Annual Report

Priority: Medical Home for Children and Youth with Special Health Care Needs

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

The annual indicator for reporting year 2016 was 45.3% for children and youth with, and 49.7% for children and youth without, special needs. The target for reporting year 2016 was 50%. It is unknown if the target was met since updated national data are not comparable to the previous data collected in 2011-12, due to changes in the methodology used for the National Survey of Children’s Health. The 2016 national survey data will be used as baseline to set new targets for NPM 11.

The percent of children and youth with special health care needs who receive MCH-funded care coordination services and have an interagency shared plan of care for the agencies in target communities was developed as the ESM for NPM 11.

The MCH priority of supporting medical homes for children and youth with special health care needs (CYSHCN) was continued in 2016 under the new NPM 11. New state and local logic models and action plans were developed to guide implementation of MCH medical home strategies for 2016-2020. These strategies are focused on identifying and implementing policy/systems changes that:

●       support communication and collaboration between programs that provide care coordination for children and youth

●       enhance statewide access to pediatric specialty care

●       strengthen transitions for youth and their families

●       expand access to information and resources for children, youth and their families

To support communication and collaboration between programs that provide care coordination for children and youth, MCH staff coordinated the Colorado Care Coordination Collaborative (Team 4C). Team 4C was a pilot that focused on increasing efficiency and reducing duplication of care coordination services for CYSHCN provided through Medicaid’s Accountable Care Collaborative Program, Healthy Communities (EPSDT Outreach Program) and Title V. State MCH staff used lessons learned from the Team 4C pilot to provide input to the state Medicaid agency, as they crafted phase II of the Accountable Care Collaborative Program that will be launched in July 2018. MCH staff documented the Team 4C process and the lessons learned helped shape the design of the state medical home action plan, as well as the local medical home action plan template.

To support the implementation of local medical home efforts, MCH staff provide technical assistance and training to five local public health agencies (LPHAs). An example of a tangible local success was the execution of a data sharing agreement to facilitate communication between the local health department and their RCCO about their respective care coordination caseloads. Additionally, a group was formed to focus on interagency care conferencing for CYSHCN receiving services from both the health department and the RCCO. The case conferencing workgroup clarified roles of each program and identified tangible policy and process changes that were implemented within and between agencies.

In addition, MCH/CYSHCN staff established a workgroup with the Children’s Hospital Colorado (CHCO) called Team 5C (CDPHE/CHCO Care Coordination Collaborative). While CHCO is based in metro Denver, their patient panel represents CYSHCN from every county in the state. Likewise, LPHAs provide community-based information and resources and/or care coordination services for CYSHCN statewide. Team 5C’s purpose is to align CHCO’s clinical care management with community-based LPHA care coordination services throughout Colorado. An initial focus of this group was to enhance the LPHA referral form within CHCO’s electronic medical record to be more accessible and user-friendly for CHCO staff. In addition, the group developed a systematic process for feedback and referrals between CHCO and the LPHAs that provide care coordination services. A longer term activity that was begun during this timeframe was to explore opportunities to pilot shared plans of care between CHCO clinics and LPHAs.  To further support this effort, the group leveraged the successes, challenges and opportunities identified through CHCO’s CMMI-CARE Award and the CYSHCN Systems Integration Grant.

MCH staff also partnered with CHCO to enhance statewide access to pediatric specialty care for CYSHCN. CDPHE contracted with CHCO and University Physicians, Inc. to increase access to specialty care in rural areas of Colorado. Through this partnership, a number of systems level challenges were identified that pose barriers to families accessing care. During the first part of 2016 the work group expanded the discussion to include the Regional Care Collaborative Organizations (RCCOs), with a focus on the western slope where the LPHA is doing the largest amount of specialty care gap-filling. In addition to the systems level work, LPHAs streamlined the triaging of CYSHCN accessing specialty care by setting up policies and processes to ensure that children who need follow up care were referred back to their primary care provider and provided access to the specialist for consultation. This streamlined process increased efficiency of provider time and promoted a medical home approach.

Strengthening transitions for youth and their families was incorporated into the medical home logic model and action plan. Because this was a new component of the medical home priority, staff conducted a series of transition scoping meetings to identify existing youth to adult transition efforts across the state and evidence based strategies to be used to craft future action plan activities. Based on resources and staff capacity, this component of the medical home action plan was deferred for future development.

The fourth strategy included in the state medical home logic model and action plan was expanding access to information and resources for children, youth and their families through the development and implementation of a Help Me Grow Hybrid contact center. Leadership from CDPHE, the Department of Health Care Policy and Financing and the Department of Human Services aligned in support of the effort and developed a plan, in partnership with private foundations, to braid funding to support the development of an implementation plan. During FFY16, MCH/CYSHCN staff took an active role on Help Me Grow Hybrid committees to shape the development of the plan to ensure that the CYSHCN population was included in the target population in the design of the contact center.

The MCH implementation team lead for the medical home priority continued to coordinate and facilitate the Medical Home Coalition and the Medical Home Community Forum to support and sustain a statewide medical home infrastructure for children and youth. These groups were used to further the activities outlined in the medical home state action plan. Examples of topics discussed in these forums included: leveraging Colorado’s State Innovation Model Grant; improving communication across providers through the development of shared plans of care for children and youth receiving care coordination services; coordinating with the Regional Care Collaborative Organizations to align supports and services for CYSHCN enrolled in Medicaid; and developing recommendations for ACC 2.0 around standards for the delivery of care coordination for CYSHCN.