CMS is strengthening its public health services and systems for all CYSHCN with the goal that every child with medically complex conditions receive high quality, evidence-based, family-centered care, regardless of health insurance.  This plan started with existing CMS condition-specific specialty contracts (regardless of their funding source).  Contracts were re-aligned to include tasks associated with: 1) Identified Title V CYSHCN priorities 2) The Standards for Systems of Care for Children and Youth with Special Health Care Needs, version 2.0 3) Implementation of a Quality of Life measurement tool 4) Completion of the CYSHCN single organization assessment tool.

A framework of change management and adaptive leadership was instrumental in this realignment and in launching a Learning Action Network (LAN) and Quality Improvement initiative, done in partnership with the National Institute for Children’s Health Quality (NICHQ).  Seven condition-specific programs (Behavioral Health, Craniofacial, Endocrine, Chronic Kidney, Hematology-Oncology, HIV/AIDS and Pulmonary), representing 24 tertiary care/university teams across the state have joined in this endeavor.   This foundation transformed these historical specialty contracts, focused on direct care services, into the emergence of Statewide Networks for Access and Quality (SNAQs). A series of virtual meetings and in-person meetings and an online platform (for data and resource sharing amongst teams) supported the training, coaching and peer-to-peer learning in quality improvement methods.  These teams were guided in the development and testing of small cycles of change using the Plan Do Study Act (PDSA) cycle and sequence of improvement within their individual institutions.   At the time of this writing, over 40 PDSA cycles have been completed for approximately 20 active quality improvement projects in these organizations across the state. 

Community systems approaches include the evidence-informed strategy of public health detailing.  This initial pilot program was expanded with the use of 17 regional CMS staff (which includes five family leaders) that were experts in direct services for CYSHCN.  Extensive training in the core functions of public health and Title V CYSHCN priorities was provided.  This public health detailing workforce provides outreach, education, training and linkage of resources to community partners including providers that serve CYSHCN.  CMS hopes to expand the next phase of this pilot initiative with 10 additional staff.

Additional informed strategies for community systems approaches includes the integration of multisector service systems that work together on community needs, addressing social determinates of health.  CMS developed a framework for its regional network for access and quality (RNAQ) model.  The aim is to work with existing community partnerships with the goal to improve access and quality for children in their community.  Tenets of this model follow the core functions of public health and includes the Standards for Systems of Care for Children and Youth with Special Health Care Needs, version 2.0. CMS developed a request for application for community partners to apply for this funding and successfully awarded funding for two community programs to pilot this model.  Implementation has begun with one of the programs and the second is imminent.   Results from these programs will inform future decision making.

For NPM 11, CMS partnered 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 provided 1:1 technical assistance support to 24 pediatric practices regarding Patient Centered Medical Home (PCMH) practice transformation, it is anticipated that 80-90 percent will complete transformation and becoming PCMH recognized by June 30, 2020.  In order increase the impact and build capacity with this resource, a population health approach is being implemented for 2020.

Public health detailing efforts for the first six months of operations showed that 360 community providers were given education, technical assistance and resources on the need and value of becoming a PCMH.  Of those 39 percent (N=140) indicated they would like to have additional knowledge on how to become a PCMH as a barrier and 48 percent (N=174) expressed interest in receiving further technical assistance in becoming a PCMH.  To meet this identified need, in collaboration with UCF, a PCMH readiness assessment tool was developed and training was provided for the public health detailing specialist to implement.  These readiness assessments will be used to stage readiness for the next PCMH cohort (which will be increased to accommodate 36 practice sites) or the option to participate in a LAN to assist them in moving further along in readiness for consideration of the next cohort.  This LAN will consist of eight virtual meetings with a two- day in-person meeting to introduce and review the six core components needed to become a PCMH. Open offices hours will be offered to provide additional technical assistances as providers work towards PCMH transformation.  The public health detailing specialist will participate in the LAN activities for skill building capacity to further support and sustain this model.  Geo-mapping of Florida’s current designated PCMH practices is occurring, to help identify unmet needs in underserved areas for intentional outreach and engagement in these activities.

For NPM 12, continued collaboration is ongoing with FloridaHATS (our state transition partner) and Got Transition (our national transition partner).  Public health detailing efforts, in the first six-months of operations, included promoting the Six Core Elements of Healthcare Transition with 453 community providers.  CMS is working with all of Florida’s MCHB partners and other transition experts to collaboratively update and create a uniform Transition education module, which will be an additional resource for health care providers. CMS is currently researching evidenced-based or informed approaches as well as exploring other state’s CYSHCN transition programs activities to assist in the development of a request for proposal for a statewide youth led transition council.  This helps ensure youth voice is incorporated into future transition program planning, policy development and initiatives and may provide an opportunity to tap into existing resources without duplication of efforts.  The Jacksonville Health and Transition Services program (JaxHATS) continues to provide clinic services and skill-building strategies to transitioning youths. 

In conjunction with Got Transition, CMS Title V and the CMS Managed Care Plan operated by WellCare, are in the beginning stages of an 18-month project related to exploring, developing and implementing a small pilot focused on value-based payments to increase the percentage of 18 to 21-year-old members who transition from a pediatric provider to an adult care provider.  Elements of this may include coordinated exchange of current medical information, plan of care, communication between pediatric and adult providers, and facilitated integration into adult care consistent with Got Transition’s Six Core Elements of Health Care Transition.

In addressing our SPM specific to access to mental (behavioral) health treatment, CMS is expanding the evidenced-based practice of Behavioral Health Integration (BHI) by increasing the reach from two to five contracted university partners, also known as academic hubs. This includes the University of South Florida, Florida State University, University of Florida, University of Miami and Florida International University.  National guidelines and frameworks (such as the Center of Excellence for Integrated Health Solutions) steered the development of tasks and deliverables in the BHI contracts which include ongoing quality improvement activities.  The academic hubs partner with pediatric primary care practices and behavioral health organizations. The aim is to improve identification and treatment of children with behavioral health care needs by increasing the confidence, knowledge, and skill sets of pediatric primary care providers through skill building, technical assistance, and the availability of expert mental health clinicians to support management of behavior health conditions in primary care settings.  This includes the use of telehealth.

Current academic hubs represent five out seven regions in Florida and along with our external stakeholders, form a statewide network that collaborates on monthly statewide calls to ensure quality improvement, addressing challenges and barriers for future sustainability.  External stakeholders include other state agencies such as Florida’s Department of Children and Families: Substance Abuse and Mental Health agency; Agency for Health Care Administration; family representatives from the National Alliance on Mental Illness, etc. Future efforts include identifying partners in the two remaining regions.  A university partner will serve as the external evaluator to inform future decision making for sustainability and further replication of this model.

In the wake of our nation’s pandemic, COVID-19, key issues for all children will include their emotional wellbeing and mental health.  CMS will continue to survey needs and anticipates furthering its initial investment in behavioral health treatment, especially telehealth.  As part of these activities CMS’s Title V CYSHCN director is participating in the HRSA MCHB funded grant with the American Academy of Pediatrics, to improve care of children with ECHO’s model of education; Florida teams who care for children with medical complexity will be eligible to participate.

Florida’s Pediatric Psychiatry Hotline, funded by the Agency for Health Care Administration (AHCA), provides timely telephonic psychiatric consultation to primary care clinicians.  CMS partnered with this existing resource to add care coordination services.  This will help build capacity for additional referrals and include linkage to community resources for psychosocial supports and social determinates of health.

Public health detailing specialists provided education on the need for integrated behavioral health services to 462 community providers. Resources linkage was comprised of community specific resources, including those for social determinates of health, developed pediatric behavioral health guidelines by CMS, Florida’s Best Practice Psychotropic Medication Guidelines (sponsored by AHCA), AAP Behavioral Health Took Kits and informational flyers about Florida’s Pediatric Psychiatry Hotline.  Practices that are interested in integrating behavioral health services and demonstrate readiness will be staged for engagement with their regional academic hubs.