Medical Home – Application Year

The Division of Public Health and Birth to Three will be meeting with a social marketing vendor this summer to establish a campaign on available early intervention services and to how to access services.  We will also be developing messaging on what a medical home is and the importance of a medical home. Work will also continue on promoting the developed care coordination notebook for families to help promote medical home and care coordination for CYSHCN. Specifically through contracts with Delaware’s Family Voices and Hands & Voices Chapters a care coordination handbook was modified for families with children who are deaf or hard of hearing will be developed. Likewise, through collaborations with the Delaware Building Bridges Project, Autism Delaware and Family Voices care coordination for families with children diagnosed with Autism Spectrum Disorder will be developed. 

Along with the condition-specific materials the CYSHCN Director will work with Family SHADE, Delaware Family Voices and the Part C State Systemic Improvement Plan Implementation Team to select care coordination and medical home materials for families with CYSHCN and their service providers.  Continuing in Year 5 will be our work with the Delaware Center for Health Innovation (DCHI) State Innovation Model (SIM) initiative. Our Family SHADE leaders will continue to represent the needs of CYSHCN with respect to medical home and care coordination.

Throughout the year we will continue to use the Family SHADE Families Know Best survey to keep a pulse on how families are experiencing the level of care for their children. Questions will be included on a quarterly basis regarding the families’ perspective on care coordination and the components of a medical home. Our measure for this strategy will be the number of responses and category of response to the survey question.

Continuing in Year 3 will be the Pilot Project to provide outreach and education to our primary care providers in Sussex County around Part C services, care coordination and community services. Through the personal contact of the Advanced Practice Nurse, with knowledge of the community, Part C and services, with the key personnel within the Primary Care Practices we hope to be able to track measurable outcomes including: knowledge of community services and referral processes to Part C and Part B.  The increased knowledge within the practice should lead to an increase in the number of all families responding positively to questions around medical home in the bi-annual children’s survey.

The work plan for 2019 Family SHADE/Title V partnership consists of the following:

• Families of children and youth with special health care needs (CYSHCN) will have access to the community-based services that they need.
  • Continue to support the development of the Family SHADE organization and its mission of improving the quality of life for CYSHCN by connecting families and providers to information, resources and services.
  • Improve access of CYSHCN and their families to information, resources, and services.
  • Support an improvement in the infrastructure, capacity, and effectiveness of services of Family SHADE member organizations.
• Improve the health and access to health care of CYSHCN in Delaware.
  • Provide assistance in implementing the strategic plan for Delaware Division of Public Health, Maternal and Child Health Bureau.
  • Increase the knowledge of families of CYSHCN about medical insurance, medical homes and access to healthcare in Delaware.
  • Increase access of CYSHCN to healthcare by providing families with information about insurance options for CYSHCN in Delaware.
  • Assist Delaware MCHB in addressing cross-cutting priorities which also meet the needs of CYSHCN and their families.
• Delaware YSHCN and their families will be better prepared for the transition to adulthood.
  • Connect youth with special health care needs and their families to information about transition to adult life including healthcare services and systems.
• Enhance the role of the Family SHADE program to include educating governmental entities and others regarding recognized gaps in services and family support to CYSCN and their families.
  • Provide information to policy makers via letters and/or meetings from Family SHADE Advisory and/or members regarding issues of concern to families of CYSHCN.

In the next couple of months, we will be soliciting feedback from Family Shade Board members and/or partners on strengths and gaps of the current program.  We need to release a new RFP for our Family Shade program.  As we develop this solicitation, we would like to hear from folks engaged in the work to ensure the request is inclusive of pertinent stakeholders needs.  We are working with an evaluator who has developed a survey that will be used to conduct 5-10 key informant interviews. 

Adequate Insurance Coverage – Plan for the Coming Year

Now that our Title V/Title XIX Memorandum of Understanding has been completed and is now in place, our plan for the coming year is to work on the establishment of the Cross-Agency Coordination Committee.  Delaware sent a team to the 2018 MCHB Skills Institute in Tempe, Arizona and the team comprised of two MCH staff and two DMMA staff.  Our challenge that we brought to Institute was to leverage skills and tools to design, define, and document the vision, mission, and charge of the Cross-Agency Coordination Committee.  As described in our MOU this committee will work to establish a multi-disciplinary coordination committee.  The committee will be responsible for working together on training, messaging, case management, and procedures. Two members of this four-person team have since vacated their positions.  Once, these positions are filled, we will proceed with implementation of this committee.

We continue to support of the Family Voices Managed Care Calls in Spanish and English as they continue to be a wanted resource.  Title V will also continue to participate in CMCAC to support their recommendations:

• Keep the CMCAC in place
• Perform a comprehensive data analysis as it related to children with medical complexity
• Strengthen systems of care for children with medical complexity
• Be clear in contracts about the role of managed care organizations in identifying and providing services to children with medical complexity
• Develop and/or strengthen existing resources for caregivers, providers, and the larger community involved in the care of children with medical complexity
• Strengthen the network of home health providers for children with medical complexity