CSHCN Overview
Children with special health care needs (CSHCN) include children with a wide variety of physical, emotional and behavioral conditions, some of which qualify to receive support through the Children’s Special Health Care Services (CSHCS) program within MDHHS. CSHCS annual program enrollment has grown to approximately 50,000 beneficiaries. The CSHCS Division is housed in the Bureau of Medicaid Care Management and Customer Service. The CSHCS Division includes the Family Center for Children and Youth with Special Health Care Needs (Family Center), which is parent-directed and designed to support and connect families with the care they need using a family-centered approach. CSHCS also includes sections focused on customer support, policy and program development, quality and program services, and the special needs fund. For the CSHCS population, Title V funds are primarily used to support medical care and treatment for CSHCN. Other federal funds that support CSHCS include a HRSA Epilepsy grant and Medicaid. Key partners include Medicaid, Medicaid Health Plans, local health departments (LHDs), service providers, CSHCN and their families, the CSHCS Advisory Committee, the Family Leadership Network, Michigan Family to Family Health Information Center, and Michigan Family Voices.
Michigan’s approach to improving the health and well-being of CSHCN focuses on access to continuous health coverage and benefits. Services offered are patient-centered/family friendly, culturally appropriate and coordinated. These attributes are reflected in all CSHCS services, including those specific to health care transition. In the current five-year cycle, the CSHCS program also began to work on bullying prevention for CSHCS.
In addition to direct CSHCS funding received by LHDs, agencies can elect to expend additional LMCH funds for CSHCN. Three LHDs selected NPM 12 (transition) to identify enrollees of transition age and provide education and plans of care for gap-filling transition services. Additionally, three LHDs used LMCH funds to address SPM 4 (medical care and treatment for CSHCN) by providing gap-filling case management services, assistance with CSHCS enrollment, outreach and social media activities. Most agencies were able to complete these activities at reduced capacity due to COVID-19.
According to the 2017-2018 National Survey of Children’s Health (NSCH), 19.8% of Michigan’s children have special health care needs, as compared to the national average of 18.5%. However, more than a third of non-Hispanic Black children (34.5%) were identified with a special health care need. Additionally, only 15.9% of Michigan parents of children with special health care needs report that their children receive care in a well-functioning system.
Transition (FY 2020 Annual Report)
In response to previous needs assessment findings that 41.2% of CYSHCN received the services needed for transition to an adult care provider, Michigan adopted NPM 12 (“Percent of adolescents with and without special health care needs who received services necessary to make transitions to adult health care”) as a priority focus. To address this NPM, CSHCS created a comprehensive strategic plan to improve transition services across the state. Specific strategies were identified for local health departments (LHDs), Medicaid Health Plans (MHPs), medical providers, school-based health centers, adolescents, and families.
Accomplishments in FY 2020 included significant integration of medical transition considerations into transition efforts in the education sector through involvement in the Michigan Interagency Transition Taskforce (MITT); completion of MHP Focus Studies with a focus on transition, creating a quality improvement initiative for use by school-based health centers across the state; and expanded utilization of transition resources by providers of Michigan’s Children and Youth with Epilepsy (CYE) project. CSHCS worked with MHPs, LHDs, the MDHHS Child and Adolescent Health Center (CAHC) section, HRSA-funded CYE grant participants, Got Transition, AMCHP’s Replication Grant team, and other MCH-funded organizations such as Florida Health and Transition Services (HATS). Challenges included slowed implementation of strategies due to COVID-19. In response to these challenges, CSHCS adapted program strategies to a virtual environment, focused efforts on establishing infrastructure, and invested in statewide collaboration efforts to maximize impact. Existing strategies were adjusted to provide maximum flexibility for partners who were focused on responding to COVID-19.
Objective A: By 2020, increase the number of youth who have a plan of care that includes transition planning, beginning at age 14, by 4.1%.
The first strategy for this objective was to provide health care transition technical assistance to community partners, including LHDs and MHPs. The transition specialist assists with transition for LHDs through technical assistance trainings on request, maintaining a website of resources, and assisting with individual clients. In FY 2020, LHDs assisted with transition through 1,527 billable encounters for 1,387 unduplicated families.
The transition specialist participated in focus studies with each of the MHPs. In FY 2020, CSHCS included transition expectations in the MHP contract. The focus studies were utilized to determine the level of compliance with the new language. The focus studies allowed the opportunity to build relationships with MHP staff, learn about current transition activities at the MHPs, provide resources, and offer ongoing support. Information gathered at these focus studies will provide a baseline and will help to inform future opportunities to engage MHPs in transition interventions.
The second strategy for this objective was to update current automated letters in Community Health Automated Medicaid Processing System (CHAMPS) claims processing system. In FY 2020, letters for 16-, 17-, 18-, and 21-year-old CSHCS Clients were updated with Got Transition Six Core Elements 3.0, edited to provide consistency, and finalized. The letters were shared with diverse stakeholders for review and approval. The changes were proposed to and accepted by Medical Services Administration (MSA) for integration into the CHAMPS processing system with an anticipated “go live” in March 2021. In FY 2020, a new letter targeting 14-year-old CSHCS enrollees was created with the assistance of a diverse subcommittee containing Office of Medical Affairs physician consultants, Family Center staff, the Family Center Youth Consultant, the project coordinator for the CYE grant initiative, local health department representatives, and the transition specialist. The letter was shared with and approved by multiple stakeholders. The letter will be piloted in FY 2021.
For the final strategy, CSHCS continues to utilize the MDHHS Data Warehouse to track when CSHCS clients transfer care from a pediatric to an adult provider. Through a contract with the University of Michigan’s Child Health Evaluation and Research (CHEAR) unit, an Evidence-informed Strategy Measure (ESM) was developed to provide ongoing analysis and support related to the CSHCS program. The measure is based upon selected groups that include cardiology, endocrinology, gastroenterology, hematology-oncology, nephrology, neurology, pulmonology, and rheumatology. The measure combines encounter data from three sources: 1) CSHCS database; 2) CHAMPS (Medicaid Claims) database; and 3) University of Michigan’s provider database which includes providers statewide. In FY 2020, CHEAR reported 46.5% of targeted clients had encounters with only adult providers, indicating a successful transition to the adult model of care. After further investigation, an additional 7.7% of clients in the targeted population had encounters with both pediatric and adult providers. Based on current transition strategies, this would indicate individuals who are in the process of transferring to an adult model of care.
In FY 2020, CSHCS began the process of working with CHEAR to further stratify data regarding race, ethnicity, and other socioeconomic factors. Moving forward these data will help to identify health inequities and inform future interventions.
Objective B: By 2020, increase the number of youth and families by 50 that are aware of and understand the transition to adulthood process.
The first strategy for this objective was to pilot a school-based adolescent transition replication project in one school. In FY 2020, pilot results and outcomes were shared with stakeholders. Outcomes were presented at AMCHP’s 2020 Conference as part of a panel to provide information on and promote replication projects. The project was featured on a Poster Presentation in partnership with Got Transition. Outcomes were also shared with the CSHCS Advisory Council, Child and Adolescent Health leadership, and clinic teams from across the state.
Plans to replicate the project in five schools through a learning collaborative model were impeded by the COVID-19 pandemic. As schools responded to the changing pandemic environment, each Child and Adolescent Health Center had unique responsibilities. In response, the transition specialist modified the replication project and created tiers of collaboration for Child and Adolescent Health Centers. Each tier offered an Assessment of Current Health Care Transition Activities, access to resources, and technical assistance. For those with the capacity to fully engage in the replication process, they would have the opportunity to create a team and implement a full quality improvement project around transition. For those Centers with limited capacity, the transition specialist offered a mid-range option with streamlined data reporting requirements. The third tier was created for those Centers with little capacity to engage. Resources and technical assistance are available on demand with few reporting requirements. These options were communicated with the Health Centers. Work continues to engage these Centers in FY 2021.
One outcome from the pilot project was the collection of significant feedback on the Transition to Adulthood Online Module. The Transition to Adulthood Online Module was designed to assist adolescents in preparing for transition and ultimately transferring to an adult provider. The Family Center Youth Consultant spearheaded the project to ensure the course is adolescent-friendly and relevant to current challenges. Feedback from multiple stakeholders was integrated into the course. Work will continue in FY 2021 to promote the Transition to Adulthood Online Module to adolescents and families. This will include outreach to LHDs, Child and Adolescent Health Centers, and providers across the state to encourage them to share the online module with the families they serve.
The second strategy for this objective was to ensure health care transition is considered during secondary transition in school systems. During the grant period, the transition specialist served as an integral member of the Michigan Interagency Transition Taskforce (MITT). This taskforce is a diverse collaboration with representation from the Department of Education, Protection & Advocacy Services, Developmental Disabilities Council, Department of Labor and Economic Opportunity, the Arc Michigan, Behavioral Health and Development Disabilities Administration, Disability Rights Council, and Services to Enhance Potential. The Taskforce is working with the National Technical Assistance Center on Transition to create a Michigan State Model for Secondary Transition. The model combines different best practice models with the goal of improving post-secondary outcomes for students and youth with disabilities. The model incorporates the following objectives: building skills to safely navigate community and access services; setting expectations of competitive integrated employment; setting expectations and developing skills to live independently; exploring post-secondary education options; and building self-determination, advocacy, and leadership skills. The transition specialist provides the health care perspective to the collaboration as well as serving as a liaison between this statewide initiative and CSHCS. Work will continue in FY 2021.
The second strategy for this objective was to collaborate with Michigan Family Voices to provide transition information to families. The transition specialist meets regularly with Michigan Family Voices to discuss opportunities to reach families needing assistance with Transition. In FY 2020, outreach activities were severely limited due to COVID-19. In response, the transition specialist modified existing strategies and focused efforts on updating transition resources available on the website. A diverse committee was formed to review, update, and add to website resources for families, providers, LHDs, and MHPs. The committee included the Family Center Youth Consultant, representation from Office of Medical Affairs physician consultant, Family Center representatives, CYE project coordination, and representatives from three local health departments. The goal of the committee is to update existing content to be consistent with Got Transitions Six Core Elements of Transition 3.0, organize information to make the site more user-friendly, and create a plan to promote the new website. Work on this activity will continue into the next grant period.
The final strategy for this objective was to integrate youth voice and participation in the development of transition interventions. The Family Center Youth Consultant is integral to the success of Michigan’s health care transition efforts. During the grant period, the Youth Consultant co-presented with the transition specialist at the annual conference for Child and Adolescent Health Centers. This presentation shared outcomes from the Transition pilot, led attendees through the process of evaluating their transition activities, and laid the groundwork for replicating the transition project. In addition, the Youth Consultant participated in a youth panel for the CYE annual meeting, sharing the youth perspective on transition. Also, at the CYE annual meeting, the Youth Consultant provided a presentation highlighting technology apps to help youth manage their epilepsy. Providers will utilize these resources to help youth in their practice learn to manage their epilepsy condition. In addition, these templates will be utilized to create resources for other conditions and will be available to families on the Family Center website. The Youth Consultant is a member of the AAP’s Children and Youth with Epilepsy Advisory Committee and the Pediatric Care Young Adult Advisory Committee. Work continues to integrate the Youth Consultant in projects across the CSHCS division.
Objective C: Increase provider awareness and understanding of the transition to adulthood process by 25% through the establishment and offering of a free online Medical Transition course.
For the first strategy in this objective, Michigan reviewed various online transition courses targeted to providers. Instead of replicating an existing medical education transition project, the decision was made to promote Got Transition’s Health professional courses. Got Transition provides free continuing education credits for physicians, nurses, and social workers through their respective state-based societies. In FY 2021, Michigan will create a marketing plan that targets health professionals and promotes Got Transition online course resources. The transition specialist will work with Got Transition to collect data to monitor the number of Michigan providers that complete the course.
The second strategy is to work through HRSA funded CYE grant’s learning collaborative to increase the number of completed health care transition readiness assessments of youth (ages 14-22) with epilepsy in the targeted population. To accomplish this strategy, the Quality Improvement (QI) Leadership Team created a plan for monthly learning/meetings, continuing education credits, the annual in-person meeting, and Year One clinic site QI activities. The Advisory Work Group, a larger group of stakeholders, met on a quarterly basis to provide further guidance to project planning. Each clinic site identified a team lead and clinical representative; all clinic teams identified a patient/family representative. Subcontracts and workplans were established with each of the clinic sites and project partners.
During FY 2020, clinic teams received training on health care transition topics at the in-person meeting, through a webinar, and Got Transition resources were shared. Teams completed an assessment of their health care transition activities at the December 2019 in-person meeting. The Leadership Team developed a mini teen survey to help clinic teams gauge the teen-friendliness of their clinics. More than 200 youth completed the mini surveys across seven clinical sites. The survey documented youth perspectives on their experience in the clinic by asking questions about whether they checked themselves into their appointment, whether clinic staff spoke directly to the teen, whether the teen answered questions from the nurse or doctor, whether the teen felt the doctor listened as much to the teen as the parents, and whether the teen asked questions of the nurse or doctor during the visit. The project coordinator, evaluator, and medical consultant also conducted one-on-one calls with each clinic team during February and March to discuss health care transition activities, survey findings, and assist teams with refining their QI project. Work continues for this strategy in FY 2021.
Medical Care and Treatment for CSHCN (FY 2020 Annual Report)
Michigan’s SPM for the CYSHCN population measures the percent of CYSHCN enrolled in Children’s Special Health Care Services (CSHCS) that receive timely medical care and treatment without difficulty. The measure was originally aimed at addressing Michigan’s 2015-2020 state priority need to reduce barriers, improve access, and increase the availability of health services for all populations. CSHCS was created to find, diagnose, and treat children who have chronic illnesses or disabling conditions enabling them to have improved health outcomes and enhanced quality of life.
CSHCS accomplishes this mission by reducing barriers to medical care and treatment and minimizing financial burden for families. In FY 2020, approximately 36% of Michigan’s Title V funding was used for medical care and treatment for CSHCN. CSHCS utilizes two survey questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) to determine the “Percent of CYSHCN enrolled in CSHCS that receive timely medical care and treatment without difficulty” (SPM 4). In FY 2020, the result was 88%.
FY 2020 challenges included the COVID-19 pandemic and increased tensions related to racial bias, social injustice, and health disparities in Michigan. CSHCS responded to challenges by embracing technology, reviewing lessons learned from the pandemic, identifying ways to assess health disparities and apply a health equity lens, and focusing on program development. COVID-19 had and continues to have a substantial impact on the CYSHCN population including causing fear in accessing the health care system, stress from the impact of school closures, and pressure to make the correct decisions for their family. COVID-19 impacted the health care system causing closure of offices early in the pandemic, workforces transitioning to remote work environments, and rapid adjustment to telemedicine practices to ensure continued access to care.
CSHCS converted to a remote workforce and increased use of technology to ensure continuation of services while maintaining staff safety. In-person site visits, trainings, and collaborative meetings shifted to virtual, including Children’s Multidisciplinary Specialty Clinic (CMDS) site visits, Medicaid Health Plan (MHP) focus studies, advisory committee meetings, trainings, and others. Telemedicine expansion within clinic settings led to improved access to services for CYSHCN who were impacted by decreasing availability of face-to-face services. COVID-19 created significant policy challenges, to which CSHCS responded by adjusting policies and procedures, and participating in Medicaid policy groups to ensure no negative impact for CSHCS enrollees. Adjustments were also made to transportation services including discontinuing rideshare practices and the requirement of an in-person signature.
Despite COVID-19, CSHCS participated in the MCH Workforce Development Cohort (WDC) to create a comprehensive program evaluation, was accepted into the Boston Children’s Care Coordination Academy to improve service coordination for children with medical complexities and supported a pilot pediatric palliative care program.
Objective A: By 2020, reduce barriers to medical care and treatment by minimizing financial barriers from the increased medical services associated with the child’s special need, as measured by a 5% increase in the Insurance Premium Payment Benefit Assistance program.
The first strategy was to provide payment assistance for specialty care and treatment related to a qualifying condition by enrolling CYSHCN in CSHCS. CSHCS covered an average of 44,000 individuals each month in 2020 with more than 2,600 qualifying diagnoses. Approximately 26% of enrollees have more than one severe, chronic health condition. Families with CSHCS receive care coordination through local health departments (LHDs). In FY 2020 LHDs provided more than 17,000 care coordination or case management encounters to 10,905 unduplicated clients.
CSHCS made operational changes to minimize the impact of the COVID-19 on CSHCS clients. Clients due for medical renewals received a one-year extension. Physician submission requirements were relaxed to allow NPs and PAs to submit enrollment and renewal documentation. Guidance was issued to CMDS clinics that allowed them to use telemedicine to conduct team visits with clients in their home and to LHDs to provide case management telephonically. Temporary enrollment and client audit procedures were suspended. COVID-19 vaccine administration fees became covered services for enrollees who lack other insurance.
The Family Center for Youth with Special Health Care Needs (Family Center) is a statewide parent-directed center within CSHCS. The Family Center offers emotional support, information, and connections to community resources to families of CYSHCN. The Family Center responded to COVID-19 by shifting current programs to a virtual environment. Parent Mentor and Bereavement Parent Mentor Trainings were provided virtually. Family Leadership Network (FLN) and other advisory committee meetings were held virtually, Parent to Parent trainings were initiated to provide education and conversations around CSHCS services and transition. In FY 2020, the Family Center provided 46 presentations to families and communities, answered 9,534 Family Phone Line calls, completed 25 parent-to-parent matches, and funded 19 camp or conference scholarships.
The second strategy for this objective was to continue offering the Insurance Premium Payment Assistance Benefit (IPPAB) program. The IPPAB provides financial support to eligible families who lack adequate financial resources to pay the portion of their family’s private or employer-based insurance premium specific to the eligible child. In 2020, 172 families qualified for IPPAB and received $304,500 in support.
The final strategy for this objective was to continue providing support for CYSHCN and their families through the Children’s Special Needs (CSN) Fund. The mission of the CSN Fund is to provide support to CYSHCN in Michigan to obtain equipment and services to promote optimal health. In FY 2020, the CSN Fund received 148 applications, approved 92 grants, and provided $404,156 to purchase equipment.
Objective B: By 2020, improve access to medical care and treatment by improving the systems of care for CSHCN clients, as measured by the CMDS patient satisfaction survey.
Michigan utilizes CMDS clinics to offer highly coordinated, interdisciplinary teams to care manage chronic conditions for CSHCS enrollees. CMDS clinics provide enhanced, patient-centered, family-friendly, and equitable care coordination services. Utilizing this model helps to address provider shortages in Michigan, while simultaneously wrapping services around families. CMDS clinics have a medical director and operate under the authority of hospitals/medical universities. Teams include social workers, nurses, therapists, dieticians, and other specialties as needed to provide comprehensive care for enrollees. CSHCS provides enhanced reimbursement to support the ancillary members of the team and offset the time and resources needed to provide complex care coordination. In FY 2019 (the most recent year with final data), CMDS clinics reported 3,315 client encounters with more than $472,800 of enhanced benefit provided to the clinics.
The first strategy for this objective is to improve the quality and effectiveness of CMDS clinics by conducting site reviews. Four site visits were conducted by CSHCS, Family Center and Office of Medical Affairs staff in FY 2020. Due to COVID-19, two of the four site visits were completed virtually. Clinic sites are evaluated on their ability to provide patient-centered, family-friendly care in a coordinated and equitable manner.
In FY 2020, CSHCS accepted a proposal from Michigan Medicine to add an audiology field clinic in an area with a high population of Amish residents. In the field clinic model, a provider travels to a rural or distant area in Michigan to provide subspecialty exams, evaluations, and treatments for a specific medical condition. For Amish families, the distance between their county of residence and Michigan Medicine’s location made seeking care difficult. The field clinic will remove that barrier to care. Work to establish the clinic will continue in FY 2021.
As a second strategy for this objective, CSHCS was accepted to the National Center for Care Coordination’s Care Coordination Academy. The objective for the project is to establish specific case management and care coordination protocols to reflect promising and/or evidence-based practices for children with medical complexity. CSHCS utilized National Care Coordination Technical Assistance Center’s (NCCTAC) assistance to customize the Pediatric Integrated Care (PIC) Survey. Once completed, staff gained approval from the MDHHS privacy and security office to implement the survey. CSHCS piloted the PIC survey in a CMDS clinic located in rural Michigan. A second pilot of the survey will occur in FY 2021.
The third strategy for this objective was to facilitate discussions with three of the state’s largest Children’s Hospitals. In FY 2019-2020, CSHCS held meetings with C.S. Mott Children’s Hospital, DeVos Children’s Hospital and Children’s Hospital of Michigan. Information from these meetings was compiled, and staff has followed up on items within the scope of CSHCS. The discussions provided an opportunity for CSHCS to meet hospital administrators, assess program satisfaction, and identify opportunities to improve relationships with the medical community. In FY 2021, CSHCS will explore future partnership opportunities.
For the fourth strategy, CSHCS established a contractual relationship with Michigan Medicine’s Partners for Children (PFC) program to explore the feasibility of providing a palliative care benefit package for medically complex children enrolled in CSHCS. PFC is a team-based, home visitation, palliative care program, which provides 24/7 access for families. Due to the pandemic, many of PFC services have shifted to telemedicine.
MDHHS contracted with University of Michigan’s Child Health Evaluation and Research (CHEAR) Center to conduct pre-post comparisons of utilization and costs for children in PFC. For the first year, the study demonstrated positive impacts on reducing inpatient utilization and costs for medically complex children, yielding an average savings for the state Medicaid program of $1,915 per child per month. Cost savings were due to decreased inpatient care, particularly critical care. Increased expenditures for prescription medication and other outpatient services demonstrated that savings were not due to constrained care. Moving forward, CSHCS will work with Michigan Health Endowment Fund to explore and determine sustainability efforts.
For the fifth strategy, CSHCS held focus studies with all 10 Michigan MHPs in FY 2020. The focus studies discussed topics such as processes impacting enrollment for CYSHCN, health equity, care coordination/case management, transition, and family engagement. The CSHCS team consisted of OMA medical consultants, the manager of quality program services, quality analyst, and representatives from Customer Support Section, Policy and Program Development, and the Family Center. The studies identified opportunities to improve consistency in care coordination and transition services delivery. In addition to focus studies, CSHCS seeks to improve relationships between MHP and LHDs through regularly scheduled, joint conference calls to discuss challenges coordinating care for CSHCS clients.
In 2020, the Title V five-year needs assessment was completed and served as a springboard for creating a comprehensive evaluation for the CSHCS program. CSHSC was accepted as a team for the National MCH WDC’s 2020 Cohort with the project goal of creating a comprehensive program evaluation. The team adopted the CDC’s Framework for Evaluation in Public Health. In FY 2020 the team engaged stakeholders, utilized diverse perspectives to create a program description, and began the process of focusing the evaluation design. Due to COVID-19, the process became extended. The team continues to work with the WDC in a single-state arrangement. Work on the comprehensive evaluation project is continuing in FY 2021.
The third objective for this strategy is to assess health disparities and inequities for CYSHCN. In FY 2020 CSHCS’s health equity committee identified perceived health disparities in transition to adult health care for sickle cell disease patients and access to durable medical equipment for youth with type I diabetes. Committees were formed to evaluate these topics and work is continuing in FY 2021.
Objective C: By 2020, increase the availability of health services, particularly in underserved regions, through the utilization of telemedicine and community-based services.
The first strategy for this objective was to provide ongoing technical assistance and education for LHDs. LHD staff implement the program, identify enrollees, provide care coordination/case management service in the home and telephonically, and assist with access to and utilization of local resources. In FY 2020, COVID-19 significantly impacted the CSHCS Division’s ability to provide education to LHDs. Both workforces adjusted to remote working environments and many LHDs diverted time and resources to frontline COVID-19 response. CSHCS began the process of shifting annual, in-person training sessions to a virtual environment. CSHCS is planning to offer a half day, virtual training session for LHDs. CSHCS also adopted virtual meeting modalities for monthly LHD and CSHCS LHD Advisory Committee meetings to provide technical assistance, and gain LHD feedback.
The second strategy for this objective was to convene an interagency collaboration to reduce barriers for children with complex medical and developmental/behavioral needs. The collaborative committee included representatives from both state and local CSHCS and Behavioral Health, as well as ARC of Michigan, Community Mental Health (CMH) Association and child welfare. As a result of the collaboration, presentations were provided at three statewide conferences. The presentations were designed to improve understanding of CSHCS and how mental health providers can help families and youth with special health care needs. The collaborative began to develop tools for families, LHD staff, and CMH staff. A leadership committee was established to guide the work of the collaborative moving forward.
The third strategy for this objective was to incorporate telemedicine into patient care. In FY 2020, new telemedicine policy was promulgated to allow for provision of services to patients in their home. In response to COVID-19 there was a necessary shift to providing services via telemedicine. Additional flexibilities associated with providing telemedicine were granted and policies promulgated. The telemedicine workgroup reviewed these flexibilities, along with outcomes to identify what telemedicine components allowed during COVID-19 should be institutionalized for the future.
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