Priority - Medical home for children and youth with special health care needs

Update on PM annual objectives:

NPM 11: Percent of children with special health care needs who have a medical home was 40.9%. The annual objective for reporting year 2019 was 47.0%. The annual objective was not met. The drop between reporting year 2018 (46.2%; CI: 38.4-54.1) and 2019 (40.9%; CI: 33.2-49.2) was not statistically significant. There is some large fluctuation among the medical home components between the two years, but nothing significant since the confidence intervals are very wide (the CYSHCN sample size is small). There were no methodologic changes that could have accounted for the drop. The annual objective for reporting year 2020 is 41.0%.

ESM 11.2: Number of practices offering pediatric behavioral health services through telehealth/teleconsultation had a baseline of 0. Since ESM 11.2 was newly developed in 2019, we are unable to compare it to an annual objective. The annual objective for reporting year 2020 is 6.

For this reporting period, MCH Block Grant dollars were leveraged with State General Funds, earmarked for children and youth with special needs, to provide implementation oversight for this priority. These braided funds have supported the implementation of the strategies outlined in the medical home state action plan, a contract with the University of Colorado to support access to specialty care, a contract with Mile High United Way 2-1-1 to support access to information and resources and contracts with local public health agencies to implement medical home local action plans and provide care coordination services. In addition, Colorado received funds through an MCHB Pediatric Mental Health Care Access Grant and an MCHB Children with Medical Complexity Collaborative Improvement and Innovation Network (CoIIN). Approximately, 5 FTE at CDPHE are supported through these braided funds to oversee the CYSHCN strategies and associated outcomes summarized below. For a more detailed description, refer to the full state action plan.

The MCH state action plan to support medical homes for children and youth with special health care needs (CYSHCN) has been focused on identifying and implementing policy and system change focusing on three areas:

• Improved communication and collaboration across statewide programs that deliver care coordination for CYSHCN.
• Increased access to pediatric specialty care, including behavioral health.
• Improved access to information and resources for CYSHCN.

To improve communication and collaboration across statewide care coordination programs, the CYSHCN team at CDPHE participated in a collaboration between CDPHE, Special Care Clinic and Child Health Clinic at Children’s Hospital Colorado, and the MCH-funded care coordination teams from the three local public health agencies that serve the greatest number of children and youth who receive care through the hospital (Denver Health, Jefferson County and Tri-County health departments). This collaborative reviewed and enhanced existing referral processes and developed a communication workflow for making referrals and sharing plans of care when care coordinators from Children’s Hospital Colorado and local public health are working with the same family. The collaborative began testing care coordination work flow maps and evaluating the impact of the system on interagency communication and coordination of care between the hospital and local public health, identifying areas for process improvement and expanding to include the hospital’s outpatient clinics. The team members across the collaborative report improved communication, a better understanding of roles and responsibility. One of the collaborative team members participating in this new workflow said “MCH funded care coordination...has connected me to the school and the Community Centered Board. I work with these groups now instead of working in isolation.  This process has opened the horizon. I know I don’t have to manage all the care myself.”

The CYSHCN team continued to develop and strengthen relationships with Colorado Medicaid’s Regional Accountable Entities (RAEs). Each RAE is contractually responsible for ensuring access to primary care and coordinating care for their members, as well as fostering health neighborhoods. Health neighborhoods are considered to be an extension of the medical neighborhood and include other community-based supports that improve the health and wellbeing of Colorado's Medicaid members. In May 2019, the CYSHCN team participated in an online provider education series along with care coordination representatives from each RAE to discuss MCH-funded care coordination across Colorado. The series combined interactive learning and case-based discussion for health professionals to share and build knowledge and experience. Colorado Medicaid’s Program Improvement Advisory Committee provides stakeholder guidance and input for the Accountable Care Collaborative program that supports the statewide RAE infrastructure. The CYSHCN team participates on the Advisory’s Performance Measurement and Member Engagement subcommittee, and, in the current year, took on the role of voting member. The CYSHCN team continues to utilize this forum to foster relationships with the RAEs, advance population health strategies for CYSHCN and influence policy decisions that impact systems of care for CYSHCN. As an example, the CYSHCN team began working with the Colorado Court Appointed Special Advocates for Children (CASA) to better understand the child welfare system and supports needed by biological and foster parents, as well as case managers and CASA volunteers, and to identify and reduce barriers to accessing systems and supports. Each of the RAEs has selected children and youth in foster care as a special population to strengthen screening and referral services. The CYSHCN team has incorporated strategies into medical home priority local action plans to explore a cross system partnership with the RAEs and CASA to further support early detection and access to intervention for this population.

The health care landscape in Colorado shows a concentration of pediatricians and pediatric subspecialists along the front range. Outside of the metro areas, there is a significant decrease in pediatricians and severe shortage of pediatric subspecialists. To increase access to pediatric specialty care, the CYSHCN team partnered with providers from Children’s Hospital Colorado/University of Colorado and the six local public health agencies that were focused on access to pediatric specialty care in their communities. This was accomplished through an ongoing contract with the University of Colorado and one-time supplemental funding to the local public health agencies that administered specialty care clinics in their communities. The funding was to implement community-identified activities to improve access to pediatric specialty care. Collaborative implementation efforts resulted in:

• Successfully transitioned the coordination of local clinics from CDPHE to CU Medicine, while maintaining and increasing the number of clinics and types of specialities at each location.
• Expanding the use of telemedicine both at existing clinic locations and through identification and establishment of nine new host sites.
• Increasing types of specialties offered to include diabetes management, behavioral health, genetics and pulmonology.
• Ensuring care coordination is embedded in the specialty care services.
• Building a specialty care community of practice through the use of online platforms to strengthen expertise of community-based providers’ support for CYSHCN.

In the fall of 2020, San Juan Basin Public Health and Pueblo Department of Public Health and Environment were awarded additional MCH funding to continue their policy and system change efforts to improve access to pediatric specialty care. Northeast Colorado Health Department is also continuing to focus on access to pediatric specialty care through a grant from CDPHE’s Office of Planning, Partnerships and Improvement.

The CYSHCN team contracted with the University of Colorado School of Medicine and their Developmental Pediatrics staff to improve access to timely diagnosis and quality care for children with Autism Spectrum Disorder and other developmental disabilities in underserved communities. With support from MCH, and Upper Payment Limit funds, the Developmental Pediatrics piloted five strategies to decrease wait times. To date, 49 primary care providers throughout the state have been trained by Developmental Pediatrics staff to use the STAT tool, a second level autism screening.  These primary care providers have access to ongoing technical assistance from the Developmental Pediatrics staff, as well as a community of practice to continue learning how to interpret screening results and ensure appropriate referrals to services.

Results after the first year showed a 16% decrease in the waitlist for a full developmental evaluation (from 1,377 patients in January 2019 to 1,131 in January 2020) as well as an 18% increase in the number of patient visits (from 5,970 visits in 2018 to 7,053 in 2019). The pilot also expands the use of telehealth, teleconsultation and e-consultation to triage developmental evaluation referrals with trained community-based providers.

In fall of 2018, the CYSHCN team developed a one-time mini-grant opportunity, which allowed primary care provider organizations to purchase telehealth equipment to replace outdated equipment and/or enhance existing systems with additional telehealth peripherals. This opportunity reimbursed a total of $46,634 to 12 primary care organizations for new technology. As a result of this project, six of the 12 practices began offering telehealth and the other six were able to enhance or expand their telehealth capacity. Early successes include:

• The provision of integrated health care (tele-psychology, counseling, integrated behavioral health services);
• Access to new specialties including dermatology and diabetes management;
• Increased primary care access (medication checks, minor injuries/illness), after-hours consults, and follow-up on minor injuries/illness via school-based primary care clinics;
• Three of the recipients were subsequently selected to receive in-depth technical assistance from the School of Medicine piloting telehealth for diabetes and/or hypertension and cholesterol management.

To increase access to pediatric behavioral health care, the CYSHCN team was awarded the Pediatric Mental Health Care Access Program (PMHCAP) grant from MCHB in late 2018. According to the State of Mental Health in America report, Colorado ranks 33rd in overall youth mental health. This is attributed to workforce shortages and unmet mental health needs among children and youth across the state. CDPHE is contracting with the Pediatric Mental Health Institute and the Department of Psychiatry at the University of Colorado to implement CoPPCAP (Colorado Pediatric Psychiatric Consultation and Access Program). The goal of the program is to increase timely detection, assessment, treatment and referral of children and youth with behavioral health disorders in pediatric primary care settings especially in rural and underserved areas. CoPPCAP creates a mechanism for timely consultation between a primary care provider and a child and adolescent psychiatrist and offers support for identifying community resources. CoPPCAP strategies include 1) increase the availability and access to child and adolescent psychiatrists for primary care providers, 2) increase provider skills and knowledge through communities of practice, and 3) create a website to house tools and resources. CoPPCAP is payer-blind and therefore provides consultations with any enrolled physician at no charge. The team also offers a one-time in person visit at no cost.

The CoPPCAP team established an advisory committee comprised of representatives from the RAEs, the state’s Medicaid program, mental health centers, primary care providers and a family representative. The committee meets quarterly to inform strategies to create a coordinated statewide approach between the state’s two psychiatry access programs. Together, these programs’ coordinated efforts to ensure children and providers in Colorado have access to resources regardless of location. The advisory committee offered suggestions to the Colorado Governor’s Behavioral Health Task Force, Children’s Subcommittee on the usefulness and sustainability of psychiatric access programs.

In September of 2019, the consultation accessline for CoPPCAP went live, as well as the website. As of March 2020, 97 providers from 16 practices were enrolled, which represents coverage of 103,483 lives. Practices have asked for and received training on anxiety, depression, and several other mental health topics. CoPPCAP’s ECHO series, which combines interactive learning and case-based discussion for health professionals, launched in March 2020 and enrolled a full roster of participants. Participation has remained steady and providers have shared their appreciation for the ECHO, particularly as they balance their work with COVID-19.

The third area of the medical home state action plan is to improve access to information and resources for children and youth with special needs and their families. CDPHE contracts with Mile High United Way 2-1-1 to operate a resource and referral contact center for the MCH population, including a landing page with resources for CYSHCN. CDPHE partnered with Parent to Parent during the reporting year to revise the categorical descriptions on the CYSHCN landing page in plain language. Web hits to the CYSHCN landing page more than doubled following a push to promote the page, from 626 web hits in the last quarter of 2018 to 1,557 and 1,650 hits during the first and second quarters of 2019, respectively. After this initial push, the number of webhits plateaued around 815-945 hits until the second quarter of 2020, when the number of hits decreased to 523. This year, Colorado 2-1-1 is in the process of a phased website overhaul. A soft launch of the new website occurred in February 2020, and CDPHE continues to partner with Mile High United Way 2-1-1 to ensure changes to the website make it easier for families to navigate and find family-friendly resources. Some of these efforts are on pause as Mile High United Way 2-1-1 partnered with the Colorado State Emergency Operations Center to support an influx of information and referral calls and texts related to the COVID-19 pandemic.

The CYSHCN team at CDPHE developed customized medical home priority technical assistance plans for each local public health agency to better meet their individualized and evolving needs for support. As part of the development process for local action plans, CDPHE staff held meetings to gather input from local public health agencies to allow for more flexibility and ensure they are able to pursue the policy and system changes most needed in their community. In October 2018, a skills building meeting was held to develop logic models, action plans and identify measures to capture local impact. With increased flexibility, agencies:

• Leveraged resources to develop multi-pronged approaches to reduce barriers to timely services and supports;
• Developed relationships and share workload with non-traditional partners;
• Strategically aligned with agency public health improvement plans to support the needs of CYSHCN;
• Improved referral systems.

Of the six local public health agencies that selected the medical home priority, five chose to work on improving access to information and resources for children and youth with special health care needs. For example, Jefferson County Public Health is working on a project to ensure children (0-5) with a founded case of abuse or neglect receive developmental screening and early intervention services, when applicable, as required by state statute. In Jefferson County, 80% of children who were referred with a founded case of abuse or neglect were never screened or evaluated because the agency was not able to contact the family or the family declined services. To identify and support high risk children with additional services, Jefferson County Public Health is leveraging an existing committee where key stakeholders are already at the table (e.g. Human Services, Developmental Disabilities Resource Center, Child Find) to make significant changes to workflow, such as, moving developmental screening responsibilities for these types of referrals from the Community Centered Board to county nurses already working with families involved in Child Welfare to increase efficiencies. This move ensures that the screenings are completed within allotted timeframes and improves communication between care teams. 

Throughout the summer and fall of 2019, the CYSHCN team, in partnership with providers, RAEs, family organizations and family members, developed a policy agenda - the ABC’s of Health Equity for Children and Youth with Special Health Care Needs: A Policy Agenda for Colorado - which outlines specific recommendations to guide state and community organizations to align efforts, create momentum, and focus resources to increase the likelihood of impactful changes that benefit CYSHCN. A launch event was held in February 2020, with opening remarks from Title V’s CYSHCN Director and a keynote from the Lt. Governor.

In addition to utilizing the policy agenda to inform the statewide needs assessment and prioritization process, the CYSHCN policy agenda was used by the legislatively mandated Childrens subcommittee of the Behavioral Health Task Force to develop recommendations that will go to the governor for consideration.  The CYSHCN Policy Agenda included a policy strategy that would provide sustainable funding for a statewide Pediatric Psychiatric Access and Consultation Program.  The Children's Behavioral Health subcommittee representatives attended the policy agenda launch and subsequently met with the Title V CYSHCN Director and Children’s Health Policy Specialist to review and strengthen the subcommittee recommendations which will go to the Governor during June 2020.

In addition, the team cross-walked the CYSHCN policy agenda with the priorities of each state department and held strategic conversations with Health Care Policy and Financing to understand their priorities over the coming year.  The department has stated on several occasions that they will focus on the Children and Youth with Special Health Care Needs population and the CYSHCN director has communicated with the Director of Medicaid to identify staff persons within the ACC that we will coordinate with.  The policy agenda will be leveraged to inform a care coordination policy for children with complex needs as well as cost saving initiatives such as employing a co-management model between primary and specialty care.