NPM 11 – Medical Home: percent of children with and without special health care needs, ages 0 through 17, who have a medical home.

 

Meeting National Standards for Systems of Care for CYSHCN

 

Children’s Special Health Services (CSHS) addresses NPM 11 by offering gap-filling programs, such as peer support services and resource coordination programs, to all children and their families in Montana. CSHS offers a variety of population health and direct service programs while collaborating with CYSHCN programs across DPHHS. CSHS has 4.75  program staff and 1.0 Americorps VISTA, supervised by the CYSHCN Director/Section Supervisor.

 

There were significant staff transitions in the first six months of FFY21. The CYSHCN Director began her position at the beginning of the time-period, and these four program staff have since been hired: Nurse Program Manager; MAPP-net Program Specialist; CYSHN Health Education Specialist; and CSHS Program Assistant. The CYSHCN Specialist and Program Assistant are new positions in the section.

 

CSHS manages critical programs for children and youth with special health needs: Cleft/Craniofacial Clinics; Statewide Genetics and Metabolic program; Newborn Hearing Screening Program; and the Montana Access for Youth Psychiatry Program. Through Title V funding, CSHS supports initiatives to increase parent leaders and peer-to-peer support through the Parent Partner program and Circle of Parents.  Population-based initiatives are supported through the Transitions Project and the Medical Home Portal.

 

CSHS also serves as a key collaboration facilitator across state programs. For example, CSHS is leading an inter-division collaboration between Medicaid and Child & Family Services to increase the number of Parent Child-Interactive Therapy (PCIT) trained mental health practitioners in the state, and create referral pathways for children involved in child welfare services.

 

Overview of Programs Directly Funded through Title V

 

The HALI Project: Montana Parent Partner Program - FFY21 Update

 

The Montana Parent Partner Program (MPPP) continues to provide peer services to families of children with special health needs across Montana. The impact of COVID-19 endures into FFY21, resulting in: Parent Partner turnover; a decrease in referrals; and, barriers to starting programs in new practices. However, training is ongoing via telecommunications.

 

In the first half of FFY21, PP has served 87 distinct clients in 357 different encounters; offering valuable support, encouragement, and hope to families. The number of distinct clients this fiscal year is currently trending to be less than last fiscal year. This may be due to a decrease in the number of sites and PPs. There are currently 5 PPs at four clinic locations in Billings, Kalispell, Butte, and Great Falls.

 

The COVID-19 pandemic has significantly impacted the effort to increase parent partners and the needs of practices and families to shift their priorities and adhere to public health protocols and social distancing. It is anticipated that with the implementation of vaccines, recruitment and retention of PP will increase. Expansion is expected to one additional clinical site in this fiscal year, Shodair Children's Hospital. They will provide services via telecommunications.

 

CSHS is collaborating with the University of Montana Rural Institute (UMRI) to host a Montana team’s participation in the National Care Coordination Academy. The CSHS Section Supervisor and a UMRI staffer co-lead an interdisciplinary team that includes family leaders, payer representation (Medicaid and Blue Cross Blue Shield), Title V CYSHCN, pediatricians, and clinicians. The State Director for the Parent Partner program participates in the workshop-structured learning opportunities, regular virtual meetings, and targeted technical assistance. She will be presenting the MPPP model to the MT team as part of an ongoing series of cross-education on care coordination and care coordination allied programs across the state.

 

As detailed later in this narrative, CSHS is collaborating with the State Director and the Family to Family Information Center to review applications for the financial assistance program. This collaborative effort has: resulted in opportunities to refer new families to the MPPP program;  highlights opportunities for improved integration between programs for CSHS; and, ensures referrals for CSHS programs are not siloed.

 

MPPP - Plans for FFY22

 

CSHS remains committed to expanding peer services for families of CYSHCN in Montana. CSHS will meet with potential partner agencies like the MT Peer Network to explore sustainable peer models, and further work with the PP program to evaluate efficacy and operations. CSHS applied for the Early Childhood Support Systems Grant (ECSS) to expand capacity for the prenatal-to-three population. If awarded, one focus will include assessing opportunities for scaling and growth for the PP program, and care coordination for children with special health conditions. ECFSD was recently notified that we were not awarded the funding; however, the division will continue to pursue other relevant opportunities to support the same goals when such opportunities are available. CSHS intends to increase the number of parent partners in the state by providing technical assistance to the Hali Project and improving program oversight by implementing quality and performance metrics.  CSHS will partner with the Hali Project to expand peer services provided via telecommunications. 

 

Circle of Parents

 

CSHS continues to partner with Butte 4-C’s to establish and facilitate Circle of Parents (COP) groups in Montana. Through a collaboration with the Children's Trust Fund, CSHS has expanded the partnership to support the growth of new COP groups in different parts of the state. Each group is founded on eight principles: Trust; reciprocity; leadership and personal accountability; respect; parenting in the present; shared leadership; responsibility; and non-violence. These groups aim to decrease isolation, prevent child abuse and neglect and strengthen families through free monthly caregiver support groups.

 

Each caregiver leading a group is provided a stipend to coordinate a supportive environment with a free meal and free childcare.  COP facilitators host seven possible groups depending on their specific communities' needs: Grandparents raising Grandchildren; Families with CYSHCN or Mental Health Concerns; Parents in Recovery; Positive Parenting; and Love and Laundry.  As of January 2021, there are currently seven facilitation sites providing specific services as indicated:

 

Butte: parents of children with special health care needs and or mental health care needs, and grandparents raising children;

Missoula: parents of children with special health care needs and or mental health care needs;

Billings: parents of children with special health care needs and or mental health care needs (expected to begin later in FFY21);

Helena: parents of children with special health care needs and or mental health care needs;

Mission Valley: parents of children with special health care needs and or mental health care needs;

Havre: parents of children with special health care needs and or mental health care needs (expected to begin later in FFY21);

Great Falls: parents of children with special health care needs and or mental health care needs, parents that have been in recovery; Positive Parenting.

 

CSHS currently funds two national trainers. They intend to conduct trainings in person in FFY21 and 22 to onboard new parent leaders in new communities. COP intends to expand to Kalispell, Bozeman, Helena, Lame Deer, located on the Northern Cheyenne Indian Reservation, and other rural and tribal communities in FFY21 and 22.

 

University of Montana Rural Institute (UMRI): Transitioning Youth into Adulthood

 

UMRI FFY 21 Update

 

CSHS continues to partner with UMRI to provide evidence-based transition resources to Montana’s youth and families.  This program works to: maintain and expand the 15-member Consumer Advisory Council (CAC); maintain and disseminate a health care transition (HCT) guide; develop evidence-based/informed HCT training and resource materials; conduct distance learning opportunities; maintain a transition website; and, provide technical assistance to other initiatives related to HCT.

 

The CAC continues to recruit new members and provide member orientation.  This team facilitates ongoing leadership development and mentoring of all members, with a focus on youth engagement and self-advocacy.  The CAC facilitates quarterly meetings and work groups, and they participate in an annual Montana Youth Transition conference, in which they can exercise their leadership skills.

 

On an ongoing basis, project staff at UMRI collect and develop new resources and distance learning opportunities for families and medical providers in Montana. Project staff continues to disseminate this information via the Transition and Employment Projects website (http://transition.ruralinstitute.umt.edu/), which is reviewed and updated quarterly.

 

UMRI Plans for FFY22

 

UMRI will continue the FFY21 activities in FFY22. CSHS is collaborating with UMRI on hosting the Montana team (MT) within the National Care Coordination academy.  CSHS will continue to coordinate the MT team into FFY22, to support ongoing resource sharing and identification of care coordination improvement opportunities across stakeholder groups.

 

Montana Medical Home Portal (MMHP)

 

MMHP FFY21 Update

 

CSHS continues to contract for a Montana-specific services directory on the Montana Medical Home Portal (MMHP) https://mt.medicalhomeportal.org/, a website developed by the University of Utah. It is an easy to navigate, one-stop-shop which provides diagnosis information, treatment options and state and local resources to families, providers and agencies. The MHP includes vetted, up-to-date clinical information, materials on accessing care, and a statewide services directory specific to Montana. CSHS is dedicating a partial FTE of an Americorps VISTA to support the maintenance and growth of the resource directory.

 

In Montana, the MMHP tool can be utilized as an up-to-date and accurate resource directory for professionals and families.  CSHS is exploring several different partnerships to advance that effort.  The MPPP program was re-trained in the tool in March; and will be required to continue to enter, edit and maintain resources specific to CYHSCN and their communities. In January 2021, CSHS and MMHP met with the “211” resource locator to explore sharing resource databases and to help ensure that the MMHP has up-to-date information.

 

MMHP FFY22 Plans

 

CSHS will work this year and next to ensure that the resource directory is up-to-date while partnering with similar platforms for synergy and data sharing. Other platforms identified across the state include CONNECT, a bi-directional referral system supporting clinic-community linkages. CSHS, MCH, and other MCH partners are discussing how to ensure programs are maintained within CONNECT, and explore opportunities specific to CSYHCN populations. CSHS is in discussion to start a sub-group of the State Health Improvement Plan Committee, which would be devoted to creating a workplan to improve resource and system collaboration for CYSHCN populations.

 

Financial Assistance Program

 

FAP FFY21 Update

 

The CSHS Financial Assistance Program (FAP) was in operation through the beginning of FFY 21 and moved to a temporarily closed status in December 2020, due to increased number of applicants and limited funding. Through the FAP, qualifying families can apply for the FAP to cover out-of-pocket expenses for medical and enabling services, such as therapeutic services, occupational therapy items, adaptive equipment, and respite care. Qualifying families are eligible to receive up to $2000 per federal fiscal year, per child.

 

In response to increased applications, the program processes in place, and limited funding, CSHS made changes to the program, including organizing a committee of: three-parent leaders (PP); the Parent Partner State Director; two staff from the Family Information Center, and, three state staff who reviewed all FFY21 applications. In instances where funding was not possible, the committee compiled resources and reached out to partners like Medicaid and Part C to redirect the applicants to other available resources.

 

FAP FFY22 Plans

 

CSHS plans to reopen the FAP and will continue utilizing the review committee with a focus on referral and resource navigation.

 

Other CSHS Programs

 

The CYSHCN Title V Director/CSHS Section Supervisor oversees other programs including:  Newborn Hearing Screening; a statewide genetics program; metabolic clinics; and the Montana Access to Pediatric Psychiatry Network (MAPP-net).

 

In FFY21 MAPP-net has implemented: Project Echo clinics; an access line for providers; and the second annual Symposium of Pediatric Mental Health. Monthly meetings with Medicaid were initiated to partner on similar initiatives and discuss options for sustainability.  In FFY22 MAPP-net will continue these activities and focus on sustainability. The advisory council will expand to include more primary care representation. MAPP-net will continue to partner with Medicaid; and build upon the Bright App, a behavioral health telehealth provider directory. This work will align with other section programs with the goal of improving service navigation for families.

 

In FFY21 Cleft/Craniofacial clinics restarted with COVID regulations in place. Attendance per clinic has decreased, and CSHS is reviewing and assessing data on clients. The remaining portion of FFY21 and FFY22 will focus on supporting consistency and continuity of care at the cleft clinics and an assessment on the outcomes of care. CSHS will engage with providers and families of CYSHCN to determine the strategy for FFY23 to ensure that children with cleft and craniofacial anomalies are receiving quality care in their communities.

 

These CSHS Programs support the advancement of medical homes for CYSHCN and their families and align with National Standards for Systems of Care for CYSHCN.  Further details are available at: http://www.amchp.org/programsandtopics/CYSHCN/.