The Title V program and the Title XIX Medicaid program are under the organizational structure of the Health Department. The health care for the low income population, Medicaid and CHIP eligible are channel through the PRHIA that contract private Health Insurance Companies (HICs) to provide de clinical services needed and included in the State Plan submitted to CMS. It includes special coverage for CSHCN and ASD (included as attachment). The PRHIA receive the Medicaid, CHIP, Local Central government and Municipalities fund to cover for the GHP.
The terms of services delivery by the HICs for the GHP beneficiaries changed. The main change is that each HIC will cover beneficiaries all over the island and not only by regions as before.
Services coordination isn’t mandatory by CMS and not included in the PR State Plan. That limitation has provided a good opportunity for TV MCAHD staff collaboration with Title XIX Medicaid program, especially with the Medical Assistance Office (MAO) which performs the eligibility evaluation.
The MCAHD CHWs and the HEs are in the community constantly looking for pregnant women to offer them education on health issues that can impact them and one specific task is the referral to the MAO for the evaluation of eligibility to the GHP to those without health insurance coverage and to other services needed as are identified. This contact with the population at the community level allows our personnel to refer for the HVP and to recruit for the Prenatal and Parenting courses, tools that increase the prevention and promotion of health. At the same time MAO personnel at their local offices refer to MCAHD staff the pregnant women that they certify as eligible for the GHP. This collaboration allows MCAHD a more extensive impact toward improving the overall health of the MCH population.
The HVP provide the education and support by nursing personnel, to high risk pregnant women for complications that complement the clinical services provided by the GHP.
The MCAHD began collecting data for the CDC collaborative project, PRAMS on March 2017. This project will provide data that will help to guide our efforts toward healthier MCH population. Also during 2017, the CDC collaborative project, Zika Pos-Partum Emergency Response Survey II (ZPER) was implemented in birthing hospital to identify different aspect that helped direct the efforts in the fight against the Zika virus, specially the most vulnerable pregnant women. During 2018, a Disaster Supplemental –PRAMS was implemented, which data helped to establish preventive measures on health care services.
The Early Intervention (EI), IDEA Part C program is under the MCAHD which allows the direct access for the families’ referred from the HVP and other staff. The services provided under EI at the children natural environment increase those needed by the MCH population and not covered in the same way as in the GHP.
As a part of the CSMND response to the 2016 Zika Epidemic, collaborative working relationships were established with other federal, state and non-governmental partners to complement the Title V CSHCNP leadership efforts to provide a system’s approach to ensure access to quality health care and needed services for infants born to mothers with laboratory evidence of possible Zika virus infection during pregnancy. The Title V CSHCNP was among the first responders and the backbone for services for infants and children born to mothers with laboratory evidence of possible Zika virus infection during pregnancy.
In coordination with the CDC, ZAPSS was established to identify and actively monitor pregnant women with laboratory evidence of possible Zika virus infection and prenatally or perinatally exposed infants born to these women. The information collected by ZAPSS is being used to inform best practices in care for women infected with Zika virus during pregnancy and their infants. Also, the ZBDSS was established to rapidly identify and track birth defects that might be related to Zika virus infection during pregnancy.
The CSMND also has a close working relationship with PR Maternal and Fetal Medicine (MFM) specialists. Ultrasounds and amniocentesis results of birth defects cases, as well as those of pregnant women with laboratory evidence of possible Zika virus infection, are shared with ZAPSS, BDSPS and ZBDSS. This allows for the prenatal identification of infants with birth defects and pregnancy interruptions. The information is also being used to inform best practices in care for women infected with Zika virus during pregnancy and their infants. A MFM Liaison regularly visits their offices to obtain the studies reports.
The HRSA Zika MCH Services Program provides for increasing the capacity of the Title V-CSHCNP to track children potentially exposed to ZIKV infection during pregnancy, provide screening and assessment services, and ensure accessibility to comprehensive health care services. Funds are being used to address unmet workforce needs, buy necessary equipment to provide screening, diagnosis, treatment and care; acquire health information and tele-health technology and equipment; implement family engagement strategies and provide family to family support services that ensure coordinated and comprehensive care in a medical home.
The CMS Zika Health Care Services Program also provides for increasing access to specialized health care services for pregnant women, infants and children adversely or potentially affected by Zika. Funds are being used to address unmet workforce needs, buy necessary equipment to provide screening, diagnosis and care services for pregnant women, increase access to specialized services for infants and children, transportation services and to ensure coordinated and comprehensive care in a medical home, among others.
There is also collaboration with APNI in the implementation of HRSA FOA Optimizing Family Support for Families of Children with or at-risk for Congenital ZIKA Virus Infection: “Empowering families in the prevention and care of the ZIKA virus”. Funds are being used to identify and disseminate culturally appropriate information regarding the health care needs to families of children with or at-risk for congenital ZIKV infection, assist families of children with or at-risk for congenital ZIKV infection in identifying and accessing resources in order to secure essential health care and community-based family support services, increase in knowledge of families and professionals regarding the care of children with or at risk for congenital ZIKV infection, and promoting families active engagement in their children’s health care, among others.
Collaboration with HRSA National Health Service Corps (NHSC) Loan Repayment Program helped to recruit qualified health care providers, including pediatricians, nurses, social workers and other direct services professionals, who chose to take their skills to the CSHCN Program at the RPCs.
Collaboration with HRSA EHDI program allows for the identification and early referral to services of infants with possible congenital Zika virus infection and congenital hearing loss.
Regarding the current Title V – Title XIX IAA/MOU, CSMND staff established contact with the PRHIA (PR Medicaid Agency) to work on strategies that can lead to successful collaborations between the PRHIA and the CSHCNP. Strategies developed by the National Academy of State Health Policy (NASHP) and AMCHP Standards for Systems of Care for CYSHCN (July 2017) are used as a guide to strengthen the agreement. Two meetings have taken place and topics over the table are the enhancement of data sharing, strategies for a better understanding of the relationship between CSHNP-service coordination and GHP-case management, and educating PRHIA staff about Title V. The PR-UNHSP has also met with the PRHIA to identify strategies for children with positive hearing screenings to access a diagnostic evaluation without the need of a pediatrician’s referral, and GHP special coverage for children diagnosed with hearing loss. These activities are still in progress.
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