Priority Need: Increase the Number of Children, Both With and Without Special Health Care Needs, Who Have a Medical Home

NPM 11: Medical Home

Percent of children with and without special health care needs, ages 0 through 17, who have a medical home

NPM 11 Strategies:

11.1a Expand the use of telehealth technology to improve access to audiological and early intervention services for children and youth with special health care needs.

11.1b Facilitate efforts to educate families about telehealth as an option for care.

11.1c Provide ongoing evaluation of the Department’s telehealth network to ensure pediatric specialty services meet the needs of families and patients.

11.1d Develop and implement a quality improvement plan for Title V’s Children and Youth with Special Health Care Needs program to identify opportunities in which telehealth technology may be used to improve medical home access.

11.2a Expand the capacity of HMG liaisons to help families navigate/access comprehensive services.

11.2b Improve access to information and resources for CYSHCN.

11.2c Develop an outreach plan to engage partners, providers, and families in the utilization of HMG, a shared resource to assist families to navigate the early childhood system/

11.3a Engage stakeholders with a shared vision and common understanding for the needs of a medical home and willingness to join into an approach to solve the problem through agreed-upon actions.

11.3b Construct an informative PowerPoint/Webinar that can be utilized to educate partners on the importance of encouraging families to seek a medical home and that will offer stakeholders’ innovative ideas on how to expand the concept of a medical home, which ultimately will increase the number of families with a medical home.

The CYSHCN program will continue to ensure children with chronic and complex medical needs have access to affordable, family-centered, continuous, and coordinated quality health care. In counties which are considered rural and there is limited access to pediatric subspecialty care, the CYSHCN program will utilize the DPH’s robust telehealth/telemedicine infrastructure to provide access to specialty clinical care. With more than a decade of experience with partnering with pediatric healthcare systems, university systems, and private specialty providers, the CYSHCN program will coordinate pediatric sub-specialty care for seven telemedicine clinic sites and serve more than 700 families annually. The program will continue to identify opportunities to utilize telehealth technology to engage with families and adolescents across the State. Telemedicine specialty care types includes genetic testing, diagnostics and counseling, sickle cell follow up care, and endocrine, pulmonology, pediatric neurosurgery, and nephrology services.

In the upcoming year, the CYSHCN program will improve access to timely and affordable diagnostic evaluations and treatment services for children with special health care needs to increase the percent of children with and without special health care needs, ages zero through 17, who have a medical home. With the transition to the Pathways platform, there will be greater opportunity to partner with more providers with diverse specialties.

CYSHCN will also utilize existing partnerships with community-based organizations and physician groups to promote education and awareness of telehealth opportunities with families as well as continue to monitor and evaluate the satisfaction of telemedicine services provided to families across child serving programs. The program will partner with DPH’s Office of Quality, Performance, & Accreditation to identify additional opportunities for the CYSHCN program to utilize telehealth for improved coordination of care for youth and their families, enhanced collaboration with physicians, pediatric specialists, and interventionists, and develop a streamlined process for collecting and reporting statewide telehealth/telemedicine initiatives supporting children and youth with special health care needs.

Priority Need: Improve Systems of Care for Children and Youth with Special Health Care Needs

NPM 12: Transition to Adult Care for All Children

Percent of adolescents with and without special health care needs, ages 12 through 17, who received services necessary to make transitions to adult health care

NPM 12 Strategies:

12.1a Develop and implement a health care transition quality improvement and evaluation plan to assess the effectiveness and efficiencies of the Department’s health care transition program activities that impact youth and families.

12.1b Provide technical assistance and guidance on health care transition planning for care coordinators, supporting the Title V Children and Youth with Special Health Care Needs program.

12.1c Implement condition specific transition planning protocols for adolescents enrolled in the Title V Children and Youth with Special Health Care Needs program.

12.1d Provide educational opportunities for youth and families to increase their knowledge on health care transition planning services and resources.

12.2a Establish an advisory group to include youths, families, and providers to support practice improvement efforts for health care transition.

12.2b Partner with adolescent health programs within the Department to implement best practices that support health care transition planning for youth and young adults with or without special health care needs.

12.2c Develop and implement a health care transition communication plan to share targeted messaging for transitioning youth/young adults with and without special health care needs from pediatric to adult care for audiences to include youth/young adults, families, health plans, medical providers, state agencies, and community partners.

12.2d Provide continuing education opportunities on the six core elements of health care transition for medical and nursing students, pediatric and adult providers.

The upcoming priorities for the CYSHCN program will include designing and implementing a process to collect and disseminate information on the various statewide health care transition initiatives that occur across health systems, academic spaces, state agency partners, and community-based organizations to ensure youth, families, and health care providers have access to current information as it relates to health care transition services and resources.

CYSHCN program staff will also engage and collaborate with subject matter experts representing various health care, community, and family support arenas to establishing a diverse health care transition advisory group to direct and lead efforts to support statewide transition services transformation activities. Focusing on activities which assess and strategize in the areas of workforce development and training, communications, outreach and awareness, youth and family support and program eligibility, and service delivery initiatives.

The transition advisory group will be one effort to increase the number of community stakeholders that work to implement health care transition processes and procedures for youth and young adults with or without special health care needs. The program will also partner with the DPH adolescent health program to implement best practices that support health care transition planning for youth and young adults with or without special health care needs receiving services in local public health district adolescent health programs. This effort will include developing an implementation toolkit for clinical staff to provide care within an adolescent friendly framework.

The CYSHCN program will work diligently to increase the number of youth and young adults enrolled for services that transition to an adult model of care by providing ongoing technical assistance to local public health district CMS programs on engaging and partnering with local adult providers that serve as potential resources to link youth and young adults to continued care. Trainings for care coordinators will be provided on local community resources that will aid in youth/young adults’ transition to adult services and educational opportunities to youth and families on health care transition preparation and planning will be promoted. The program will also implement a streamlined process for receiving feedback from young adults and families on their experiences with accessing transition services through the CYSHCN program.

During the latter part of 2020, the CYSHCN program expanded telehealth services due to the restrictions placed on home visitation services during the COVID-19 pandemic. Local CMS program staff began providing care coordination services for existing and newly enrolled families via DPH’s secure videoconferencing platform. The telehealth technology available to local public health district CMS programs will continue to be used to explore additional opportunities to engage with youth and young adults during their transition planning activities. Activities may include transition goal setting, feedback sessions, and educational opportunities with medical providers. The opportunities are vast, and the program looks forward to engaging with youth to solidify some of these ideas.

Overall, the CYSHCN program’s health care transition efforts during the upcoming year will focus on developing streamlined processes for gathering and disseminating information for youth, families, subject matter experts, and community partners to advise on workforce development and training, communications, outreach and awareness, youth and family support and program eligibility, and service delivery initiatives. The CYSHCN program will continue to monitor and evaluate CMS health care transition program activities to ensure youth and young adults and their families are satisfied with services and their transition needs are being met. The program will also explore the best strategies to utilize telehealth technology to better prepare the youth and young adult to successfully transition from pediatric to adult care.

Priority Need: Promote Oral Health to All Populations

NPM 13: Preventive Dental Visits

Percent of children, ages 1 through 17, who had a preventive dental visit in the past year

The Oral Health program will continue to educate public health district’s oral health staff on special considerations and treatment needs for special needs patients. Education and training on caring for children and youth with special health care needs will be condition-specific and include evidence informed practices. Education and training for school-based programs that include all children will continue.

Other CYSHCN Programs

Babies Can’t Wait

BCW will continue to serve children birth to three with developmental delay and Category One chronic conditions. BCW will continue to focus on increasing provider capacity and is working on addressing strengths and challenges within the program.

BCW will continue to revise and clarify policies and procedures related to consistent implementation of the Part C program across public health districts. As policies are updated, related trainings will be developed and delivered to district staff and contractors to ensure understanding of program requirements and expectations. A BCW Training & Support Coordinator will assist the program in developing and delivering a state-wide training program for BCW District and Contract providers. Partnerships with Institutes of Higher Education will be providing intensive training and technical assistance to BCW state leaders and community providers. Developing Master Coaches and Fidelity Coaches within the BCW program will directly improve the quality of services provided and support improved outcomes for children and families.

Transition between Part C and Part B will continue to be a targeted effort. BCW will continue to work with Part B partners to ensure a consistent understanding of the transition requirements between programs. BCW, Part B/619, and Head Start have launched transition forums across the state, allowing opportunities for BCW Districts, Local Education Agencies (LEAs), and Head Start programs to come together to discuss transition expectations and local implementation plans.

BCW has implemented a data monitoring plan across the districts that will continue to ensure that districts are regularly reviewing their program data so that the APR reporting process will become more streamlined and efficient and accurate.

Georgia Autism Initiative
In the upcoming year, the Autism program will continue to improve and increase early identification and screening for ASD in children. Increasing early identification of autism and other developmental disabilities will help to improve outcomes for children by connecting them to early intervention services and supports. The program will implement statewide screening, evaluation, and treatment for children and youth with ASD.

MCH will continue to provide academic detailing, such as educational outreach and training, to medical providers, including pediatricians, family physicians, physician’s assistants, nurse practitioners, and nurse managers, who utilize evidence-based practices. Information on topics including the importance of screening, listening to parental concerns, using screening tools during well-child visits, implementing standardized screening practices, billing for reimbursement, as well as referring children for diagnosis, early intervention services, and community supports, will be presented. Outreach will continue to be conducted using a variety of strategies to include webinars, telehealth, and practice visits.

MCH will maintain its partnerships with local programs and agencies to meet goals and objectives. The following is a list of internal and external partners:

• Babies Can’t Wait (Part C Early Intervention Program)
• Children’s Medical Services (State Children with Special Health Care Needs Program)
• Children First (Single point of entry for child health services in public health)
• Georgia Department of Community Health (Medicaid)
• Georgia Department of Behavioral Health and Developmental Disabilities
• Georgia Department of Education
• Georgia Chapter of the American Academy of Pediatrics
• Georgia Academy of Family Physicians
• Centers for Disease Control and Prevention
• Georgia State University
• Marcus Autism Center
• Emory Autism Center

MCH will continue to utilize quantitative evaluation methods to examine the achievement of goals in relation to the medical provider’s pre-knowledge and skills, as well as the effectiveness of the learning outcomes. Referrals will continue to be tracked from participating practices to Child Health programs for children who screen positive for developmental delays. Qualitative evaluation methods will also examine the process of the educational interventions.

Early Hearing Detection Intervention

In the upcoming year, the EHDI program plans to improve the system of care through strategies to decrease loss to follow-up and documentation, maintain and document hearing screenings for 95 percent or more of Georgia’s occurrent births, increase timeliness and receipt of diagnostic evaluations for infants who do not pass the newborn hearing screening, improve data sharing between EHDI, family support and Early Intervention providers, improve change management, and improve stakeholder and family engagement.

The EHDI program will continue the work that was enhanced by Legislative Act 462, which brings into focus the academic landscape for children who are deaf or hard of hearing (D/HH). EHDI and Part C programs will continue to work more collaboratively with DECAL and the DOE to monitor and strengthen the systems that support early identification, intervention, language development academic achievement for D/HH children across the continuum of service they receive from birth to third grade.

EHDI will continue to collaborate with key stakeholders to enhance the quality and timeliness of the EHDI system and continue to promote activities that result in access to needed resources and interventions to promote language acquisition and optimal social, emotional and cognitive development for children who are deaf or hard of hearing. EHDI will continue to engage two family support programs through Georgia Hands and Voices: Guide By Your Side and Advocacy Support and Training.

The EHDI program will also continue to support Georgia PINES Deaf Mentor program to provide families who have children with hearing loss with family-centered, home-based, and curriculum-led early education, focusing on visual communication, American Sign Language, and Deaf Culture.