Maternal and Child Health (MCH) continues to integrate best practices and incorporate community feedback into programming. In fiscal year (FY)24, Texas will focus on medical home access, transition to adult health care, and community inclusion.

 

NPM 11: Percent of children with and without special health care needs having a medical home.

 

To gain a better understanding of families' barriers to receiving high-quality, comprehensive care, MCH will distribute the FY24 Caregiver and Young Adult Outreach Surveys and partner with family-serving organizations to distribute English and Spanish surveys. Survey results will inform future MCH initiatives and help identify areas where additional resources and support are needed to improve family service access. MCH’s goal is to receive at least 700 caregiver and young adult surveys.

 

MCH will increase stakeholders’ medical home knowledge and awareness by:

• Distributing educational materials;
• Developing social media content;
• Communicating through Granicus (email delivery);
• Updating website content; and
• Conference exhibiting.

 

MCH will distribute at least 5,300 medical home brochures to families, community organizations, and medical providers. Medical home brochures are available for print and digitally in English and Spanish. MCH will create at least 2 medical home social media posts and Granicus messages. MCH plans to exhibit or present at 2 conferences. To measure reach, MCH will analyze social media post engagements and impressions, webpage views, Granicus subscribers, and document downloads.

 

MCH will not continue convening the Medical Home Learning Collaborative (MHLC) in FY24 due to overlapping activities in the state. Collaborative members voted to shift from quarterly meetings to a monthly newsletter with:

• Resources;
• Recent publications;
• Upcoming events; and
• Learning opportunities.

 

MCH will distribute 12 newsletters to former MHLC members and CYSHCN Granicus distribution list subscribers. MCH will distribute an annual survey to assess newsletter impact. For FY24, MCH’s goal is at least 80% of survey respondents report an increase in medical home model resource and support knowledge.

 

MCH will also explore collaboration opportunities with state departments doing medical home-promoting activities like Texas Health and Human Service Commission’s Office of Disability Prevention for Children. By improving access to resources and support related to the medical home model, MCH helps support model adoption and implementation.

 

MCH will fund the Texas Institute for Child and Family Wellbeing (TXIFCW) for the 5th year. In FY24, TXIFCW will:

• Provide participating case managers with technical assistance (TA) follow-up on practice model implementation;
• Collect and analyze data to understand case managers’ concept retention and training effectiveness perceptions;
• Evaluate families’ and case managers’ practice model satisfaction; and
• Develop practice model fidelity assessment tools.

 

MCH will monitor deliverable progress through TXIFCW monthly meetings and quarterly reports. 75% of participating case managers will report fidelity to the practice model demonstrated by the created assessment tools.

 

In FY24, MCH will fund the final year of the 5-year cycle for the case management (CM) and family supports and community resources (FSCR) contracts. All CM and FSCR contractors will continue meeting quarterly with their Texas Public Health Region (PHR) case management supervisor to increase collaboration and prevent service duplication.

 

MCH’s 8 CM contractors and PHR case managers will conduct initial children and youth with special health care needs (CYSHCN) intake evaluations and family needs assessments to develop individual service plans. In F24, to facilitate CYSHCN’s medical home access and support care coordination, CM contractors will:

• Educate families about medical home services;
• Connect families with primary and specialty providers, mental and behavioral health services, dental care, medical transportation, and other needed services;
• Help families find and apply for affordable health coverage to pay for care; and
• Assist families with developing preparedness plans and registering with community emergency responders.

 

In FY24, all CM contractors will conduct initial intake evaluations and hope to see an increase in families’ resource connection and medical home access. MCH’s 14 FSCR contractors provide CYSHCN and their families with gap-filling services based on community needs. In FY24, FSCR contractors will:

• Host family educational events to learn about the importance of a medical home, health and wellness, and self-care;
• Partner with first responders to host at least 2 emergency preparedness events for CYSHCN and their families; and
• Educate first responders on practices that support people with disabilities.

 

MCH requires CM and FSCR contractors to provide translation and interpretation services to meet the needs of all families served. CM and FSCR contractors will conduct at least 2 outreach activities for underserved populations to help reduce health disparities and improve optimal family health outcomes. In FY24, activities consist of:

• Presenting and or event exhibiting in rural or other underserved areas;
• Collaborating with organizations working to improve underserved populations’ outcomes; and
• Serving on a community board or group that impacts underserved populations.

 

MCH will convene CM and FSCR contractors quarterly to provide program updates, facilitate discussion to address systemic challenges families experience, and share solutions.

 

In FY24, CM and FSCR contractors will submit to MCH quarterly activity reports. To further assist with compliance and contract requirement understanding, MCH will host a Fall 2023 training to:

• Share parent stories highlighting contractor service help received and how this relationship benefited their CYSHCN and family;
• Offer contractor-requested topic learning sessions;
• Facilitate contractor networking and idea exchange opportunities; and
• Provide CYSHCN performance measure implementation TA and contract reporting requirements.

 

MCH will distribute a post-meeting survey to assess training effectiveness with the goal of at least 90% of survey respondents reporting increased contract implementation knowledge and meeting content satisfaction.

 

In FY24, collection will continue for CM and FSCR contractor client feedback via the Family Experience Survey (FES). MCH requires CM and FSCR contractors to offer the FES to every family they provide services to at least once during the fiscal year. MCH shares survey results with contractors to improve program planning and service delivery. MCH will customize contractor TA and guidance based on FES results and support CM and FSCR contractors with increasing response rates. In FY24, MCH plans to increase FES responses by 3% with the goal of at least 90% of survey respondents reporting service satisfaction.

 

In FY24, MCH will continue funding the Texas Health and Human Services Commission’s Children with Special Health Care Needs Services Program (CSHCN SP).

 

The CSHCN SP outcome measures are the number of CYSHCN provided health care benefits and removed from the program waitlist.

 

MCH will meet monthly with CSHCN SP to strengthen program collaboration and stay informed on current activities. MCH will conduct outreach to families about CSHCN SP benefits and how to sign up for the program waiting list. In FY24, MCH will use multiple community outreach forums like social media, email distribution lists, presentations, and stakeholder discussions. MCH plans to distribute at least 2,000 CSHCN SP one-pagers to organizations that support families with CYSHCN.

 

MCH is a key member of the 5-year Health Resources and Services Administration’s Enhancing Systems of Care for Children with Medical Complexity project. This initiative advances integrated care for children with medical complexity (CMC). Primary goals include:

• Supporting Dell Children’s Medical Center’s Children’s Comprehensive Care Clinic’s whole child visit model expansion and continuous quality improvement;
• Piloting a sustainable alternative payment system model; and
• Evaluating and disseminating findings that inform and improve policy to reduce disparities and optimize health and quality of life in a cost-effective manner.

 

In FY24, grant activities will focus on developing outcome measures based on:

• Family experience and priorities;
• Addressing disparities;
• Streamlining administrative processes; and
• Improving the whole child visit model.

 

The clinic team will use the Family Engagement in Systems Toolkit and other tools to measure family experience. MCH will contribute public health expertise, provide at least 10 resource linkages, and recommend potential partner connections.

 

In the last year of the 4-year grant cycle, the Mountain States Regional Genetics Network (MSRGN) Texas Team will improve access to genetic services and quality of care for children with genetic disorders and their families. MCH will:

• Participate in at least 8 of 10 MSRGN FY24 monthly meetings to support MSRGN team activities;
• Further identify needs, gaps, and opportunities to increase state genetic services awareness; and
• Attend webinars and other virtual events to increase knowledge relevant to accomplishing MSRGN goals.

 

MCH will serve on Texas Health Steps Online Provider Education (THSteps) module review team to update and create new materials to increase provider knowledge. MCH will track the following THSteps modules:

• Building a Comprehensive and Effective Medical Home;
• First Dental Home;
• Recognizing, Reporting, and Preventing Child Abuse; and
• Autism Spectrum Disorder: Screening, Diagnosis, and Management.

 

MCH expects a 5% increase in the number of THSteps modules completed.

 

In FY24, MCH will serve on the Texas Primary Care Consortium (TPCC) steering committee dedicated to engaging stakeholders and examining the most effective methods to improve all Texans’ health. TPCC will host the Texas Primary Care and Health Home Summit an annual conference focused on primary care and the medical home. MCH will promote the conference through social media, email distribution lists, and targeted stakeholder outreach. For FY24, the goal is a 10% attendance increase. Increasing attendance at the Texas Primary Care and Health Home Summit can improve Texas primary care and medical home services knowledge leading to better health outcomes for all Texans.

 

During FY24, MCH will attend workgroup and committee meetings to stay informed on current medical home issues and challenges CYSHCN and their families experience. For FY24, MCH will attend:

• Policy Council for Children and Families;
• STAR Kids Advisory Committee; and
• Developmental Screening Workgroup.

 

Participation in these groups allows insight into CYSHCN and their families’ lived experience, deepens knowledge of families’ systemic barriers, colleague networking, and relationship building. MCH will contribute public health expertise, provide at least 5 resource linkages, and recommend potential partner connections.

NPM 12: Percent of children with and without special health care needs who received services necessary to transition to adult health care.

 

In FY24, MCH will lead quarterly Transition to Adulthood Learning Collaborative (TALC) meetings to improve knowledge in all the following transition areas:

• Health care;
• Higher education;
• Employment; and
• Independent living.

 

Each meeting features a transition topic expert. Through post-meeting evaluations, MCH hopes 80% of survey respondents report increased transition knowledge, that their educational needs were met, and the resources shared were helpful.

 

MCH will increase stakeholders’ transition knowledge and awareness by:

• Distributing educational materials;
• Developing social media;
• Communicating through Granicus;
• Updating website content; and
• Conference exhibiting.

 

MCH intends to distribute at least 7,000 transition brochures to families, community organizations, and medical providers. MCH will develop at least 2 transition social media posts, Granicus messages, or website content. MCH will present or exhibit at 1 or more events to educate youth, parents, and professionals on moving from pediatric to adult-based care. Refer to NPM 11 for more information.

 

In FY24, MCH will continue requiring FSCR and CM contractors to improve families’ health care transition understanding and increase intentional planning for the move to adult-based care.

 

In FY24, CM contractors will:

• Administer health care transition readiness assessments for all youth ages 12 and older or their parents;
• Promote health care self-management;
• Educate families on pediatric practices’ and children’s hospitals’ age limit policies;
• Develop and update individualized transition plans based on youth’s and families’ priorities for all youth aged 12 and older; and
• Provide adult service linkages.

 

FSCR contractors will:

• Collaborate with youth, families, and community partners to plan and host transition fairs and workshops;
• Host or co-host education events for youth, families, and professionals to learn about adult health care transition, higher education, employment, and independent living;
• Partner with state and local organizations (such as the Texas Workforce Commission) to offer vocational rehabilitation services training for families in rural areas; and
• Share transition information including Texas Parent to Parent (TxP2P) Pathways to Adulthood program.

 

Contractors will increase the percentage of CYSHCN and their families who receive transition education and support by 2% from FY23.

 

The annual Chronic Illness and Disability: Transition from Pediatric to Adult-based Care Conference is scheduled for October 2024. This event will bring together national and international thought leaders to share expertise on facilitating successful transitions from pediatric to adult health care. MCH will serve on the conference’s advisory group and contribute 2024 and 2025 conference ideas. MCH expects conference evaluations to indicate increased provider knowledge on how to implement practice changes to prepare youth for adult-based care. MCH will fund TxP2P to distribute at least 10 2024 conference scholarships for youth, young adults, or parents.

 

MCH will provide expertise for THSteps material updates and creation as requested to increase providers’ transition knowledge. MCH will track Transition Services for Children and Youth with Special Health Care Needs module completion. For FY24, the goal is a 5% increase in modules completed.

 

MCH will attend at least 75% of FY24 Adolescent Health Workgroup meetings to stay informed on current adulthood transition issues and challenges CYSHCN and their families experience.
 

SPM 1: Percent of CYSHCN and their families who participate in social or recreational activities with families who have children with or without disabilities.

 

MCH will increase stakeholders’ community inclusion knowledge and awareness by:

• Distributing educational materials;
• Developing social media;
• Communicating through Granicus;
• Updating website content; and
• Conference exhibiting.

 

MCH intends to distribute at least 10,000 community inclusion brochures to families, community organizations, and medical providers. MCH will create at least 2 transition social media campaigns, Granicus messages, and website content to support outreach goals. MCH will present or exhibit at 1 or more statewide or local event to provide resources and education on the importance of community inclusion for CYSHCN and their families. Refer to NPM 11 for more information.

 

In FY24, MCH will fund TXIFCW to develop training and provide TA to community-based organizations (CBOs) serving families experiencing health disparities. TXIFCW will prioritize communities with the greatest FSCR service need. In FY24, TXIFCW will:

• Work with MCH and community stakeholders to identify CBOs not currently receiving FSCR funding who are serving families experiencing health disparities;
• Partner with each CBO to identify community resources, strengths, and service gaps;
• Develop and implement an individualized TA plan with each CBO;
• Guide CBO outreach plan development; and
• Facilitate region-wide coordination between CBOs, DSHS PHRs, and other providers serving CYSHCN and their families.

 

MCH will monitor goal progress through monthly TXIFCW meetings and quarterly reports. Improving CBOs’ capacity to provide FSCR services to CYSHCN and their families experiencing health disparities can lead to improved health outcomes for this population.

 

MCH funds CBOs to support CYSHCN’s and their families’ inclusion in community life, decrease CYSHCN’s feelings of isolation, and strengthen the family unit. FSCR contractors will advance inclusion by:

• Collaborating with local organizations to host social and recreational events welcoming to CYSHCN and their families;
• Providing respite, parent and sibling support groups, and basic needs resource linkages;
• Offering parent networking and leadership development opportunities; and
• Giving families free vouchers to visit museums, zoos, concerts, and other inclusive recreational activities.

 

To better identify CYSHCN and their families not receiving needed services and support, MCH will require CM and FSCR contractors to conduct direct outreach to these populations at least twice per quarter. MCH anticipates these contractor efforts will strengthen community partnerships and help underserved CYSHCN and their families learn about and access needed services.

 

In FY24, MCH will serve on the following statewide groups to provide public health expertise, support projects and priorities, and contribute ideas to improve family-serving systems:

• Texas Council for Developmental Disabilities;
• Community Resources and Coordination Groups Statewide Workgroup; and
• Policy Council for Children and Families.

 

Through participation in these activities, MCH will gain knowledge of systemic barriers CYSHCN and their families experience, increase understanding of unmet needs, build colleague relationships, and identify future partnership opportunities to advance community inclusion. MCH will contribute public health expertise, provide at least 5 resource linkages, and recommend potential partner connections.