Transition (FY 2020 Application)

Through the five-year needs assessment process, the state priority need to “Increase family and provider support and education for Children with Special Health Care Needs” was linked to NPM 12, the percent of adolescents with and without special health care needs who received services necessary to make transitions to adult health care. Building upon the work initiated in FY 2018 and currently underway in FY 2019, three broad-based objectives have been identified to increase knowledge of medical transition. These strategies target local health departments, medical providers, and adolescents and families.

Many of these strategies, though more process-oriented, seek to increase Michigan’s capacity for integrating transition planning through automation, and will ultimately lead to more patient-centered, family friendly care. They also seek to promote medical transition as part of the standard of care for adolescents. These objectives and strategies, when implemented in tandem, represent an approach that creates both awareness and an ability to deliver medical transition services in Michigan that are comprehensive, coordinated, and responsive to clients’ needs.

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 associated with this objective will focus on Medicaid Health Plans (MHPs). During FY 2020, CSHCS will build upon the lessons learned from the MHP site reviews to identify areas of improvement related to transition. These areas will be used to propose contract language revisions to strengthen health care transition services offered by the MHPs and their network of providers. Reporting requirements specific to transition will be considered and data collected from these reports will be routinely reviewed.

To follow through on this objective’s second strategy, the transition specialist will provide continued support and technical assistance to local health departments (LHDs) related to health care transition. This will be accomplished by: 

• Creating customized reports for each LHD identifying youth preparing for transition on a quarterly basis. Reports will be uploaded into the MDHHS HIPAA secure data management portal, which LHDs can then download to obtain information about clients reaching one of the pre-identified transition ages and stages.
• Utilizing the LHD Share Point site to consolidate resources, templates, and training materials for LHD staff on transition.
• Providing ongoing training for LHDs on specific topics such as self-determination, social security benefits, authorization of protected health information and other transition-related topics. These trainings will be offered via webinars and adobe connect videoconferences and recorded so LHD staff can access them as needed.

Also included in this objective is the completion of work to automate transition letters that was initiated during FY 2017 and FY 2018. Due to staffing changes, this project was paused until a designated transition specialist was hired. Now that staff is in place, the work group assigned to review and revise the transition letters has reconvened and is working to complete four transition letters and remap the system automation logic. This work is expected to be completed in FY 2019, and the system upgrades, testing, and release are expected to occur during FY 2020.

The third strategy will build upon work completed in FY 2019 with the CareConnect 360 system. CareConnect 360, an integrated care management system, improves the coordination of services delivered by multiple entities. It allows effective use of healthcare data for assessment and analysis purposes, which helps to improve decision-making processes and evaluation, and can lead to reduced costs and improved health outcomes. CareConnect 360 will facilitate joint care plans among LHDs, MHPs, community mental health (CMH), foster care, and other health and human service providers, and streamline the care planning process in order to assure that families are receiving maximum care coordination/case management services with minimum confusion.

In 2019, CSHCS will complete a pilot project under the guidance of Michigan State University’s Institute for Health Policy (IHP) to operationalize the use of CareConnect 360 with a subset of clients being served by two local health departments located in the Upper Peninsula. The activities of the pilot will seek to determine:

• training needs;
• applicable system functionality;
• policies, procedures, protocols; and
• best practices for integrated care plans.

During FY 2020, this partnership will continue and CSHCS and the MSU Institute for Health Policy will work with the Michigan Association of Local Public Health (MALPH) to determine the best way to engage other LHDs to integrate care planning in CareConnect 360.

Lastly, as discussed in the FY 2018 annual report, Michigan will continue to utilize the Evidence-informed Strategy Measure (ESM) developed by the University of Michigan’s Child Health Evaluation and Research (CHEAR) unit. The ESM provides data on the percent of CSHCS clients age 18 to 21 years in selected diagnosis groups that have transferred care from a pediatric to an adult provider.

Objective B: By 2020, increase the number youth and families by 10% that are aware and understand the transition to adulthood process.

The first strategy for this objective is to implement the marketing plan for the online Adolescent Transition Online Course developed in FY 2019. During FY 2019, CSHCS piloted the Adolescent Transition Online Course with 1) the Family Center youth consultant and 2) participants in an AMCHP transition replication pilot project that was located within a school wellness clinic. Feedback received from student participants was incorporated into the online course during FY 2019.

Working together, the youth consultant and students representing the school clinic advisory group will participate in the development of a marketing plan for the Adolescent Transition Online Course which will be fully implemented during FY 2020. The purpose of the marketing plan is to make adolescents and their families aware of this new course, as well as the need for health care transition services. Benchmark data established at the end of 2018 will serve as a baseline for measuring the course’s appeal and applicability. The course will be evaluated each year to assure that the information provided is correct and relevant for youth.

The second strategy for this objective is to establish Adolescent Transition as one of the quality improvement initiative options for MDHHS-funded Child and Adolescent Health Center (CAHC) programs. Each year, CAHC-funded programs must implement a continuous quality improvement initiative that utilizes a PDSA cycle. The AMCHP Transition Replication project, as currently designed, meets these requirements. Beginning in FY 2020, CSHCS will work with MDHHS CAHC state staff to replicate the pilot’s efforts in other school-based clinics, school-linked clinics and school wellness centers.

Given MDHHS’s well-defined network of CAHCs located throughout Michigan (with over 100 sites that serve an adolescent population that exceeds 36,000 patients), the incorporation of transition programing would represent a major accomplishment. These centers—staffed by mid-level practitioners, social workers and medical professionals—deliver a wide-range of services including primary, preventive and early intervention health care. School clinic staff work collaboratively with students, parents, school personnel, LHDs and the human service community to assure that students have what they need to be well and successful, and to practice self-health maintenance. Health care transition, including the knowledge of health conditions, the ability to communicate health needs, and maintenance of affordable health insurance coverage, is a natural fit that reflects their overall mission.

In addition to these strategies, MDHHS will continue to partner with local health departments and other partners to offer community presentations and implement print and social media strategies designed to improve knowledge of, and resources for, health care transition throughout FY 2020.

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.

The first strategy for FY 2020 for this objective is to develop an online program that is modeled after the University of Florida’s “Health and Transition Services” (HATS) training for health care professionals (i.e., nurses, social workers and physicians). MDHHS will work to condense the original ten modules down to three to five modules and will seek to integrate Michigan-specific resources into the curriculum.

The training is based upon evidence-informed materials from GotTransition’s Six Core Elements 2.0. Through this training, participants will better understand how to:

• Establish a transition policy;
• Track and monitor transitioning youth and their activities;
• Assess transition readiness and orient adolescents to an adult practice;
• Develop a transition plan of care;
• Transfer care to an adult provider; and
• Assure the transfer is complete.

In addition, participants will receive coding and reimbursement information and condition-specific tools for subspecialists from the American College of Physicians. As part of this strategy, the transition specialist will investigate the opportunity to provide continuing education credits for completion of these courses for different medical specialties. Once the course is developed, the transition specialist will pilot the course with the Office of Medical Affairs (OMA) within MDHHS, and a select group of medical professionals from outside of MDHHS, including LHD nurses and social workers. Their feedback will be utilized to finalize the coursework. The transition specialist will then work with the CSHCS communication team to develop a marketing plan to promote the free course to physicians, nurses and social workers. Evaluation data collected during the course will be used to monitor the course’s effectiveness, as well as participant satisfaction with the overall course. The online courses will be reviewed annually and updated as needed.

The second strategy related to this objective will be accomplished through the HRSA Children and Youth with Epilepsy (CYE) Grant. The CYE project has focused on the transition process for youth with epilepsy. Participating organizations have demonstrated significant growth, with more than 50% of clinics scoring a three or better on the GotTransition assessment for transition planning.

MDHHS is currently responding to the HRSA CYE continuation funding request.  Working collaboratively with the Epilepsy Foundation of Michigan, Michigan Association of Health Plans, Michigan Center for Rural health, Michigan Chapter of the American Academy of Pediatrics, Michigan Health Information Network, Michigan Primary Care Association, Michigan Public Health Institute, DeVos Children’s Hospital, Children’s Hospital of Michigan, UP Health System Marquette and Beaumont Health, in conjunction with six primary care sites and parent representatives, the project will continue to improve access to coordinated, quality health care in a patient/family centered medical home for children and youth with epilepsy that reside in underserved/rural areas of the state. Preliminary sub-strategies identified for the upcoming grant cycle include:

• Increasing the percentage of CYE who complete a health care transition readiness assessment;
• Increasing the number of participating primary care providers serving CYE who report increased communication, collaboration and co-management with specialty providers;
• Increasing access to care for CYE through telehealth strategies;
• Increasing the percent of families of CYE that report they are partners in a shared decision-making process as it relates to their child’s care; and
• Increasing the percentage of clinics that report utilization of best practices in support of health care transition, collaboration and co-management, telemedicine and/or telehealth and shared decision-making.

The University of Michigan’s CHEAR Unit will continue to provide evaluation support as part of the grant award, if funded.

Medical Care and Treatment for CSHCN (FY 2020 Application)

Michigan’s State Performance Measure (SPM) for the CSHCN population domain measures the percent of CYSHCN enrolled in Children’s Special Health Care Services (CSHCS) that receive timely medical care and treatment without difficulty. This measure addresses Michigan’s 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. The mission of CSHCS, to improve health outcomes and enhance quality of life of children served, is accomplished by assisting children and their families in accessing the broadest range of appropriate medical care, health education, and support. This is accomplished by removing barriers to care, including financial barriers, improving access to services, and strengthening existing systems of care. As discussed in the budget narrative, over 30% of Michigan’s Title V funding is used to support medical care and treatment for children with special health care needs.

CSHCS empowers families to become engaged, self-determining, and informed caregivers who are strong advocates for their children. Examples include the following:

• CMDS clinics consider parents and caregivers as part of the care team.
• The Family Center offers various leadership opportunities at state and local levels through organization such as the Family Leadership Network.
• The Family Center offers scholarships for families to attend conferences to learn more about relevant diagnoses and advocate better for their children.
• The Family Center offers peer-to-peer support.

Much of this work is accomplished through the CSHCS Family Center for Children and Youth with Special Health Care Needs, which provides ongoing support, education, and resources to families of children with special health care needs. In FY 2018, the Family Center received more than 14,000 phone calls through the family phone line and reported an additional 1,353 contacts with families through health fairs, presentations, trainings, and other events.

Although there is an annual fee to enroll in CSHCS, this fee is waived if the client has Medicaid, Healthy Kids Expansion, a court-appointed guardian, or lives in a foster home. The fee, which includes six possible payment levels paid through a payment agreement, is based upon family income and family size. The lowest payment level is $120 for individuals below 200% of the Federal Poverty Level (FPL), and the highest level is $2,964 for those above 500% of FPL.

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.

The first strategy to meet this objective is for CSHCS to continue enrolling children with special needs into the medical care and treatment benefit, which provides payment for medical care and treatment related to the child’s qualifying condition. This benefit, while not intended to cover all the care a child needs, helps to reassure families that necessary specialty care for their child’s qualifying diagnosis will not create undue financial burden. CSHCS is the payer of last resort and requires that families follow their primary and secondary insurance rules. Additionally, if a family’s income indicates that they may be eligible for Medicaid, they are required to apply for Medicaid.

Children with special needs who qualify for Medicaid and CSHCS will continue to receive care through Medicaid Health Plans barring a few exceptions. Children who are already receiving Medicaid, and who are determined to be medically eligible for CSHCS, are automatically enrolled. Automatic enrollment into CSHCS increases access to care coordination and case management services, which benefits families.

In addition to assisting families with the cost of specialty care, CSHCS offers an Insurance Premium Payment Assistance Benefit to eligible families. This benefit provides assistance to families who lack financial supports needed to reactivate or maintain private or employer-based insurance coverage due to their child’s complex needs. As part of a second strategy for FY 2020, staff will review the cost benefit/satisfaction study of the Insurance Premium Payment Assistance Benefit that was completed in FY 2019. The study—conducted in partnership with the University of Michigan’s Child Health Evaluation and Research Center (CHEAR) and the Commonwealth Fund—evaluated the numbers and characteristics of children receiving the insurance premium benefit, as well as the cost effectiveness of the program. Specifically, the study assessed the predictors of program cost-effectiveness and described the key components of the program, perceived program benefits or disadvantages, and the potential for expansion. In FY 2020, CSHCS will review the study’s findings and implement a workplan to integrate at least two of the suggested improvements.

A third strategy will focus on specialty clinics and the continued need to monitor and expand the use of interdisciplinary models. During FY 2020, MDHHS intends to enter into a contractual relationship with the Regents of the University of Michigan to explore the feasibility of providing and evaluating a palliative care benefit package for eligible chronically ill CSHCS enrolled children, for an amount not to exceed $200,000. During FY 2018, legislation was passed that authorized CSHCS to utilize funding to support the care management of complex chronically ill children. Also in FY 2018, the University of Michigan, in partnership with Hospice of Michigan, applied for and received funding from the Michigan Health Endowment Fund to replicate a palliative care project based in California. Together, these two events provide an opportunity for CSHCS to learn more about the feasibility of offering a palliative care benefit, and the cost benefits that can be accrued. FY 2020 will be spent learning more about the cost benefits associated with offering palliative care to children and potential modes of care delivery. CSHCS will partner with U of M Partners for Children and CHEAR Unit to support the ongoing development of a Michigan model, as well as to identify its associated costs and develop reimbursement strategies.

The fourth strategy to be implemented in FY 2020 is to make technological improvements for better delivery of the Children’s Special Needs Fund program. This program provides funding assistance to families in need of special equipment and/or structural modifications to their home and/or vehicles. The current database platform is now obsolete, and staff have identified the need for a new database that includes a module to track donations. During FY 2020, MDHHS intends to enter into a contractual relationship with WizeHive to purchase a data base system (with installation and maintenance) for an amount not to exceed $35,000 to meet the CSN program needs for improved tracking and reporting.

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, like many states, is feeling the impact of health professional shortages. According to the Bureau of Health Work Force, Michigan currently has 366 Primary Care Health Professional Shortage designations and is in need of an estimated 647 more practitioners to achieve a ratio that removes the Primary Care Health Professional Shortage designation. This shortage is not confined to primary care physicians, but also extends to specialists.

Understanding that the health professional shortages being experienced in Michigan reflect a national trend, CSHCS is working to minimize the effects by gaining efficiencies where possible. Knowing that team-based approaches are one way to address shortages and gain efficiencies, CSHCS supports the provision of specialty care through multi-disciplinary specialty clinics, which are designed to wrap services around families. Led by a medical director and operated under the authority of hospitals/medical universities, these clinics provide coordinated and family-centered care delivered by a team that includes social workers, nurses, therapists, dieticians, and others. Enhanced reimbursement for CMDS services provided by CSHCS helps to support the ancillary members of the team and to offset the time and resources needed to provide an enhanced level of care coordination.

During FY 2020, CSHCS will focus on improving quality within the CMDS model.  The first strategy to improve the quality and effectiveness of CMDS clinics is to continue to conduct site reviews. In FY 2019, CSHCS began conducting site reviews to evaluate the clinics using several established measures. In FY 2020, CSHCS will continue to implement the site review schedule, visiting approximately one quarter of the CMDS clinics. The site review cycle takes approximately four years to visit all clinics. Once the cycle is complete, data from the site visits will be reviewed and results from the CMDS clinics regarding the experience will be used to retool site visit materials. Recommendations for improvements, along with plans of corrective action, when needed, will be shared and monitored. At the end of the four-year cycle, the process will be adjusted, and the cycle will be repeated.

A second strategy for FY 2020 is to launch a website with resources for CMDS clinics and the Pediatric Intensive Feeding Program Services. The website will include CMDS policy, clinic staffing requirements, a fee screen, a flier detailing enhanced reimbursement information, frequent error code troubleshooting information, the enrollment form, and a list of all CMDS clinics and contacts. The following materials specific to Pediatric Intensive Feeding Program Services will also be made available: Medicaid policy, guidance materials, certification form, and other materials to assist providers in learning more about evidenced-based and -informed feeding service practices. This webpage will provide information that service providers frequently need in one easily accessible site.

In FY 2019, the CMDS clinics are implementing an electronic client satisfaction survey.  For the third strategy, in FY 2020, CSHCS will review data from surveys collected in FY 2019 and release a report that documents client satisfaction and client outcomes. This information will be shared with CMDS clinic staff and will serve as the basis for a CQI project. Using data in this fashion will enable the CMDS clinics to ensure that they are always patient-centered as they work to meet the needs of clients and families.

The third strategy to meet this objective is to continue to support LHDs as local staff work to promote the CSHCS program, recruit enrollees, provide care coordination/case management services in the home, and assist with access and utilization of local resources. In FY 2020, CSHCS will work with MSU Health Policy Institute to offer regional trainings at selected locations to ensure competency of LHD CSHCS nurses and program representatives. In addition, CSHCS will work to provide ongoing educational and training opportunities, via various technological platforms.

The final strategy for this objective is to explore and identify challenges in accessing services by populations served by both Community Mental Health (CMH) and CSHCS systems. Beginning in FY 2019 and continuing through FY 2020, CSHCS is convening a subcommittee consisting of staff from CSHCS and MDHHS Behavioral Health, along with representatives from the Family Center, local community mental health (CMH) organizations, local health departments, ARC of Michigan, CMH Association, child welfare, juvenile justice, and Medicaid Health Plans. This group will develop tools and resources to enable partners to provide more comprehensive and integrated care to children and their families.

Objective C: By 2020, increase the availability of health services, particularly in underserved regions, through the utilization of telemedicine and community-based services.

CSHCS is working to increase access to specialty health care services through the support of specialty clinics. In FY 2018 and 2019, CSHCS began to investigate telemedicine as a possible resource for increasing access to medical care and treatment for non-epileptic conditions. A telemedicine workgroup was convened in FY 2019 to research other state models, collect data from regional telemedicine resource networks, and identify different telehealth applications and their suitability of use within the CSHCS program as a method for improving access to care. In FY 2020, CSHCS will continue to explore the feasibility and barriers associated with specialist use of telemedicine. The CSHCS group will also consider possible changes that may be needed in its telemedicine reimbursement policies. CSHCS will utilize shared knowledge of other programs within the state and neighboring states to develop an approach that meets the needs of specialist providers and their patients and leads to improved patient experience and outcomes.

A second strategy includes continued support of the CMDS clinics which utilize a team-based approach to delivering family-centered, coordinated care. Work will be initiated in FY 2020 to assist CMDS clinics in learning how to coordinate care across disciplines in order to improve communication and satisfaction. Trainings will be developed and offered that promote interdisciplinary collaboration and address health equity.

The third strategy will be to continue to provide training opportunities for LHDs that focus on care coordination, case management, and locally-based services. During FY 2020, MDHHS intends to enter into a contractual relationship with the MSU Institute for Public Policy to facilitate regional training opportunities for an amount not to exceed $25,000 so as to ensure a competent local CSHCS workforce. In addition, LHD staff will continue to receive orientation webinars, accreditation visits, monthly phone calls and periodic Technical Assistance Tuesdays. CSHCS will also work through the Southeastern Michigan Health Association (SEMHA) to facilitate network development opportunities for the regional southeast Michigan group of CSHCS LHD providers to share best practices, promote dialogue, and improve the quality of services delivered to CSHCS and their families.

A fourth strategy that will be implemented in FY 2020 relates to health equity. CSHCS has been actively involved in learning about and addressing issues regarding health disparities, health inequities and the social determinants of health since 2010. Work began as part of the PRIME initiative and was continued in 2017 after PRIME ended. In August 2017 the CSHCS Health Equity Team was formed. The team consists of 14 staff from across the division who are committed to promoting health equity and inclusion in CSHCS policies, practices and outreach. To this end, the Health Equity Team has developed mission, vision and value statements. The team has also identified three focus areas, including Workforce/Staff Development, Awareness and Data. CSHCS has institutionalized its focus on health equity by including health equity in its management and staff performance measures and employee engagement plan. In addition, health equity has been operationalized by making health equity a focus in the MHP (Medicaid Health Plan) and CMDS site visits as well as CSHCS communication/outreach plan.

In FY 2019, CSHCS began a process to review data using a health equity lens in order to better understand health disparities and the social determinants of health that impact the CSHCS population. In FY 2020, these activities will expand to include the review of qualitative data gathered through focus groups, guided conversations, and key informant interviews which will be used to inform future MCH Block Grants reports and applications. Through this process, CSHCS is positioning itself to better understand root causes of health inequities and address institutional racism.