Priority Need: Family and provider connectedness, medical home, and care coordination

NPM-11: Percent of children with and without special health care needs, ages 0 through 17, who have a medical home

Annual Plan FY24

The Office of Children with Special Health Care Needs (CSHCN) through the Integrated Services Program (ISP) will continue to fund external partners to further work related to the medical home, particularly care coordination efforts, including the Utah Parent Center; Utah Children’s Care Coordination Network (UCCCN), and the Medical Home Portal; and the four local health departments with which DHHS has contracts for care coordination services. CSHCN is partnering with the UCCCN and the Medical Home Portal to promote educational opportunities for care coordinators, practice managers, medical providers, and staff through monthly UCCCN virtual training meetings and ongoing Pediatric Project ECHO online training sessions. Surveys vetted through both the Medical Home Committee and the Pediatric Project ECHO development team will be utilized to measure learning objectives, and implementation and improvement of medical home standards including care coordination.

In conjunction with these projects, emphasis is placed on promoting a hybrid medical and health care model that includes live and virtual assessment and diagnostic visits to meet family needs including time, location, and proximity. ISP will track families referred to the program for evaluative and diagnostic care and/or care coordination and, upon intake, will ascertain whether or not those families are connected with a primary care provider. Where none exists, the ISP team will help families establish care with a local provider who can become the family’s and patient’s medical home. The Medical Home Committee will establish and vet surveys with UCCCN member practices and administer them to the families they serve to understand (1) how the practice implements components of a medical home; (2) how the practice improves and increases medical homes; and (3) family satisfaction with their medical home. Feedback on individual practices will be provided for quality improvement purposes, and overall trends will be discussed. The Medical Home Committee will look to include input, guidance, and consultation from the Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ) in this quality improvement initiative.

• ISP will continue to fund external partners that further the role of the medical home.
• The UCCCN will serve as an educational forum to promote care coordination and the tenets of the medical home.
• Pediatric Project ECHO will continue to provide online training sessions that include medical home principles and practices, and will survey participants to measure achievement of learning objectives.
• Through member practices of the UCCCN, the Medical Home Committee will survey families about their perceptions of medical home including care coordination services.
• The Medical Home Committee will request consultation from the UPIQ to create a quality improvement project for practices desiring to enhance their medical home model.

Table 17: Logic Model for National Performance Measure 11


Priority Need: Transition to adulthood

NPM-12: Percent of adolescents with and without special health care needs, ages 12 through 17, who received services necessary to make transitions to adult health care

Annual Plan FY24

The Office of CSHCN will continue to convene a monthly interagency Transition to Adult Healthcare meeting with a focus on curriculum dissemination, promoting standard messaging, evaluating the best way to gather patient/family experience across disparate systems, and planning ways to improve systems and collaboration statewide. CSHCN will work with stakeholders to coordinate and standardize data collection efforts to determine the reach and number of youth and families who are in the transition to adult medicine process and who have completed and successfully transitioned to adult medicine.

CSHCN will continue to fund partner organizations such as the Medical Home Portal, UCCCN, Utah Parent Center, and Utah Family Voices to further transition to adult medicine activities. CSHCN will fund the development of educational short videos and animations through Transition University on transition-related themes to be stored on the Utah Parent Center website, and links provided to care coordinators and service providers to share with families for educational purposes.

ISP will promote transition activities in-house and with care coordinators at the four local health departments to prepare families to meet the ISP Transition Specialist so that youth and young adults may feel prepared to transition to adult healthcare. The ISP Transition Specialist will begin outreach efforts to targeted youth within the Utah Birth Defect Network registry through an approved data sharing agreement. The ISP team will continue to support care coordination and transition guidance in tandem with staff at the Homeless Youth Resource Center through Volunteers of America.

The Transition to Adult Healthcare Committee will work in conjunction with the Intermountain Health Teen to Adult Healthcare Governance Committee to determine the best method to measure patient satisfaction with the transition education, skill building, and eventual transition to adult provider processes. The ISP team and CSHCN will continue to partner with key stakeholders and community partners within existing committees such as DHHS's Youth Empowered Solutions for Success, Utah State Board of Education’s Transition Advisory Committee, Intermountain Healthcare’s Teen to Adult Healthcare Governance Committee, and the Transition University Planning committee; and will seek to foster other partnership opportunities.

• The Office of CSHCN will continue to convene a monthly interagency Transition to Adult Healthcare meeting with a focus on curriculum dissemination, promoting standard messaging, evaluating the best way to gather patient/family experience across disparate systems, and continuously seek ways to improve systems and collaboration.
• CSHCN will fund the development of educational short videos and animations through Transition University on transition-related themes to be stored on the Utah Parent Center website, and links provided to care coordinators and service providers to share with families for educational purposes.
• The ISP Transition Specialist will begin outreach efforts to targeted youth within the Utah Birth Defect Network registry through an approved data sharing agreement.
• The ISP team will work with the staff at the Homeless Youth Resource Center (Volunteers of America) to establish a system to provide consultation, care coordination, and transition guidance for homeless youth in Salt Lake City.

Table 18: Logic Model for National Performance Measure 12