Wisconsin - 2020 - III.E.2.c. State Action Plan - CSHCN

Children and Youth with Special Health Care Needs (CYSHCN) Population in the State

Nearly 230,000 or 17.8% of Wisconsin children have a special health care need (CSHCN). Among CSHCN in Wisconsin, nearly 1 in 12 children missed 11 or more days of school due to illness and close to 1 in 9 families report that a family member had to cut back on work hours or stop working because of their child's health or health conditions. Additionally, 36.5% of families with health coverage report that their insurance is inadequate. Furthermore, approximately 1 in 4 families report spending $1,000 or more each year for out of pocket medical expenses. In Wisconsin, only 12.3% of CSHCN ages 0 through 17, receive care in a well-functioning system. Source: 2016-2017 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website, accessed 2-15-19.

CYSHCN Program Infrastructure, Financing, and Roles

In 2000, the Wisconsin CYSHCN Program (https://www.dhs.wisconsin.gov/cyshcn/index.htm) administered by the Family Health Section (FHS) in the Bureau of Community Health Promotion within the Division of Public Health (DPH) made significant changes to its structure and administration in order to better support an integrated systems-building approach to its work. The CYSHCN Program discontinued its provision of direct health services and its payment for direct health services provided by others. This change coincided with expansions in Medicaid coverage for children in Wisconsin. The Title V CYSHCN Program does not receive additional state funds to provide direct health services, care coordination services, transportation or other enabling services. Title V funds were redirected to fund five Regional Centers for CYSHCN (RCs) (https://www.dhs.wisconsin.gov/cyshcn/regionalcenters.htm), one in each of the five DPH regions. The RCs provide information, referral, and follow-up services for families and providers along with outreach, education, and training. The CYSHCN Program, in partnership with other public health programs, funds the Wisconsin Women’s Health Foundation (WWHF) who administer the Well Badger Resource Center (https://wellbadger.org/), which includes a phone line (teletypewriter and language line), website, chat, and email functionality for parents and providers to access resources and information.

The RCs and Well Badger provide a regional and statewide structure that supports the integrated service systems at the community level. Beginning in 2010, the CYSHCN Program established “hubs of expertise” to serve as leads for select National Performance Measures (NPMs) and for CYSHCN system improvement efforts. Family Voices of Wisconsin (FVW) (www.familyvoicesofwisconsin.com/) supports family leadership, CYSHCN advocacy, public policy, family education and training. Parent-to-Parent of Wisconsin (P2PWI) (www.p2pwi.org) provides individual parent matching support. Wisconsin Medical Home Initiative (WisMHI) (https://www.chawisconsin.org/initiatives/medical-home/) promotes Medical Home (MH) implementation for providers and families including grants to support quality improvement at the health practice/health system level. ABC for Health, Inc. (www.safetyweb.org) provides health benefits assistance in partnership with the RCs and supports health benefits advocacy for families with CYSHCN. The Youth Health Transition Initiative (YHTI) (www.healthtransitionwi.org) provides outreach, education, and training including a Learning Community, and onsite training. The Genetics Systems Integration (GSI) hub (https://geneticsinwisconsin.wisc.edu/) integrates genetics with public health systems in order to support individuals with genetic conditions. These form the CYSHCN Collaborators Network (Network) that works together to advance systems of care for CYSHCN in addition to the MH and YHTI NPM by implementing strategies at the individual (youth and family), community, health practice/health system, and state level.

As described in Health Care Delivery System (Section iii.E.2.b.iii), the Bureau of Children’s Long Term Support Services (BCLTSS) (https://www.dhs.wisconsin.gov/children/index.htm) within the Division of Medicaid Services (DMS) administers the Katie Beckett Program, Birth to 3 Program (Part C Early Intervention), the Children’s Long-Term Support (CLTS) Waiver, and the Children’s Community Options Program (CCOP). The CLTS Waiver Program provides § 1915(c) waiver services for eligible children from birth up to 22 years. The approved § 1915(c) waiver permits the Department of Health Services (DHS) to provide an array of community-based services and supports to enable children, who would otherwise require institutionalization, to remain in their home and community under the care of their family or guardians. The approved waiver period for both applications is effective April 1, 2017 through December 31, 2021. Collectively, these programs assist in the coordination of care for over 30,000 Wisconsin children with disabilities and expend approximately $200 million in federal, state, and local funds. The CYSHCN Medical Director is a member of the BCLTSS Advisory Council along with FVW. The 2017-2018 State’s budget included $39 million to eliminate the waitlist for long-term supports for 2,200 children with developmental disabilities, physical disabilities, or severe emotional disturbances. Implementation of the elimination of the waitlist remains a priority for the BCLTSS. The budget provides sufficient resources so that all children eligible for CLTS receive services. Additionally, the budget provided funds to help families of children with disabilities identify available services and supports in the community that will meet their needs.

In September 2017, the DMS began funding care coordination for children with medical complexity (CMC) enrolled in the complex care programs at Children’s Hospital of Wisconsin (CHW) and University of Wisconsin (UW) American Family Children’s Hospital (AFCH). The CHW and AFCH complex care programs are participating in the US Department of Health Resources and Services Administration (HRSA) funded CMC collaborative improvement and innovation network (CoIIN) with CHW as the lead. With respect to birth defects and newborn screening (NBS), limited state dollars ($95,000) are provided to the FHS to support the Wisconsin Birth Defect Prevention and Surveillance Program, including its registry. Fees generated by the NBS blood card (currently $109/birth approximately $7M) support the NBS Program, also administered in the FHS, including the provision of nutrition products and support for diagnostic centers.

As noted earlier, the role of the Title V CYSHCN Program is not one of provider or payer. Instead, the CYSHCN Program’s roles, in partnership with its Network, are to provide vision, lead or facilitate systems quality improvement for CYSHCN that includes strategic partnerships, utilize data/evaluation to inform strategic decisions, and to build and sustain workforce capacity, including family leadership. These roles are consistent with the DPH Strategic Plan’s four infrastructure pillars with health equity as an undergirding to the framework. The four infrastructure pillars are to provide public health leadership, forge and strengthen key partnerships, promote informed decisions and to assure strong workforce and business practices. The CYSHCN Program meets regularly with Network Directors (RCs and hubs of expertise), RC Directors, Quality Improvement (QI) Project Team Integrated Supports, and REDCap/Data Work Groups to assure coordination/alignment of work across the Network. In addition, the CYSHCN Program supports workforce development including workforce development days for the staff of the Network. Since January 2018, program data has been reported quarterly and presented at the Network Directors meetings.

CYSHCN Domain NPM Selection

Overall, 41.0% of Wisconsin CYSHCN have a MH. A MH is defined as accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. The percentage of CYSHCN with a MH is lower for children who are: low income, with public insurance only, behavioral, or developmental issue. While greater than the nationwide percentage of 16.6%, only 19.1% of Wisconsin adolescents with special health care needs ages 12-17 received services necessary to make transitions to adult health care. Source: 2016-2017 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website, accessed 4-1-19. As part of the 2015 Maternal and Child Health (MCH) Title V needs assessment process, it was identified that “too many children with special health care needs do not receive medical care within the context of a medical home and “too few adolescents with special health care needs ages 12 through 17 receive the services and supports necessary to transition to adult health care.” In 2018, the Wisconsin Title V Program selected NPMs related to MH and transition. The Title V Program, with partners that included the CYSHCN Network, MCH Advisory Committee, and others, selected evidence-based and/or informed strategies and measures related to NPM 11 for MH and NPM 12 for transition.

National Performance Measure 11: Percent of children with special health care needs having a medical home. (Addresses MCH Priority: Health Care Access and Quality)

WisMHI was identified as the lead for Title V MH related activities in 2018 in partnership with the CYSHCN Program, MCH Program and the Network. Listed are the 2018 strategies and outcomes:

Promote concepts of Medical Home using a unified definition, set of tools, and messages.

The Wisconsin State MH Plan https://www.dhs.wisconsin.gov/publications/p01149.pdf continued to guide MH implementation. In 2018, monthly MH Minute e-newsletters that promote aspects of MH implementation were sent with an average of 1,185 recipients per e-newsletter and an average open rate of 16.7% (up from 13.7%) with the highest open rate (22%) in May featuring the topic of the Pediatric Mental Health in Primary Care. Promotions of the MH brochure included featuring the brochure on partnering agency websites, as part of materials shared at trainings, in the WisMHI MH Minute, and ABC for Health’s Health Watch newsletters with more than 5,500 subscribers combined and 2,774 copies requested from DHS publications. The WisMHI website was updated at least monthly. The most frequently visited pages included the home page (998 views), resources for care coordination (308 views), resources for public health departments (266 views), the request for proposals QI grant project (180 views) and developmental screening under the Families tab (139 views). WisMHI conducted 16 pediatric primary care team trainings related to MH with a total attendance of 180 including 54 clinicians. Furthermore, 18 individuals received Continuing Medical Education credit for their participation, and 59 pre-assessments and 7 post-assessments were completed. Within the 16 total trainings, 28 clinics/agencies (9 health clinics, 5 health departments, and the following agency types: Department of Health Long Term Care Program, school district, family resource center, child protective services, and preventative medicine residency program) were reached. Three of the four MH mental health trainings were conducted by WisMHI in collaboration with the Child Psychiatry Consultation Program funded by state General Purpose Revenue and administered by FHS through the Medical College of Wisconsin provides consultation, education, and referral support to enrolled primary care providers caring for children and adolescents with behavioral health concerns. Trainings were conducted in all five DPH regions. Nine final reviews with sites trained in the previous six to nine months were conducted with all sites reporting using developmental screening and mental health screening tools at the American Academy of Pediatrics recommended ages.

Figure 1: Cumulative (2006-2018) MH training sites by county.

Data Source: WisMHI data report.

Between 2006 and 2018, 241 MH/developmental screening trainings were held. In 2011, pediatric mental health screening tools trainings were added; 44 were held by the end of 2018. Since 2006, trainings have been held across the state with multiple trainings held in the most populous counties (see map). The RCs provided information on MH concepts to 171 families (up from 119 in 2017).

Advance family understanding of the importance of high-quality care coordination within and across systems. In 2018, 15 MH trainings for families were conducted with 212 participants. Based on feedback from surveys and parent focus groups, “Coordinating Your Child’s Health Care” was modified to a 40-minute online training https://familyvoiceswi.org/learn/. Utilization of this online training was lower than expected. Families reported that face to face trainings offered opportunities for networking and stressed the importance of providing a variety of methods for families to access trainings. One RC tested using care mapping as a focus of training content that is being further tested in 2019. In 2018, a team created an evaluation form for all trainings that included common impact questions to measure increase in knowledge and skills. The form was piloted and then adopted for use by the Network in the last quarter of 2018.

Figure 2: 2018 Medical Home Trainings.

Data Source: RedCap report. Note: Coordinating Your Child’s Health Care is a webinar. However, one in-person session was held with nine attendees and two webinar participants did not provide their zip code and are not on the map.

Support care coordination and Continuous Quality Improvement methodologies to include promotion of family partners (contract with WisMHI to administer). In 2018, the CYSHCN Program contracted with nine tribal health centers (one withdrew midyear because of staff departures) and eight practice sites selected through a competitive process to participate in the Advancing Family-Centered Care Coordination Learning Community QI Project lead by WISMHI.

Figure 3: 2018 QI project team sites.

Data Source: 2018 WisMHI report.

All sites were asked to implement a Shared Plan of Care (SPoC) consistent with the Lucile Packard Foundation's “Achieving a Shared Plan of Care” for at least 10 children. The SPoC includes three required elements: family strengths and preferences, a negotiated plan of action, and a medical summary. The QI teams participated in three Learning Community calls and one all-day grantee meeting. In addition, the clinical practice teams (physician, nurse) and families piloting the SPoC reported quarterly on a set of measure listed below.

Figure 4: Driver Diagram: Advancing Family-Centered Care Coordination Learning Community QI Project

Data Source: 2018 WisMHI report.

Figure 5: Number of teams participating in learning community calls and in-person meeting

Data Source: Call attendance report.

Figure 9: Percent of teams’ use of SPoC helps their team communicate more efficiently.

Data Source: RedCap quarterly provider and family survey.

Review of feedback on quarterly care team surveys highlights both challenges and learned lessons from the care team’s perspective on how using SPoC impacted the care they provide as well as how they interact with families. Communication improved with families and health care colleagues. The SPoC was identified as a structured way to share and communicate a child’s information. Enrolling families and updating the SPoC were challenges for clinics when children and families returned infrequently. Opportunities for better communication and coordination as well as improvements in identifying and understanding family needs were learned through this SPoC work. This was most evident in Q3 and Q4, after the teams and families had time to work together. Of the families that responded to the survey question asking whether they had access to the SPoC, the range of accessibility was 85% - 97% throughout the year. Time tracking of care coordination activities occurred in May 2018 using the Care Coordination Measurement Tool (CCMT) for teams https://medicalhomeinfo.aap.org/tools-resources/Documents/CCMT_2017.pdf. Results of the CCMT indicated of the 363 encounters, the top area of focus was clinical/medical management (72%) and the top care coordination need was coordination of services: schools, agencies, payers (58%). The top activity performed was chart review (31%). Practices reported unnecessary visits to the pediatric office/clinic were prevented (20%) and positive outcomes, which occurred as a result of coordination, included meeting family needs, questions, and concerns (43%). The average time per encounter was 17 minutes with approximately 6,109 minutes (102 hours) total time documented. Events were the primary way that clinics engaged families. Only three clinics routinely were engaging families as representatives in QI team meetings. This evidence reinforced the need to provide additional resources to support family engagement as partners in this QI systems level work. The 2018 SPoC project materials are available at: https://www.chawisconsin.org/initiatives/medical-home/learning-communities/.

The 2018 fall workforce development day focused on how, as a CYSHCN Network, we could better support youth/family engagement in this QI work with the UW Center for Patient Partnerships facilitating the training. Roles and responsibilities were documented for the RCs, FVW, P2PWI, and YHTI in partnership with WisMHI as the lead. A welcome guide was developed (approved by DHS in 2019) for use with QI teams https://www.dhs.wisconsin.gov/publications/p02349.pdf. The CYSHCN Program also participates in the CMC CoIIN. CHW serves as the project lead and fiscal agent in partnership with the UW AFCH. The CYSHCN Program through Title V funding supports the participation of FVW, the Southern and Southeastern RCs, the CYSHCN Program staff, and the MCH QI Program Director who participate on biweekly calls with the practice teams along with a day-long team retreat. An aim of the CMC CoIIN is a 10% increase over baseline of Complex Care Program participants also enrolled in CLTS waiver program. Both clinical teams have recruited family participants who participate in team meetings.

Administer the implementation of the CPCP to increase primary care provider access to psychiatric consultation for children with mental health concerns (contract with the Medical College of Wisconsin). The Medical College of Wisconsin continued to receive funds from DHS to implement the CPCP. In 2018, CPCP received increased state general purpose revenue funding from $500K to $1M to expand to at least one or more additional DHS public health region. This program supports the behavioral health needs of children and families by providing: consultation to primary care providers (PCPs) regarding diagnosis and management options for children and adolescents with mental health problems, referral support system for pediatric patients to other mental health professionals, community resources as identified and needed, education and training in mental health issues for primary care providers. Since program inception through December 31, 2018, 152 clinics and 645 providers have been enrolled and there were 2,492 CPCP consults given to enrolled providers. In October 2018, DHS was awarded a five-year grant ($450K) titled Pediatric Mental Health Care Access Program from the HRSA Maternal Child Health Bureau to extend the current CPCP services to additional primary care providers in southern and southwestern Wisconsin. For more information on CPCP, see the Child Health Domain. It is important to note that the 2020 CYSHCN MH Plan will no longer include this strategy since it is addressed in the Child Health Domain.

Provide easily accessible referral resource information to families and providers by linking families to needed supports and services. Families and providers who contact the five RCs receive direct assistance and referrals to supports and services. In 2018, there were 1,304 referrals to the RCs (12% increase from 2017) representing 1,065 families (up 50% from 2017) from 68 of 72 counties. The top sources of referrals to the RCs were health care providers, county/community agencies, and family/or friend. The most common referrals made by the RCs were to CLTS services, behavioral health, and health benefits. Only 50% of referrals resulted in receiving services.

Figure 10: Referral Outcomes.

Data Source: RedCap RC report.

The referrals with the highest unmet needs were behavioral/mental health and CLTS waiver services (similar to 2017). Among those with an unmet need, 37% were on the waitlist for CLTS. The RCs also provided informational calls and consultations to community providers. It is expected that increased funding for the CLTS waiver will reduce the waitlist. In addition, The RCs conducted promotional activities to increase awareness throughout the state.

Figure 11 (left): Types of information calls and Figure 11 (right): Top RC consultations.

Data Source: RedCap RC report.

Figure 12: Location and number of activities.

Data Source: RedCap RC report.

Well Badger received 1,537 contacts with 268 (17%) related to CYSHCN. P2PWI made 289 parent-to -parent matches (an increase of 15% in 2018) and 96% of matches were completed. This means that each parent in a match received a check-in call after one week and an evaluative call at approximately six weeks following matching. P2PWI conducted 5 trainings that resulted in 35 newly trained support parents. In 2018, FVW published a set of eight CLTS fact sheets, five of which were new. Additionally, a fact sheet on the Katie Beckett Program and one on “Finding and Keeping Direct Care Workers” were also developed. FVW utilizes a Materials Review Committee comprised of diverse family members to review fact sheets and newsletters to ensure that written materials are linguistically and culturally appropriate and accessible. At the end of 2018, FVW updated its website and URL. With the website change, end of year analytics were not available. However, prior to the URL change, there were approximately 13,500 page views. With regard to health insurance, the CYSHCN Program contracts with ABC for Health to accept referrals from the RCs to assist with complex health benefits issues, to provide training and technical assistance to the Network related to health benefits and insurance access. ABC for Health provided health benefits assistance to 176 families representing 201 CYSHCN. Annually, ABC for Health conducts a health benefits competency survey of the Network that is used to determine training needs. ABC for Health has 260 video case tips (96 new videos in 2018) currently active on their website and YouTube channel with over 37,630 video views in 2018 https://www.safetyweb.org/healthwatchwi/casetips.html.

During 2018, the GSI hub coordinated monthly meetings with the CYSHCN Program. Based on feedback from the Genetics Advisory Committee (GAC) members, meetings changed to mostly distance communication through various modes: email newsletters, a follow up survey, an in-person meeting in conjunction with the statewide genetics exchange, and December virtual meeting. These forms of communication served to update the members on genetics activities in the state, to allow members to participate in the state response to the Midwest Genetics Network (MGN) invitations and activities, and for members to advise other activities of the GSI hub and recruited additional family members to serve on the GAC. Five new members were recruited (three pediatricians, one laboratory, and one parent). The GSI hub participates in the MGN and its three work groups: Health Equity, Tele-genetics, and Provider Education. As a result of this work, the GSI hub worked with members of FVW, the Southern and Southeastern RCs, as well as the UW Waisman Center, and health system and regional partners from other states on these initiatives. Six Wisconsin delegates attended the October 2018 MGN meeting. The website https://geneticsinwisconsin.wisc.edu/ was updated and had 2,648 unique users and 3,110 sessions (hits). The GSI hub hosted the “Genetics Exchange” annual meeting with 130 participants (up from 104 in 2017).

In 2018, the CYSHCN staff, along with funded Network partners, were part of the Wisconsin Care Integration Initiative (WiCII) grant of the UW Waisman Center serving on both its advisory team and larger Learn the Signs Act Early state team. A focus of this work is to improve linkage to services for children with autism spectrum disorder and their families. Family navigators identified regional differences and barriers to access.

6. Assure family, youth, and consumer participation in MH policy development, program planning and quality improvement. FVW with P2PWI, the RCs, the YHTI, other hubs, and the CYSHCN Program created a Family Engagement and Leadership matrix for the Network, which clarified and defined terms and activities. This matrix was organized under the “identify, connect, support, and sustain” framework first created in 2015 by the Network. Activities are implemented at the individual family, community (RCs), and state level. FVW has also been a partner in the Family Action Network with the Waisman Center. The listserv includes 1,932 members (up from 1,798 in 2017). There were four newsletters created and distributed to 2,230 individuals and organizations (80% family members). FVW facilitated a listening session at Circles of Life Conference with a report of the session at https://familyvoiceswi.org/wp-content/uploads/2019/01/Family-Voices-of-WI-Listening-Session-Report-2018-2.pdf.

FVW continues work with the Survival Coalition to advocate for the elimination of the waitlist for CLTS waiver services and improved access to services for families.

A core team of representation from MCH/CYSHCN state staff including the health equity consultant along with FVW and youth representation came together to address enhancing family, youth and community engagement. This core team attended the MCH National Workforce Development Center’s summer skills institute in July 2018 and then were accepted into their 2018 fall cohort to continue their work. The aim of the core team is: By December 31, 2025, strengthen family, youth, and community member engagement within all MCH/CYSHCN programs because programs that respond to participants’ experiences are more effective. An expanded state team was created that includes the CYSHCN Medical Director, the Title V Director along with P2PWI and others who meet monthly. Beginning in late 2018, the team created tools, processes, and databases for all MCH local programs to use to measure their program’s effectiveness in family, youth and community engagement and make an action plan for improvement. The tool is called Community Assessment of Engagement Tool that measures 14 indicators of engagement. The team recruited pilot sites for 2019 to select one indicator to develop an improvement action plan. Two CYSHCN programs (FVW and the Northern RC) will serve as pilot sites in 2019.

National Performance Measure 12: Percent of adolescents with special health care needs who received services necessary to make transitions to adult health care.

As part of the 2015 MCH Title V needs assessment process, it was identified that “too few adolescents ages 12 through 17 receive the services and supports necessary to transition to adult health care.” In 2018 the CYSHCN Program selected the NPM related to youth health transition for CYSHCN. The Title V Program, with partners that included the CYSHCN Network, MCH Advisory Committee, and others, selected evidence-based and/or informed strategies and measures related to NPM 12. The Wisconsin YHTI was identified as the lead for Title V Youth Health Transition related activities in 2018 in partnership with the CYSHCN Program, the MCH Program and the CYSHCN Network. Listed are the 2018 strategies and outcomes:

1. Develop and implement consistent strategies and tools with common messaging and promotion of best practice in transition planning. As part of the strategy to promote common messaging and best practices, the Wisconsin YHTI (www.healthtransitionwi.org) and RCs websites link to the Got Transition website. In 2018, there were 1,845 unique users and 2,362 sessions (hits). The YHTI also maintained a listserv that has grown to 443 members. In 2018, 24 updates were sent via the listserv with an open rate that ranged from 15% to 26% (industry average: 13.2%). The Build Your Bridge workbook was made available for parents to download in early 2018 https://healthtransitionwi.org/wp-content/uploads/sites/178/2018/01/BuildYourBridge_2018.pdf. The YHTI maintains regular contact with the RCs and CYSHCN Network through a variety of methods including participation in quarterly Network Directors’ meetings, RC calls, and transition specific e‐mail communications. In partnership with the Title V MCH Adolescent Health Coordinator, the YHTI partnered with the Wisconsin Providers and Teens Communicating for Health (PATCH) Program to include youth health transition within the PATCH messaging. PATCH trains youth across the state to be active partners in their own health care. The YHTI encouraged PATCH to modify their message so it can also be achieved by youth with special health care needs as well.

2. Promote the adoption of transition policies and practices, and build capacity for family leadership through Transition QI grants. There were three competitive clinic/health system transition QI grants awarded in 2018. One tribal health center, with two locations, was also selected to focus on youth health transition. The YHTI provided technical assistance to grantees on a monthly basis. RCs were available to QI project teams in their region as well.

Figure 13: 2018 youth health transition QI projects.

Data Source: Youth health transition data placemat.

All clinics were asked to complete the Got Transition Assessment of Health Care Transition Activities (https://www.gottransition.org/resourceGet.cfm?id=233 ) both at the beginning of their grant cycle (baseline) and at the end of their grant cycle (follow‐up). Clinics rated themselves from level one to level four on eight Transition elements according to Got Transitions. While the four clinics all made progress, they were all different. CHW Transplant and CHW Rheumatology both started higher at baseline compared to CHW Down Syndrome and Ho Chunk. Collectively, there was improvement between baseline and follow‐up in the six core domains and two family engagement measures. The average score at baseline was 57.8% and 71.8% at follow‐up.

Figure 14 (left): Got Transition assessment of health care transition activities CHW Down Syndrome and Figure 14 (right) CHW Transplant.

Data Source: RedCap report of pre-post Got Transition assessment.

Figure 15 (left): Got Transition assessment of health care transition activities CHW Rheumatology and Figure 15 (right) Ho Chunk.

Data Source: RedCap report of pre-post Got Transition assessment.

All QI grant teams used Plan-Do-Study-Act (PDSA) cycles to determine progress and make adjustments to their plans as they worked towards their project aims. Fifty youth readiness assessments were completed, 27 families participated in the Build Your Bridge training and an additional 16 youth members participated in other transition related activities. All transition QI grant teams participated in a day-long summit where they learned more about the SPoC, the CCMT, PDSA cycles, focus area activities, as well as networking with professionals and families. Keynote speaker Dr. Jill Rinehart, M.D., F.A.A.P., from Vermont, discussed best practice use of SPoC. For more information on the QI grants see the CYSHCN Domain: MH NPM.

3. Develop and implement presentation/training opportunities for key systems and professional associations. The YHTI conducted quarterly Learning Community calls in 2018 https://healthtransitionwi.org/learningcommunity/. Attendance was a requirement for grantees but all listserv members were invited to attend. The dates and topics included:

3/27/18 ‐ Health Care Transition Payment Strategies – Wisconsin Transition Learning Community Peggy McManus, MHS, Got Transition, The National Alliance to Advance Adolescent Health (31 participants); 5/22/18 - Successfully Partnering with Youth: Strategies for Including Young Adult Perspectives to Improve Adolescent Health Outcomes – Wisconsin Transition Learning Community & PATCH Erica R. Koepsel, MA PATCH Program Manager and Eliette Soler, PATCH Teen Educator (27 participants); 9/25/18 - Transition Tools & Resources: Meeting the Needs of Different Audiences by Maia Stitt, MS Youth Health Transition Initiative (YHTI) Coordinator (20 participants); and 11/27/2018 - Part I: Journal Review: Discussion and Highlights of Updated 2018 Clinical Report on Transition. Youth Health Transition Team and Part II – Wisconsin Board for People with Developmental Disabilities Tools and Resources: Jeremy Gundlach, Communications Specialist (21 participants).

Figure 16: Participant satisfaction with training received (this question was not asked in March 2018).