Practices that accept CYSHCN transitioning to adult care, with the performance objective to increase the number of identified Adult Care Providers/ Practices PCMHs that will accept CYSHCN transitioning to Adult Care by 15 annually. Multiple challenges have interfered with getting started with this measure, including trying to determine the most appropriate approach in collecting data that captured impact over time in a meaningful way. This challenge was confirmed with the receipt of MCHB’s ESM review for Florida. Feedback included that the ESM was population based and didn’t align with a specific evidenced based strategy as well as being an outcome measure versus a process measure. Therefore, with this annual report we will discontinue this ESM.  Reflections of current strategies, activities, and leveraged opportunities, along with consultation of MCH Evidence Center has identified a new replacement ESM 11.5, Percent of youth who report having successfully transitioned from pediatric to adult health care providers/practices. Planning is in place to capture this data at an upcoming annual conference for transitioning youth and young adults with special needs as well as with opportunities described below. 

 

Strategy 11.4 details collaboration with other Title V CYSHCN Programs and internal Department of Health 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.  In partnership with Got Transition® and the CMS Health Plan, CMS Title V initiated a 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 pilot program is a 12-month program that will incorporate the coordinated exchange of medical information, a plan of care, a joint telehealth visits with member/family, pediatric and adult care provider, and facilitated integration into adult care. 12 CMS members ages 18-20 are currently participating in the VBP pilot program. Providers will receive an enhanced fee-for-service payment with reimbursement at 100% of the Medicare fee schedule for both pediatric and adult providers. Members will receive a direct-to-consumer payment incentive which will consist of a $25 Visa Prepaid card for attending each scheduled appointment within the first 6 months after the member transitions to an adult care provider.  The pilot is in early implementation and will be closely monitored for quality improvement opportunities and strategic planning for future renditions.

 

Prior to COVID-19, Florida participated with the other “big-five” populous states to collaborate on evidenced-based or informed strategies to increase the numbers of adult providers and practices that have the knowledge and capacity to care for young adults with special health care needs. Since COVID-19, significant changes in most of the state's Title V leadership has occurred. We hope to revisit this collaborative opportunity in the future.

 

In a recent survey, 60% (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 would be to assess successful transition after youth has landed safely within the care of an adult provider. Creating an “exit interview” that would be sent to the youth after the initial appointment with their new adult-care provider could 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 % 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 electronic dashboard data. 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. One of these SNAQ 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. 

 

CMS is transitioning its long-time contracted state transition clearinghouse program, Florida Health, and Transition Services (FloridaHATS) 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 being considered. A new youth to adult transition course for professionals has been designed and is in course development. This project was facilitated by CMS Title V and done in collaboration with Florida’s Maternal Child Health (MCH) partners and transition experts. We envision the transition course being released in conjunction with CMS’s new transition, allowing the website to serve as a companion education & resource portal for the transition course.

 

The Florida’s State Performance Measure to increase access to mental and behavioral health service, is aligned with National Outcome Measure (NOM) 18, which details the percent of children, ages 3 through 17, with a mental/behavioral condition who receive treatment or counseling.  There was an appreciable decrease in this indicator from the National Survey of Children’s Health Data from 2018-2019 of 52.9% to 2019-2020 of 45.4%. Performance Objective P.O 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, with a CMS Title V performance objective to increase the annual target each year. This year’s performance objective target was 1000 stakeholders; however, due to natural attrition, and the remaining Title V regional field specialists being diverted to higher state priority needs, this objective target was not reached. The ESM continues to align with state priority needs and so, objective targets are being updated based on current realities.

 

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, health equity/social determinants of health, essential public health services, and life course/cross-cutting.

 

Title V regional specialists provided outreach or education on the priority need for access to pediatric mental health treatment and promoted the value of primary care integrating behavioral health services in their practice to 493 providers or community stakeholders. As part of this effort, practices are asked to report their level of behavioral health integration which is measured against the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) Standard Framework for Levels of Integrated Healthcare. Of the practices (N=272) reporting some level of BH integration, the majority (N=237, 87%) exhibited only basic coordinated behavioral health efforts. A smaller percentage indicated providing a co-located (N=10.3%), or fully integrated (N=34 or 12%) level of behavioral health integration. Current annual data indicates a 2.7% increase in the number of fully integrated practices from the previous year.

 

P.O 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% annually from baseline. As the strategies under this ESM have interconnected, 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 were to include behavioral health system mapping for about half of the counties in the state, with the other half expected by the end of the calendar year. These maps would then be integrated with other mapping activities, such as geo-maps for PCMH and a vulnerability population index and used to prioritize underserved areas. Business Intelligence reports and overlaying various system maps would assist in comprehensive system analysis for gaps and needs. Challenges encompass the recruitment of staff with specialized skill sets to complete these tasks, and delays with acquiring staff have pushed these activities into the coming year.

 

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 five university partners across the state (University of South Florida, Florida State University, University of Florida, University of Miami, and Florida International University) to operate as regional pediatric mental health access programs, known as Behavioral Health Hubs (BHH). As a result of the impact of COVID-19 and it’s short- and long-term effects, the need to address children’s emotional wellbeing and mental health has been magnified. Additional Title V CYSHCN funds where pursued and the Department was awarded HRSA’s 2021 Pediatric Mental Health Care Access (PMHCA) grant which is being used for the development of two additional BHHs in underserved areas. Partners have been identified and contracts are in process. Community family focus groups were held to inform health equity needs, and the invaluable information garnered will be used in the strategic planning, implementation, and evaluation of these BHHs.

 

The development of the BHH 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, researched evidenced-based practices with a strong emphasis on quality improvement activities. The BHHs 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, through telehealth, to expert mental health clinicians to help support management of behavior health conditions in primary care settings. This year over 139 primary care and other provider types participated in the BHH program, receiving consultation or referral assistance for 1,104 children. For Children 0-12, 78.8% were from rural or underserves areas with adolescents ages 13-21 57.5% respectively. The BHHs provided 14 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 BHH model allows for diversity among clients served and is based on the needs and resources of that specific community. A common core data set was developed for data capture and analysis, both within and across the BHHs, with external, third-party evaluation services provided through a contract with the University of South Florida. Utilizing HRSA’s PMHCA grant’s updated performance measures, alignment of previous data points across the current BHHs was done with the intent to join all seven BHHs with common core data set.  The soon-to-be seventh regional BHH and accompanied statewide pediatric psychiatric consultation hotline, collectively form a statewide network of pediatric mental health access programs entitled the Florida Pediatric Mental Health Collaborative (FPMHC). Facilitated by CMS Title V, the FPMHC meets virtually, once a month, and includes state agency stakeholders such as Department of Children and Families, Substance Abuse and Mental Health and Agency for Health Care Administration’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 or challenges including sustainability. P.O 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 Florida State University’s (FSU) Center for Prevention and Early Intervention led to the development of projects to promote equity and diversity by building clinical capacity in our workforce. This included mental health professionals being trained 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 obviously need & demand, strategic plans, and the acquisition of funding for additional classes is penned for the upcoming year.

 

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 & 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.

 

Foster children who carry multiple comorbidities and significant therapeutic needs require access to specialized foster parents, trained to meet their comprehensive needs supporting their growth, learning, and ability to thrive in the community. In support of this statewide priority, CMS partnered with Mercer, a national consulting company, to collaborate with Florida’s system stakeholders for Medical Foster Care and Specialized Therapeutic Foster Care programs, to develop a white paper in consideration of building a “dual” program to serve foster care children that have both medical and therapeutic needs. Activities explored by Mercer included surveillance of similar programs in other states and review of interviews from AHCA’ s Medicaid program, Department of Children and Families Child Welfare programs and local systems of care that had detailed their experience with dual home start-ups in their community. The white paper will be shared with state and community partners to further explore opportunities to address this identified need.