Much of CSHN’s focus this year will be on the continuation of support for families during the pandemic. Many of our staff have been deployed as part of the emergency response, most notably on our childcare and school teams as well as the contact tracing team. Fortunately, the skillset of the CSHN team is perfectly aligned to support Vermonters under stress, and CSHN staff have been able to leverage their strong knowledge of systems and supports to make a meaningful impact on their emergency response teams already. For example, in alignment with other national models, CSHN care coordinators are working along side the contact tracing team to provide an added layer of support to Vermonters who need to isolate or quarantine due to Covid-19 diagnosis or exposure. Additionally, when an outbreak of Covid-19 occurred in a New American community, CSHN care coordinators were identified as the ideal, skilled workforce to navigate both the contact tracing of this community and organizing of supports to keep the community safe.

Vermont’s NPM is Transitions to Adulthood. As described elsewhere, transition of CYSHCN to young adult health care services, both primary and specialty care, will also continue to be a focus of our efforts this coming year. Since shifting from a direct-service model to population-based health, CSHN has been able to reach more adolescents with special health needs who are needing to prepare for their adult needs. Through CSHN placement in medical homes we are able to participate in anticipatory planning for adolescents, directly with them, their families, and their medical homes. The interest in transitions, within UVMMC primary care and specialty care, presents a timely opportunity to promote the pediatric medical home/care coordination model within the adult care system into which our CYSHCNs are graduating. Largely in part to our new data system that launched in July 2018, we will be able to more proactively provide anticipatory guidance about all steps related to transitions across the continuum of youth and adolescence.

CSHN will continue to work closely with VocRehab central leadership as well as the statewide system of Transition Counselors, both in hopes to partner around families, but also ensure that transitioning youth are aware of VocRehab as a resource. VT MCH will again sponsor a VocRehab organized event specifically around organizing local resources to support transitioning youth, of which CSHN social workers will be intimately involved. This year, CSHN will also be supporting and presenting at the Youth Summit, which is organized by and for transition aged youth with neurodevelopmental disabilities.

We remain dedicated to continuing our collaboration with Medical Homes in the role of care coordination. Medical social worker staff in the regions will be maintaining their partnership in regional practices and regional Part C teams and exploring additional partnerships. Lessons learned from the Collaborative, especially in Shared Plan of Care tools, will be applied. Continued promotion of Help Me Grow VT ensures that early detection leads to the linkage of at-risk children and their families to community-based programs and services, including medical homes. This coming year, as a result of nearly three years of stakeholder engagement and in collaboration with other statewide entities, CSHN care coordinators will shift from serving families directly based on their region of residence, but rather, supporting Medical Homes within certain regions. This shift will be to further support a centralized care coordination model out of the medical home where we are seeing and increased capacity across the state thanks to enhanced payments through OneCare Vermont, VT’s Accountable Care Organization.

This coming year, we will continue with our medical home care coordination pilot, in which one of our CSHN MSW is embedded in one of the more rural and underserved parts of the state to conduct monthly complex care clinics and provide subsequent coordination of care. VCHIP will continue providing support around quality improvement and measuring outcomes. We are in the early stages of determining eligibility and interventions and are hopeful that this will be a useful demonstration project for healthcare reform efforts moving forward and build upon much of what we already do well in Vermont within pediatric medical homes.

VT will continue to use some Title V funds to support access and capacity of specialty clinics managed by UVM Medical Center and other subspecialists, such as metabolic/genetics and child psychiatry. In the traditional sense, VT Title V helps to fill gaps in services that would otherwise leave patients and families with uncoordinated and insufficient care. At the same time, funds are used to ensure that medical services at these clinics are family-centered, and culturally responsive. Furthermore, CSHN Social Workers work in partnership with these specialty clinics to provide wraparound services and ensure that proper community supports are in place for patients. As these specialty clinics stabilize and adopt more comprehensive, coordinated family-centered practices, and previous gaps shrink, Title V funding can be redirected to even more foundational, public health systems approach to CYSHCN.

CSHN’s Child Development Clinic will continue to provide regionally delivered, multidisciplinary developmental pediatrics/psychology/medical social work evaluations for young children with suspected developmental conditions in certain regions of the state where need still exists, accessible to families and their community teams. Efforts to reduce the time from referral to kept appointment include streamlining CDC appointment procedures, adding clinical staff to increase capacity, and increasing outreach to pediatric medical homes through CSHN care coordination. Improvements in the operations of CDC continue to be refined.

In 2018, in anticipation of the UVM DBP program, we looked at the remaining system gaps, those regions and populations which have been the most challenging—and most urgent-- to provide child development evaluations. As in many other states, the provision of intensified early intervention services, for the youngest children with concern for ASD, must wait until the child has received a confirmed diagnosis of ASD through a multidisciplinary evaluation process. In Vermont, there is a strong collaboration between Child Development Clinic and Children’s Integrated Services-Early Intervention (CIS-EI), the statewide Part C early intervention system regionally based programs. The process by which VT children birth-to-three are referred and seen for developmental diagnosis was reviewed, and the goal of providing a more rapid response to the referral and completion of evaluation with a multidisciplinary clinic team was established. The key is the collaboration with the regional CIS-EI teams—which begin the process by identifying the children enrolled in CIS-EI who are in need of diagnostic evaluations and who have been seen by their region’s CIS-EI autism consultant. In the regions where this pilot Infant-Toddler Outreach Clinic (ITOC) model is being initiated, the CIS-EI team hosts the CDC developmental pediatrician and the autism consultant in the evaluation visit—during which the child’s overall development is assessed with the Bayley Scales, and the possibility of ASD is addressed with the ADOS-2, developmental/ medical/ behavioral history and physical examination. The ITOC model brings the diagnostic team to the child’s regional CIS-EI site or to the child’s home, builds upon the information and resources of the CIS-EI team, is completed in one half-day visit within a few weeks of the referral, and utilizes Medicaid and Title V funding. The participation of the CIS-EIS team in the visit makes it possible for a plan for next steps to be set in motion immediately. The pilot is planned for 6 months, with a decision at that time about its effectiveness and possible expansion to other regions of the state. In the first 3 months of ITOC, ten children were evaluated in their local communities with their CIS-EI team present. Their median age was 31 months, with a range of 22 to 27 months. The median time from referral to evaluation was 4 weeks, with a range of 2 to 8 weeks. All of the children were referred with concern for ASD; 7 were diagnosed with ASD.

With Title V funding in the coming year, we plan to continue family leadership programming to develop family leaders to serve as advisors for improving the system of care within Vermont’s medical home community, as well as support to the VT Family Network’s (Vermont’s Family Voices organization) family support team. Additionally, this year the expectations around engagement of racially and ethnically diverse Vermonters have improved to include all MCH-funded activities at VFN, such as supplemental funding assistance, sib-shops, and conference attendees. A strong theme in the grant to VFN this year was that all of their programs, activities, and materials need be accessible by those who are of limited English proficiency or non-English speaking. VFN and CSHN will be partnering to present a year-long virtual series “Surviving the Pandemic” which will focus on a variety of topics as the pandemic evolves, including policy updates that impact services and school and educational resources specific to CYSHN who have IEP/504 or other educational supports.

MCH/CSHN is also contracting with a parent of a child with a special health need who has professional family engagement expertise and an early childhood background to provide consultation to our entire division around building and maintaining authentic culturally responsive family engagement. Programs will be implementing the newly created Family Engagement Toolkit to partner more intentionally with families and stakeholders across programs. One of the projects family partners have already been identified for, is the payment reform project for the Medicaid High-Tech nursing program, in which the payment model is being reformed to ultimately increase utilization of services.

In addition to the activities described above to promote the medical home model and a coordinated system of care for children with special health care needs, we also aim to work on the following strategies: Promotion of the use of Bright Futures, 4th edition, as Vermont’s EPSDT periodicity schedule; participation in multi-disciplinary collaboration to increase influenza vaccination rates and documentation of vaccination status for all children, and especially those with chronic diseases.

CSHN leadership will continue to be an active partner in EPSDT efforts as described in detail in the annual report, namely through participating in a policy level project to improve the understanding and delivery of EPSDT; co-leading the project specific to EPSDT Outreach and Informing; and continuing to represent the State on Vermont’s Medicaid Exchange Advisory Board’s EPSDT workgroup. CSHN will also continue to lead improvement efforts specific to our Medicaid High Tech Nursing program in collaboration with Medicaid leadership.

CSHN leadership will continue to participate in the Autism workgroup, revising the state autism plan and identifying gaps, opportunities, programs that work well, to strengthen the system of care for children with autism spectrum disorder and other neurodevelopmental disabilities.

Please note: Only those strategies the link with national and state performance measures are identified in the Action Plan Table for this section.