CYSHCN Action Plan (October 1, 2022-September 30, 2023)
Priority Need: Improve Care Coordination for children and youth with special health care needs/Improve Coordinated and comprehensive health promotion efforts among the child and adolescent populations
One of the most important strategies for the upcoming year within the CYSHCN program centers around outreach and awareness. The program plans to collaborate with our MCH Outreach coordinator to update all materials to reflect culturally responsive, family centered care, and ensure that our providers, clinics, and partners have easy access to resources, contacts, and overall knowledge of CYSHCN services. We also plan to revitalize and update our website, increasing our presence online with tools, resources, and videos for families and providers.
CYSHCN plans to strengthen and improve the current partnership with the Telehealth Alliance of South Carolina. This partnership will allow CYSHCN to create a provider network which offers telehealth services to ensure equitable, affordable, access to care. A partnership with the telehealth alliance would also be utilized to monitor and capture transition services provided from a pediatric to adult medical providers, which is vital for continuity of care.
CYSHCN will also collaborate with our Sickle Cell community-based organizations, providers, and associates to develop a Sickle Cell Registry for patients. This registry will ensure continuity of care for all registered patients, while also creating a more robust data system, which is currently limited, as summarized in the South Carolina Sickle Cell Disease State Plan. As we enter into year three of the plan, a statewide registry would be utilized to ensure providers have access to a patient’s most up-to-date clinical data, especially for emergency services or emergency room visits, as well as compile data on healthcare utilization.
NPM 11: Percent of children with and without special health care needs, ages 0 through 17, who have a medical home
South Carolina continues to emphasize the importance of a medical home for CYSHCN. While our program continues to educate our CYSHCN families in the importance of utilizing a medical home, additional strategies are needed to enhance this measure. CYSHCN and the Bureau of Health Improvement and Equity will conduct a point in time survey to assess any barriers or racial/ethnic disparities CYSHCN families may face in establishing a medical home. The results of this survey will be used to address and alleviate some of those barriers through the CYSHCN provider network and community partnerships.
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
Health Care Transition will continue to be a priority to strengthen for the CYSHCN program. CYSHCN will partner with pediatricians and pediatric specialists to increase provider awareness and encourage and support transition efforts through education and resources. CYSHCN will also use the Telehealth Alliance partnership to educate, inform, and incentivize adult providers to guarantee a safety net and seamless transfer for our population. CYSHCN staff will continue to educate families on the importance and need for a successful transition to adult care, utilizing the tools provided by Got Transition and including the pediatrician or medical provider in our transition discussions and follow up.
Workforce Development
Building and maintaining a competent workforce continues to be critical for the CYSHCN program. Orientation plans will be strengthened, formalized, and consistent throughout the state for care coordinators and administrative and billing staff. An orientation welcome and training video will be created for all staff to ensure standardized information is provided regarding program policies and protocols. A welcome packet will also be created and available statewide which will include regional resources, program protocols, and helpful tips to reinforce a successful introduction and orientation to the CYSHCN program, with a focus on training staff to meet the needs of CYSHCN and their families. Regional trainings on program initiatives will continue, as well as our annual staff meeting focused on specific training needs identified throughout the year.
Family Engagement/Partnership
CYSHCN plans to leverage our strong partnership with Family Connection of South Carolina (FCSC) to strengthen and combine our efforts as it relates to transition services. We plan to identify barriers faced by providers in South Carolina, and work with partners, such as Department of Health and Human Services, the Hospital Association, and the Pediatric Advisory Council to address some of those concerns, align goals and objectives, and facilitate discussion between the pediatric and adult health care systems. The Parent Advisory Council will also be instrumental in ensuring the perspective of our families and youth is captured in our efforts for this measure. We are also partnering with FCSC to provide trainings for both parents, providers, and CYSHCN staff as it relates to transition services. This partnership will prove vital in our on-going efforts to enhance and address challenges unique to the CYSHCN population.
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