2023 Application Year Report- Medical Home

NPM 11: Percent of children with and without special health care needs having a medical home.

Objectives:

• Increase access to specialty medical care for children and youth with special health care needs by 2%.
• Improve the system of care coordination for children and youth with special health care needs that is provided by different agencies across the State.

Strategies:

• Improve access to a family-centered medical home for all CYSHCN by partnering with family organizations that provide parent trainings and advocacy efforts to promote parent/professional partnerships.
• Explore alternative methods to provide specialty care to CYSHCN in underserved regions of the State.
• Improve collaboration between the Title V CYSHCN program, Medicaid and the Managed Care Organizations.
• Promote the use of high-quality care coordination for CYSHCN utilizing the standards developed by the National Consensus Framework for Systems of Care for CYSCHN.

ESM. Number of family trainings completed by partnering organizations that promote parent/professional partnerships.

ESM.  Number of trainings to parents and professionals around care coordination and family centered practice based on the National Framework for Systems of Care.

System of Care for Children and Youth with Special Health Care Needs

Children’s Medical Services (CMS) will support New Mexico community-based family organizations who provide leadership and training to parents and guardians for Children and Youth with Special Health Care Needs (CYSHCN) around advocacy and access to supports and services for their children. This includes assuring access to a family-centered medical home.

CMS will continue to strengthen existing family networks to help families with CYSHCN be fully prepared, mentored and connected to meaningful opportunities of program and policy partnership and ensure that the Managed Care Organizations (MCOs), Medicaid, and state polices that can affect CYSHCN are guided by patient and family voices. Best practice for care coordination of CYSHCN involves collaborative patient and family-centered care. To continue to address these principles, CMS will sustain family participation in the Maternal and Child Health (MCH) Collaborative, NM Interagency Coordinating Council (ICC), Newborn Hearing Screening (NBHS) Advisory Council, Early Hearing Detection and Intervention (EHDI) meeting and Association of Maternal and Child Health Programs (AMCHP) Conference.  CMS funds contracts with family organizations to ensure that families partner in decision-making at all levels and that their needs are met. The scope of work includes participation in local, state and national meetings/conferences, training for staff/families, and an advisory role regarding policy. We hope to get back to more in person meetings and trainings as we move away from Covid-19 restrictions and additional pandemic related job duties.

Within our vast and diverse state, the aim is to reach all families, especially those who may be isolated due to language, citizenship status or geographic location. We work with diverse cultural, ethnic, and linguistic populations with varying citizenship status within the state of New Mexico. Organizations with whom we partner include Parents Reaching Out (PRO), Education of Parents of Indian Children with Special Needs (EPICS), Hands & Voices, Growing in Beauty (Navajo), and Navajo Family Voices.

CMS provides funding to PRO to support the annual family leadership training meeting. Lessons learned from the pandemic is that remote opportunities may improve access for families who might not be able to attend due to transportation, need for respite and other barriers. These conferences support the Title V initiatives by training families on what coordinated care should look like and how to access resources if they are experiencing challenges. Other concepts during these trainings include how to successfully transition a young adult with special health care needs to adult medicine, how to advocate for their child’s needs, especially when it comes to funding issues, what tools families can use to work successfully as a partner with their child’s health care team and other shared resources and supports that might be available in their communities.  Funding is also provided to EPICS for their family leadership training conference, which focuses on Native American families with special needs children and attracts over 400 participants annually. This conference also supports the Title V initiatives by honoring Native American traditions and values and the unique challenges around accessing care on tribal lands. The Hands & Voices chapter in NM will also continue to be funded for family-to-family support during early identification of hearing loss in infants. This initiative addresses coordination of care and early access to services.

The Navajo Family Voices will continue to be supported as well and this contract will include support for Navajo families to participate in various activities to promote traditional wellness and resiliency. By utilizing traditional wellness practices as a culturally respectful approach, staff have seen some success reaching out to families that have CYSHCN who have not been accessing services. Trainings specifically around cultural competence will be provided to CMS staff at various locations in the State to help us improve our service delivery for indigenous families[RRD1][S2].

Improve access to pediatric specialty care

A continued initiative for the Newborn Hearing Screening (NBH) program designed to reduce Loss to Follow-up of newborns who do not pass their hospital screen will focus on 1) increasing health professionals’ engagement within and knowledge of the EHDI system, 2) improving access to Early Intervention (EI) services and language acquisition, and 3) improving family engagement, partnership, and leadership within the EHDI programs and systems.  The Newborn Hearing Screening program is close to launching a tele-audiology program in the Northwest region of the state. There is a dearth of pediatric audiologists in NM and there has been great interest and support in piloting tele-audiology in Gallup. This is a joint project with NBH (Title V), Indian Health Services, a local community hospital, the Navajo Nation, the NM School for the Deaf and the University of New Mexico Audiology program. A new NBH Coordinator has been hired and he will be focusing on hospital compliance with reporting results of screening on all infants and improving the accuracy and ease of reporting by audiologist to the State program. The Newborn Hearing (NBH) and Newborn Genetic Screening (NGS) Programs will continue to include the medical home during follow-up when an infant is identified through newborn screening. When an infant requires any follow-up on a newborn screen results the medical home is immediately identified and notified and becomes the primary driver of any follow-up care.

The Newborn Genetic Screening program will continue its work with the Mountain States Regional Genetics Collaborative (MSRGC) project that is assessing access to resources and care for families that have a child with a genetic condition and live in rural and underserved areas. This project is parent driven and targeted at families from underserved regions of the state. There has been a focus on using telehealth to improve access to genetic services for families in rural areas, and especially on tribal lands. There can be up to an 18 month wait for an initial appointment with the geneticist. Telehealth was utilized effectively during the height of the pandemic and UNMH staff continue to use a hybrid model might be effective in reaching more families. The MSRGC NM Team will be rolling out an algorithm to primary care providers (PCP) on diagnostics for children who may have Ethers Danlos Syndrome. The UNM Genetics program has no capacity to accept these referrals. Because of this potential delay in service delivery to children with these conditions the algorithm was prioritized by the NM team to assist PCPs with referrals to specialty care and services for these children.

The NBG program will be adding additional screening tests to the newborn screening panel based on recommendations by the Secretary of Health and Human Services Recommended Uniform Screening Panel to include SMA, XALD, Fabry, and Gaucher.

Babies identified with a NAS (Neonatal Abstinence Syndrome) code will continue to be reported through Birth Defects Surveillance from all birthing hospitals. Even though NAS is not a birth defect, it is noted that many of these babies are at risk for birth defects and medical complications. CMS will continue its partnership with the Children, Youth and Families Department in implementing the state response to the federal Comprehensive Addiction and Recovery Act (CARA), which includes training hospitals and medical providers on Plans of Care on all newborns exposed to substances legal and illegal during pregnancy and tracking of these care plans. This is a multi-agency statewide effort to address the needs of children and families and improve the statewide system for children born exposed to substances. The CMS Coordinator assigned to this project continues to build expertise and a network of community partners to support families in recovery and to provide wrap around services to improve outcomes. A request has been made to Department leadership to fund a second Coordinator position due to increased referrals and demand. CMS social workers are assigned families with a Plan of Care whose infant is uninsured or is not on a managed care Medicaid plan. Most of these cases are thus Tribal, and the social workers offer care coordination in collaboration with Tribal social services which may include Tribal child protective services staff as well.

 CMS will continue to facilitate over 160 multidisciplinary pediatric specialty clinics in rural areas of the state including cleft palate, nephrology, endocrinology, pulmonary, neurology, and genetics in collaboration with the University of New Mexico (UNM) Department of Pediatrics and Neurology. CMS medical social workers follow CYSHCN through the multidisciplinary pediatric specialty outreach clinics, as well as assuring that specialists’ recommendations are communicated to the local (community-based) primary care providers.  Without these specialty clinics many CYSHCN would not be able to access this care. This access to health care is still an issue in the State. The outreach clinics are in alignment with the Department of Health’s mission and vision to assure health equity by working with our partners to improve health outcomes and improve access to health care services. A budget request will be made to increase clinics for neurology and gastroenterology services due to high need in the southeast and southwestern regions of the State. This also includes expansion to include a new area of specialty care, neurosurgery to see patients with head shape problems/craniosynostosis, hydrocephalus, spasticity, epilepsy, tethered cords, sacral dimples, and tumors. The neurosurgery team at UNM requested this expansion as they have seen that their patients in rural areas have many challenges trying to travel to Albuquerque for appointments.

Barriers to Specialty Care

CMS will work to strengthen the partnership between Title V and Medicaid efforts to improve systems of services, integrate health care services and supports, and leverage resources for CYSHCN and their families. The Title V/Medicaid Interagency Agreement provides a mechanism to establish dialogue and partnership.  Most children in NM are Medicaid eligible and thus Medicaid policy drives the pediatric health care system. There are three Medicaid MCOs and New Mexico has benefited from the Affordable Care Act (ACA) as a Medicaid expansion State. This has helped close the gaps in health care access for youth aged 18 and older who had historically transitioned into a system with limited health care financing.

In 2018, Medicaid implemented the revised 1115 Waiver and awarded contracts to 3 MCOs, one of which was new to the state (Western Sky/Centene). Key components of the 1115 Waiver include: care coordination enhancements, cost sharing, patient centered medical homes and integrative behavioral/physical health homes. The Title V program had developed key partnerships with the MCOs. CMS continues to monitor the Medicaid activity as the MCO a CYSHCN is enrolled in can significantly affect access and ability to have health care needs met. A new Request for Proposal is in development for bids for managed care contracts and the program will monitor and provide comment on systemic issues of care for CYSHCN.

NM Medicaid is also undergoing a complete overhaul of its information system with a new project called MMIS 2020. CMS is linked programmatically to Medicaid rules and statues and has been invited to participate in several workgroups such as billing and claims, provider enrollment, and reports. One of the goals is to create a data warehouse that can be accessed by agencies. CMS will continue to participate on workgroups and provide input on the needs of CYSHCN and their families.

Care Coordination and Quality Improvement

To address care coordination for CYSHCN in the overall state system, the contract with the New Mexico Quality Improvement Partnership will be maintained. This project includes improvement activities to address the coordination of health care and social services for children in New Mexico who have disabilities and chronic medical conditions. Complex and uncoordinated care is a contributing factor to poor health outcomes for CYSHCN.  There is an increased demand for services for CYSHCN and families at all levels necessitating health care from multiple organizations and programs. Initiatives for this multiyear project include promotion and maintenance of the NM Care Coordination Consortium to be a source of information, resources, tools, expert advice, and peer learning and support for pediatric and family practice staff, managed care organizations, Medicaid, family organizations, Title V staff and other service providers who focus on coordinating care for children, with an emphasis on those with chronic conditions and special health care needs and the family- and patient-centered Medical Home approach. The standards developed by the National Consensus Framework for Systems of Care for CYSCHN and Bright Futures will be utilized as evidenced-based recommendations to be used by entities providing care coordination. Each standard is being reviewed and analyzed by the consortium and this project will continue.

Children’s Medical Services (CMS) will continue to support the medical home concept in New Mexico through the Medical Home Portal (MHP), which provides accurate and comprehensive information on health information and community resources for families in English and Spanish. The CMS Program Manager will continue to participate in the Medical Home Portal Advisory committee. This committee will be meeting to review portal metrics and usefulness and to provide input into additions that would be helpful for New Mexico families.

CMS will also maintain a contractual relationship with the Center for Development and Disability (CDD) Information Network to support the MHP through their Information Network. The CDD Information Network provides information and referral, tip sheets, library materials and other resources to individuals with disabilities, families, physicians, educators, and other professionals in New Mexico.  The CDD Information Network maintains a database of over 4,000 resources, including agency/program names, contact information, website, what services they provide, eligibility information, etc.  .  Updates for each service provider and/or program are requested and made regularly. 

Since 2013, the CDD Information Network has shared its resource data with the Utah MHP, which has extracted a subset of those services to be included in the MHP’s services database.  The MHP provides information, tools, and other resources for physicians, families, and others who care and advocate for children with chronic and complex conditions.  .  This partnership assists CMS to continue making information available about New Mexico community services for CYSHCN to families and the healthcare providers who care for them through the Medical Home Portal.  The New Mexico Pediatric Society is a supporter of this initiative and a representative from the Society participates in the monthly stakeholder meetings. Staff will continue to present to stakeholders to promote awareness of the MHP and encourage use as a tool to improve coordination of care.

Children’s Medical Services (CMS) will continue to provide leadership around care coordination and youth transition that is family/youth-centered and culturally competent for CYSHCN.  CMS employs licensed medical social workers (LMSW) trained in the provision of care coordination for CYSHCN from birth to age 21 in New Mexico, helping to bridge the gaps in the healthcare system and link families to needed services.  This coordination of care across settings leads to an integration of services, which decreases health care costs, reduces fragmentation of care, and improves the experience for the patient and family. In rural areas, CMS is seen as the only program that addresses the needs of CYSHCN. The CMS program, with its revenue source from Medicaid billing, focuses efforts on maintaining staffing in all regions of the State, and defends the need and value of the work of the LMSW in their communities to upper management.

CMS social workers and CMS management continue to work to improve three of the core outcomes for all CYSHCN clients.  These outcomes are: 1) families partner in decision making and are satisfied with the services they receive; 2) families of CYSHCN have adequate private and/or public insurance and financing to pay for the services they need; and 3) services for CYSCHN are community based and culturally and linguistically competent.  Best practice for care coordination of CYSHCN involves collaborative patient and family-centered care.  The American Academy of Pediatrics (AAP) identifies the following desirable characteristics of coordinated care within a Medical Home: (1) a plan of care is developed by the physician, child, and family in collaboration with other providers and agencies; (2) all pertinent information about medical care and use of services is accessible to the care team while protecting confidentiality; (3) families are linked to support groups and other resources; and (4) the plan of care is coordinated with educational and community organizations to ensure goals of the care plan are addressed.  The work of CMS promotes these goals. With the height of the coronavirus pandemic behind us, we reflect on all we have been through as well as lessons learned. The program will take some time to review as we were quickly forced to change our practices, switch to telehealth and other methods of delivering care. We forged new partnerships with non-traditional agencies, such as emergency managers, first responders, food banks, churches and many others. Those of us in the CYSHCN community did find ourselves at different “tables” and these new relationships can only benefit our work as we strive for more comprehensive integrated care.

The CYSHCN Title V applied and was awarded 5 years of new funding for the Pediatric Mental Health Access Care Program.

Pediatric mental health providers in New Mexico, like other health professions in the state, face multiple challenges in providing effective and timely services. These challenges are rooted three factors: has higher levels of behavioral health issues in the pediatric and adult populations than the nation as a whole; provider shortages; and geographic and demographic characteristics of the state.

In response, the state’s Title V program in the Department of Health, in partnership with three units of the University of New Mexico’s Health Sciences Center – the Center for Development and Disability, the Department of Pediatrics and the Department of Psychiatry is establishing a new statewide Pediatric Mental Health Care Access Network in New Mexico entitled NM Access to Behavioral Health for Children (NM-ABC). The goal of NM-ABC is to increase timely detection, assessment, treatment, care coordination and referral for children and adolescents presenting to pediatric primary care settings, including pediatric practices, family and community health practices and Federally Qualified Health Centers.   Over the five years of the project, faculty and staff of the partner organizations will work to achieve three objectives: engage in outreach to identify key stakeholders obtain expert advice, and enroll multiple cohorts of Pediatric Primary Care Practices ;increase the capacity of Pediatric Primary Care Providers in diverse practice settings to identify, diagnose, treat and refer child and adolescent behavioral health problems through a TeleECHO professional development and training series in child and adolescent behavioral health; increase the capacity of Pediatric Primary Care Providers to identify, diagnose, treat and refer child and adolescent behavioral health problems through a health resource center and Information hub, Including a Peer-to-Peer Provider Access Line.

[RRD1]Are these trainings specific to Navajo families or more generalized? If so, suggest change to “improve our service delivery for indigenous families.”

[S2]like that