The CT Title V CYSHCN Program recognizes that CYSHCN and their families often do not receive effective care coordination and are not linked to the resources available in their communities that address their special needs and allow them to participate fully in public life. Programmatic strategies emphasize promotion of a medical home model of services, expansion of care coordination resources, integration of primary care and behavioral health, integration of care coordination efforts with an ideal of shared coordination across sectors and providers serving CYSHCN, and promotion of Family and Professional Partnership.

CT’s coordinated system of care for CYSHCN and their families, the CT Medical Home Initiative (CMHI) for CYSHCN, provides community-based, culturally competent care coordination and family support services to 9,500 CYSHCN in collaboration with 81 community based Medical Homes (MH) including: community health centers, hospital clinics, pediatric and family practices. CMHI care coordination network contractors include: CT Children’s Medical Center (North Central CT), St. Mary’s Hospital (Northwest), Stamford Health System (Southwest), Family Centered Services (South Central) and United Community and Family Services, (Eastern).

DPH will continue to convene the DPH Medical Home Advisory Council (MHAC), including convening the MHAC Family Experience Workgroup. MHAC is comprised of more than 40 representatives including youth representation, state and private agencies, community-based organizations, the state’s Medicaid Administrative Service Organizations (ASOs) and parents/caregivers of CYSHCN, and provides guidance to DPH and its partners in their efforts to improve the system of care for CYSHCN. The MHAC remains DPH’s chief vehicle for collaborating with state/regional/local agencies to organize easily accessible community-based service systems, identify gaps in medical and dental services, and maximize linkages with professionals and family organizations. Groups collaborate with MHAC and CMHI to develop and organize universally accessible community-based service systems and maximize linkages for their populations.

DPH will continue to partner with organizations serving CYSHCN, including legislatively mandated and other councils, e.g. the Medical Assistance Program Oversight Council, CT Interagency Birth-to-Three Coordination Council, Help Me Grow Collaborative, State Department of Education Bureau of Special Education Transition Task Force, Autism Spectrum Disorder Advisory Council, A.J. Pappanikou UCEDD Consumer Advisory Council, CT Council on Developmental Disabilities, Maternal Infant and Child Health Coalition, and Sickle Cell Disease Consortium. CMHI access information is distributed among these partners.

CT DPH will work with 7 different contractors that were awarded funding in July 2020 through a five-year RFP that had three separate components that all are involved with the CMHI. The three components were Care Coordination services, Family Professional Partnerships, and the Respite and Extended Service Funds program. The Care Coordination program provides culturally sensitive, developmentally appropriate, statewide services in community based pediatric practice settings for CYSHCN determined to be eligible under the CT CYSHCN program guidelines. These contractors work with medical home providers, the inclusion of protective factors within the framework of pediatric and other services, integration of behavioral health with primary care, and measuring progress via social networking tools. The five contractors also coordinate regional collaborative meetings. These Collaborative meetings provide a way to identify what gaps in services are happening throughout the state. Contractors will focus on reaching out to organizations in their communities to increase the number of partner organizations in their Collaboratives, including providers from Federally Qualified Health Centers (FQHC) and School Based Health Centers (SBHC).

Care coordination activities include assessment, care planning, home visits, family advocacy, linkage to specialists, dental services and community-based resources, coordination of health financing resources, coordination with school-based services, chronic disease management, integration with behavioral health, provider and family education, administration of extended services and respite funds, provider outreach including dental providers, family support and transition planning, and navigating telehealth and electronic services that developed as a response to the COVID-19 pandemic.. Collaborative outcomes experienced to date include: improved linkage to services for CYSHCN and other vulnerable children; strengthened implementation of Person Centered Medical Home by expanding care coordination capacity of primary care practices that serve CYSHCN; reduction in duplication and increased efficiency of care coordination services; increased cross-sector knowledge of resources for CYSHCN; increased capacity to perform care coordination across more than one sector; increased number of partners engaged in or connected to regional collaboratives; increased funding for care coordination through a blending of public and private resources; and increased family and provider satisfaction with care coordination.

Funding provided through the Family Professional Partnership Services component of the RFP will ensure that DPH will continue to provide statewide outreach and culturally effective education encounters for families on the medical home concept for CYSHCN including information regarding accessing community service systems, navigating insurance access, and self-advocacy. The contractor will provide several options for social media access and workshops, trainings, and education videos on topics that are important for CYSHCN and their families, including insurance access and the importance of having a dental home. The contractor will continue to provide virtual and in person support groups to help families.

A final component of the CMHI CYSHCN RFP provided state funding for Respite and Extended Service Funds. The five care coordination contractors, the family professional partnership contractor, and Child Development Infoline will all continue to work with and refer CYSHCN and their families to this contractor who will provide assistance to consumers in accessing health financing resources from all available sources. It will also provide assistance to eligible consumers in accessing available respite funding and service providers. This contractor will also provide their clients with information about the CMHI care coordination program and the family professional partnerships contractor.

In the upcoming year, for all seven (7) contracts that were awarded through the RFP, DPH staff will work with the contractors as they submit Results Based Accountability Report Card documents for the first time, and streamlining data collection and reporting to help improve efficiency.

DPH staff and the CMHI contractors will continue to be involved with highlighting the importance of developmental screening through workshops and webinars throughout Connecticut, aimed at giving information and support to providers such a home visitors, pediatricians, preschool programs, and kindergarten readiness programs to provide screenings such as Ages and Stages Questionnaire. The meetings and webinars will focus on individualized resources and needs of the communities to ensure the success of all young children through promotion, developmental awareness, and the power of community connections.

DPH will continue to work with the Office of Early Childhood on the integration of CT Medical Home Initiative Care Coordination Collaboratives and Help Me Grow Community Collaboratives. Integration of community collaborative will focus on improving communication, reviewing and improving data collection and sharing resources. Expansion and coordination across the regions, as well as getting feedback from care coordinators and families, will help to refine the model and implement effective care coordination practices around the state.

DPH staff will continue to work with CT 2-1-1 Child Development Infoline to develop an updated resource database for comprehensive health care services for all children, including CYSHCN. CT 2-1-1 currently has an interactive ALICE (Asset Limited, Income Constrained, Employed) web tool available and an online database for families to search for resources by their community. CT 2-1-1 also provides a yearly ALICE report to DPH which gives data by 15 service regions in Connecticut.  DPH will also continue to work with CT 2-1-1 on their Navigator Benefits Screener which is an anonymous tool that allows a person to answer a question to generate a list of some state and federal assistance programs that could be of help, what they may qualify for, and how to apply for them.  CT 2-1-1 will also continue to work with DPH and community providers to make sure that all the CT 2-1-1 databases stay up to date for individuals and families to access information on a variety of services such as employment assistance, transportation, housing, utilities, mental health services, COVID-19 resources, and basic needs. DPH will also work with them to provide training to community partners on generating resource lists for families of children, including CYSHCN. As a result of the large increase in web-based searches and calls to 2-1-1 from the COVID-19 pandemic, we will working with CT 2-1-1 Child Development Infoline to monitor and respond to the community needs.   

DPH staff will also continue to work with the Integrated Care for Kids (InCK) grant to improve child health outcomes, reduce avoidable out of home placement and inpatient stays and create sustainable alternative payment models to support provider accountability for cost and quality outcomes. The Connecticut grant will focus on the city of New Haven, with services to be provided by a mental health outpatient clinic. The goal is to increase access to services and reduce disparities in health outcomes for Medicaid and CHIP-enrolled children up to age 21, as well as pregnant women by providing comprehensive screenings and assigning children to a service integration level that is based on the screening results. Children, including CYSHCN and their families will receive culturally and linguistically appropriate support, including scheduling and transportation assistance and connections to community resources.  

Title V staff will also with the National Catalyst Center on NPM #15 to improve financing of care and health insurance coverage for CYSHCN. The Catalyst Center will help staff identify innovative strategies to help finance services and improve reimbursement for services used by CYSHCN. Focus will be on continued access to telemedicine as a result of the COVID-19 pandemic and working with those negatively impacted because of lack of access to computers. The Catalyst Center is a Health Resources and Services Administration funded National Center on insurance access.

The Office of Oral Health (OOH) serves as a primary source of oral health information to CT, promoting the importance of having a dental home and overall health and wellness. This is achieved through ongoing updates to resources on the website, social media messaging, federally funded grant programs, and community and inter-agency partnerships. Sharing and creating new data and resources, including bilingual content, is ongoing.

The OOH will continue to strengthen community partnerships. CT’s Dental Health Partnership (DHP), the dental administration for Medicaid works closely with the OOH to promote finding a dental home and access to Medicaid “HUSKY” dental insurance.  In the Fall of 2020, DHP invited the OOH to be part of a work group (The Affinity Group) as they explored implementing a medical dental integration concept:  medical staff applying dental sealants in pediatric setting during the well- child visits. The goal being to reduce extra visits, reduce transportation barriers, assist families in finding a dental home, and facilitate partnership between medical and dental providers as part of overall wellness. This work group will continue through the 2022 federal fiscal year.

Through a partnership with FQHCs in CT, Community Health Center, Inc, (CHC), the OOH implemented a medical dental integration pilot program (MDIP) at seven CHC sites in March 2021. The pilot features bi-directional referral between the CHC medical and dental staff in effort to reduce child obesity for children, heart disease for adults, and promote oral health as well.  An MDIP Advisory was developed in March consisting of stakeholders around the state. Quarterly meetings are held to provide guidance and technical assistance to the project and ensure sustainability.

The OOH along with the support of the CT State Department of Education (CSDE) is planning to conduct Every Smiles Counts (ESC) oral health surveillance during the 2021-2022 academic year. The ESC survey conducted every three (3) years screens kindergarten and third grade students at randomly selected school in CT as a part of ongoing evaluation of the state’s oral health.  The survey originally planned for 2020 was postponed a year due to COVID-19 and schools being remote.