CSHN is engaged in an array of ongoing projects and new initiatives. With the return of all CSHN staff to typical job duties following lengthy deployments to VDH’s COVID-19 response, much of our work is aimed at reinvigorating areas of the system of care hit hardest by the pandemic, as well as the programs and services we directly oversee.
At the organizational level, CSHN is restructuring the medical social worker role into a more population- and systems-oriented model for supporting CYSCHN in Vermont. This shift builds upon several years of work prior to the COVID pandemic, including a series of stakeholder engagement projects where families and providers contributed significant input to identify areas of opportunity for improving the care coordination system in Vermont. Planning for this restructuring takes into account several key factors and trends in Vermont: increased availability of care coordination through medical homes and specialty clinics; increased ACO attribution (OneCare VT) for CYSCHN; the transition of all state-run specialty clinics to UVMMC; telehealth and communications strategies developed during the COVID response that support broader outreach efforts.
The CSHN team has worked since early 2022 to develop a “Care Consultation and Systems Health” model that blends macro-social work, episodic and consultative care coordination, and financial/technical assistance tools. In this model, individual family contacts and outreach to/from providers are documented and categorized in a centralized tracking system, and trends are reviewed against regional needs assessments to identify barriers, gaps, and improvement opportunities. The CSHN Care Consultant is intended to be positioned further “upstream” than the medical social worker role and will represent CSHN in a leadership capacity on statewide committees and workgroups. Finally, the Care Consultation and Systems Health model further integrates CSHN’s financial technical assistance and training specialist to develop and disseminate educational resources based on population and provider needs.
A core aim of the Care Consultation and Systems Health model is to be flexible and responsive to changes in the system of care. The aforementioned increase in care coordination providers and funding available through the ACO have the potential to muddy the waters for families who have consistently expressed the need for a lead coordinator and clear roles on their care teams. Further, the seismic impact of the pandemic on the healthcare system continues to be felt, requiring projects in the works prior to COVID to adjust to the new normal.
In partnership with VCHIP, CSHN convened a broad, high-level group of stakeholders, including families, OneCare VT, UVMMC’s Children’s Specialty Center, the Vermont Family Network, and care coordinators from human services agencies and medical homes/primary care practices. The “Care Coordination Collaborative” intends to assess the landscape of care coordination for CYSHCN in Vermont, partner with stakeholders to gain consensus on priority areas, support shared learning and identify improvement strategies, and establish evaluation and measurements strategies. An initial two meeting summit series was held in March 2022, with follow up meetings in April and June. Based on an analysis of the input to date, the VCHIP team is working to implement and standardize Shared Plans of Care, as well as to present key findings to senior leadership at large organizations (OneCare VT, the Blueprint for Health, the UVM Health Network, and Vermont Medicaid). Going forward, as the VCHIP team reports on progress with implementation efforts and data from evaluation metrics, CSHN’s Care Consultation and Systems Health team will disseminate project materials more broadly across the state, adapted according to different regional and sub-population needs.
In recent months, long-term work to transition CSHN’s Child Development Clinic to our partners at UVMMC officially concluded. The CDC was the last remaining direct service clinic and was the most complex to transition, requiring a lengthy recruitment process for a Development-Behavioral Pediatrician and meticulous planning across multiple stakeholders. Now that the UVMMC clinic is fully operational, CSHN is working to reduce wait times and expand the system’s overall capacity for developmental assessments through models that leverage partnerships with primary care practices and Early Childhood/Part C providers within the Children’s Integrated Services network. To conduct this work, CSHN convened a workgroup with representatives from other Agency of Human Services departments, solicited input from UVMMC clinicians and the interagency Autism Workgroup, and engaged a VCHIP project lead with connections to the Vermont Chapter of the American Academy of Pediatrics. Details for piloting a new assessment model are underway, with a planned January 2023 start date.
Parallel to this project, CSHN’s Care Consultation and Systems Health team is developing an infographic and FAQ to assist families who are waiting for a development assessment. These resources have undergone extensive review by stakeholders and serve to communicate important information about the array supports available to children, even prior to receiving an official developmental or autism spectrum diagnosis.
Through our administration and oversight of three Vermont Medicaid programs, CSHN is working to leverage one-time investment opportunities and new policy opportunities to better serve CYSHCN and their families. For the Pediatric Palliative Care Program (PPCP), enhanced FMAP funds were earmarked to purchase goods and supplies for the home health agencies who deliver this suite of services. These supplies are not otherwise covered by the program’s payment structure and will be used directly with the children and families enrolled to deepen the impact of palliative supports they receive. For over two years, the Pediatric High-Technology Nursing program (HTN) has been engaged in a project with Vermont Medicaid’s payment reform team towards the goal of increasing service utilization rates for eligible members. HTN services are essential for keeping the most medically fragile children in the state at home with their families. Looking ahead, in addition to assessing the first full year of the new hybrid payment model implemented in January 2022, the project team will access enhanced FMAP funds to trial a value-based payment component as another pro-active measure to increase service provision to HTN families.
Children’s Personal Care Services (CPCS) is the largest Medicaid program CSHN oversees. Since the beginning of the COVID-19 Public Health Emergency, CPCS has operated under temporary waiver authority to allow parents and legally responsible caregivers to be paid for providing personal care to their eligible child. Based on family input received throughout the pandemic, CSHN partnered with Vermont Medicaid to make this payment option permanent, as part of Vermont’s recent Global Commitment to Health renewal. In the spring, CSHN conducted a comprehensive survey to obtain additional input on the impact of this payment option and set a baseline to monitor family experience going forward. Work is underway to develop policy/rule and additional guidance for parents who will access this option when there are barriers to receiving personal care services from an attendant hired by the family, as the typical service model intends. We anticipate several additional rounds of family and stakeholder engagement going forward.
CPCS is an EPSDT covered service; opening a parent/caregiver payment option removes a barrier to accessing the service, while simultaneously addressing the disproportionate financial hardship and unpaid family caregiving experienced by CYSCHN. At the same time, the intent of CPCS is for families to receive supplemental support with their child’s needs, and the impact of the pandemic on the healthcare workforce has been significant. To this end, CSHN continues to participate on the interagency HCBS FMAP workgroup to inform ongoing spending and implementation planning. One early initiative pertains to workforce retention and recruitment strategies, focused on direct care providers, such as PCAs.
CSHN will continue to use Title V funding to support family leadership and engagement programming. This will primarily occur through our sub-recipient partnership with the Vermont Family Network (VFN; one of Vermont’s Family Voices/F2F organizations). VFN organizes a family leadership series, maintains a family support team, administers a supplemental assistance fund including an option for respite, hosts SibShops, and hosts an annual conference. Building on updates to the VFN grant last year, there are increased expectations to reflect racial, ethnic, and geographic diversity in their outreach efforts, as well as measures to ensure all of their programs, activities, and materials are accessible to those who are of limited English proficiency or non-English speaking.
Throughout the majority of the last grant cycle, MCH/CSHN contracted with the parent of a child with a special health need, who has professional expertise in the field, to coordinate programmatic and divisional family engagement initiatives, including an onboarding toolkit for family partners. Given the opportunity to take on a permanent position in the Health Department’s new Health Equity and Community Engagement (HECE) team, MCH/CSHN’s family engagement coordinator will not continue in her contracted role for the next grant cycle. However, the family engagement toolkit she developed with MCH/CSHN partners is in use in several programs currently and will be implemented to onboard family partners in future projects as well. Further, MCH/CSHN will work with the new HECE team to identify strategies to continue with family engagement efforts through new partnerships.
Vermont’s NPM is Transitions to Adulthood. Transition supports for CYSHCN to young adult health care services, both primary and specialty care, will also continue to be a focus of our efforts this coming year. Part of the shift from a direct-service model to population-based health is the opportunity to ensure transition tools are available and in use across the range of care coordination providers discussed above.
CSHN will continue to support specialty care transition improvement work through a VCHIP project with the Children’s Chronic Care Initiative (CCCI). The CCCI team will continue to implement youth transition readiness assessments within condition-specific clinics at UVMMC and expand electronic health record functionality to track and report on transition efforts. The CCCI team is incorporating Got Transition’s Six Core Elements at every opportunity, including with their primary care transition focused work, where they will build upon a new workflow previously piloted in collaboration with a local family medicine practice and UVM Children’s Hospital’s Pediatric Primary Care practice. An element of CSHN’s grant with the Vermont Family Network involves transitions supports, with a focus on self-advocacy and supportive decision-making (SDM) for CYSHCN. CSHN will continue to work closely with HireAbility (formerly VocRehab) leadership to ensure the statewide system of transition counselors are well-informed and supported on the unique needs of CYSHCN.
Please note: Only those strategies the link with national and state performance measures are identified in the Action Plan Table for this section.
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