III.E.2.c. State Action Plan - CSHCN - Application Year - Kentucky - 2022
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III.E.2.c CSHCN Application Year
As the 97-year-old agency’s evolution continues, OCSHCN looks forward to continuing to collaborate with peer agencies in a way that will enhance population-based care for KY’s children and youth with special health care needs, particularly in the area of access. OCSHCN continues to leverage technical assistance resources to strengthen and better integrate the overall system of care for KY CYSHCN.
While OCSHCN will strive to enhance the support provided to the KY’s CYSHCN population, the realities of COVID-19 continue to reshape our efforts in ways both known and unknown. OCSHCN had just begun to ease its COVID-19 restriction when the delta variant of the virus came to the fore. As we continue through the pandemic, OCSHCN is committed to finding ways to adapt and enhance the care provided. OCSHCN has been conducting surveys on how well our population receives our telehealth services and the results have been robust and largely positive.
In conjunction with the strategies listed on the preliminary action plan table, OCSHCN submits the following updates:
MCHB Core Outcome #1: Families are partners in shared decision-making for child's optimal health
As part of last year’s 5-year needs assessment, stakeholders’ ideas were collected to inform decision making. In the coming year, OCSHCN will be expanding its shared decision-making by working with non-OCSHCN pediatric providers and patients.
OCSHCN will continue to collaborate with several agencies to work heavily with the Hispanic population and will continue to offer training to parents to support/mentor other Hispanic families by becoming Support Parents.
OCSHCN will continue asking for input from the Parent Advisory Council (PAC) and the Youth Advisory Council (YAC), which each meet separately on a quarterly basis. In FY20 all meetings with the PAC and YAC were held via Zoom Video Communications which has assisted with overcoming the obstacle of travel for the members. Zoom is also used to work with the complex care medical teams. In FY20 OCSHCN made advancements on the diversity of the YAC in PAC and we will continue to do so in the coming year. One of the diversifications was to have a parent of a child with hearing issues on the PAC and to have a person with down syndrome on the YAC. OCSHCN plans to continue to monitor and pursue opportunities for diversification of input in the coming year. Outreach to parents and youth to serve on the YAC or PAC will continue.
Families are the head of the team and determine what early interventions their child will receive through OCSHCN’s First Steps Point of Entry for the KIPDA region after hearing recommendations from services coordinators and providers.
As OCSHCN personnel, providers, and families have become more familiar with tele-technology due to COVID-19 OCSHCN has more easily handled the increased reliance on video communication. In the coming year OCSHCN staff will continue to survey patients on our tele-technology and adapt to serve patients and families well even after the pandemic.
OCSHCN’s transitions administrator will continue to follow up with families of aged-out CYSHCN to assist with overcoming barriers, conducting quality assurance regarding transitions efforts, and gauging how much families understand. OCSHCN has expanded the criteria for calling the aged-out patients so that we call patients who have not been seen in an OCSHCN clinic in the last two years. OCSHCN goal since the 2020 needs assessment has expanded to the wider population as opposed to just those enrolled in OCSHCN by providing instruction and education to adolescents irrespective of having a special health care need. OCSHCN will also be incorporating non-clinical audiology patients into its transition services as a way to reach even more of the CYSHCN population.
MCHB Core Outcome #2: CSHCN who receive coordinated, ongoing, comprehensive care within a medical home
OCSHCN staff will continue to advocate for the concept of a medical home and provide support to existing providers in communities. OCSHCN is participating in the CoIIN Grant on Children with Medical Complexity and although the program will end in the coming year OCSHCN is looking to apply for a 5th year to look at other program improvements. One of the goals of the CoIIN grant is to increase the number of families reporting having a medical home. In its own direct services, the use of nursing care plans supports the measurement of individual outcomes and interventions through care coordination. OCSHCN has received positive feedback from the CoIIN team and has the second highest patient population count among all the states working in the grant. In addition, the University of Kentucky’s infant complex care team will continue to collaborate with OCSHCN as part of the CoIIN grant will continue to enable OCSHCN to reach even more of the CYSHCN population. The expansion of transitions services from only focusing on OCSHCN clinic patient to all adolescents in the state, with or without special health care needs, will assist all adolescents in the state to receive appropriate care into adulthood.
MCHB Core Outcome #3: CSHCN have consistent and adequate public or private insurance
OCSHCN remains committed to enrolling families in one-on-one education or application assistance. OCSHCN front-line staff and support parents will continue participation with Kentucky’s Health Benefits Exchange (Kynect), Healthcare.gov, and other trusted resources. Kentucky re-launched its Kynect portal for Kentuckians to access health plans and has expanded to include benefits and resources. OCSHCN “kynectors” will receive continued education on the Kynect portal and the available health coverage, benefits, and resources and will continue to provide assistance to patient and families in navigating the system.
MCHB Core Outcome #4: CSHCN who are screened early and continuously for special health care needs
OCSHCN has been working to improve services to youth with autism and staff continue to meet with and develop plans in accordance with the University of Missouri’s ECHO Autisms Collaboration project. OCSHCN is developing an ECHO Autism program with a wealth of Pediatric Autism Specialist to offer education, resources and referral information to pediatricians throughout the state of Kentucky. This will provide improved access to services in the care of children with Autism. In the coming year the new service in FY20 of doing remote autism assessment will continue to expand and ECHO autism provider meetings will begin.
OCSHCN’s dietitians and other clinical staff will continue to administer the agency’s Healthy Weight Plan, focusing on how to collect healthy weight data with an ever-changing population, possibly initiating chart reviews of individual longer-term patients to determine whether the agency’s processes positively or negatively affect outcomes in any way, and will continue to collaborate with the Partnership for a Fit Kentucky and coalitions locally and statewide
OCSHCN audiology is committed to supporting and promoting periodic hearing screenings throughout childhood. The EHDI program will continue to use and develop as needed it’s “Risk Factor Fact Sheet” which is disseminated to physicians when an infant on their caseload is identified as having a risk factor for late onset or progressive hearing loss. The fact sheet includes pertinent information regarding appropriate follow up protocols that should be initiated. As part of OCSHCN audiology services loaner audiometers are made available to school systems for use in their hearing conservation programs. Our outreach to Head Start and Early Head Start Programs, previously limited to service delivery and staff training has been supplemented by making loaner Otoacoustic Emissions (OAE) test equipment available to agencies whose own equipment is malfunctioning. By policy OCSHCN makes diagnostic audiologic follow up (in the event of a “failed” hearing screening) available at no cost to the family through any one of OCSHCN regional offices.
MCHB Core Outcome #5: CSHCN who can easily access community-based services
As described in the Detail Sheet (Form 10-B) for SPM #3, OCSHCN will work on its new Access to Care Plan (see attached documents) over the next year. The Access to Care Plan has been revised this year based on the 5-year needs assessment. OCSHCN is working towards more integrated and coordinated care, and increased access, considering well-planned telemedicine expansion informed in part by the recent expansion of telehealth due to COVID-19, replication of the Spanish-speaking support group programs outside of the Louisville pilot area and subsequent Lexington program, and administration of the F2F, care coordination, and social work programs to assist with navigation of services. The hybrid clinic model put into place and modified due to the pandemic will continue to develop.
In the coming year, OCSHCN will have a new initiative called the telehealth lending library in which the equipment needed for telehealth will be loaned to families. With the delivery will be instructional videos on telehealth and some items they can keep.
Continuous education of both OCSHCN contracted and some non-contracted medical providers occurs through the OCSHCN Medical Director, implementation of the ECHO Autism project, and expansion of our video library postings.
OCSHCN is working with the state’s two Hemophilia Treatment Centers to provide more flexibility and support for operations. To further the goal of collecting better data, OCSHCN will explore how to refine the non-clinical data tool to more effectively measure the numbers of non-OCSHCN enrolled CYSHCN who may receive enabling or public health services through partnerships.
OCSHCN’s Executive Director chairs Kentucky’s State Interagency Council for Services and Supports to Children and Transition Aged Youth that focuses on improving the systems of care for those with behavioral health needs.
MCHB Core Outcome #6: CSHCN youth receive services needed for transition to adulthood
Transitions continues to be a priority need. OCSHCN intends to ensure conformity with Got Transition and AAP guidelines/best practices as described in the State Action Plan Table. OCSHCN will begin with surveying pediatricians on their transition’s awareness and processes. Results will inform OCSHCN’s education efforts.
F2F will continue to work with the Midwest Genetics Collaborative on updating videos and other materials on understanding Genetic Telehealth Medicine done in previous years. OCSHCN will continue working with families and professionals to understand the importance of transition for children with special needs.
OCSHCN works with Regional Interagency Transition Teams (“RITTs”) that are based off the 9 Special Ed Co-op districts across the state, (that were designed to help agencies collaborate better at the regional level to support youth). F2F and OCSHCN staff will continue to participate in the Regional Interagency Transition Teams to collaborate with schools with planning for transition activities, such as local transition fairs.
OCSHCN staff will continue to utilize the transition checklist to work with patients and their families on transition issues to assist patients to plan for transitioning to adulthood. As appropriate staff communicate/collaborate with community service providers (Vocational Rehabilitation, the Department of Community Based Services, Behavioral Health, and others) in order to connect patients/families with services/resources to assist them with transitioning to adulthood to the optimum ability of the patient. As appropriate OCSHCN staff attend community resource fairs to give information to families.
OCSHCN partially funds a social work position at the UofL Sickle Cell and Hemophilia pediatric program to ensure their successful transition to adult providers.
The Transition Administrator will continue to complete transition checklist audits twice a year to verify that OCSHCN staff are continuing to provide transitions services. In the coming year the physician’s referral list that OCSHCN uses will receive a thorough review and update to facilitate staff helping a wider population of adolescents in transitioning to adult health care providers.
III.E.2.c CSHCN Application Year
As the 97-year-old agency’s evolution continues, OCSHCN looks forward to continuing to collaborate with peer agencies in a way that will enhance population-based care for KY’s children and youth with special health care needs, particularly in the area of access. OCSHCN continues to leverage technical assistance resources to strengthen and better integrate the overall system of care for KY CYSHCN.
While OCSHCN will strive to enhance the support provided to the KY’s CYSHCN population, the realities of COVID-19 continue to reshape our efforts in ways both known and unknown. OCSHCN had just begun to ease its COVID-19 restriction when the delta variant of the virus came to the fore. As we continue through the pandemic, OCSHCN is committed to finding ways to adapt and enhance the care provided. OCSHCN has been conducting surveys on how well our population receives our telehealth services and the results have been robust and largely positive.
In conjunction with the strategies listed on the preliminary action plan table, OCSHCN submits the following updates:
MCHB Core Outcome #1: Families are partners in shared decision-making for child's optimal health
As part of last year’s 5-year needs assessment, stakeholders’ ideas were collected to inform decision making. In the coming year, OCSHCN will be expanding its shared decision-making by working with non-OCSHCN pediatric providers and patients.
OCSHCN will continue to collaborate with several agencies to work heavily with the Hispanic population and will continue to offer training to parents to support/mentor other Hispanic families by becoming Support Parents.
OCSHCN will continue asking for input from the Parent Advisory Council (PAC) and the Youth Advisory Council (YAC), which each meet separately on a quarterly basis. In FY20 all meetings with the PAC and YAC were held via Zoom Video Communications which has assisted with overcoming the obstacle of travel for the members. Zoom is also used to work with the complex care medical teams. In FY20 OCSHCN made advancements on the diversity of the YAC in PAC and we will continue to do so in the coming year. One of the diversifications was to have a parent of a child with hearing issues on the PAC and to have a person with down syndrome on the YAC. OCSHCN plans to continue to monitor and pursue opportunities for diversification of input in the coming year. Outreach to parents and youth to serve on the YAC or PAC will continue.
Families are the head of the team and determine what early interventions their child will receive through OCSHCN’s First Steps Point of Entry for the KIPDA region after hearing recommendations from services coordinators and providers.
As OCSHCN personnel, providers, and families have become more familiar with tele-technology due to COVID-19 OCSHCN has more easily handled the increased reliance on video communication. In the coming year OCSHCN staff will continue to survey patients on our tele-technology and adapt to serve patients and families well even after the pandemic.
OCSHCN’s transitions administrator will continue to follow up with families of aged-out CYSHCN to assist with overcoming barriers, conducting quality assurance regarding transitions efforts, and gauging how much families understand. OCSHCN has expanded the criteria for calling the aged-out patients so that we call patients who have not been seen in an OCSHCN clinic in the last two years. OCSHCN goal since the 2020 needs assessment has expanded to the wider population as opposed to just those enrolled in OCSHCN by providing instruction and education to adolescents irrespective of having a special health care need. OCSHCN will also be incorporating non-clinical audiology patients into its transition services as a way to reach even more of the CYSHCN population.
MCHB Core Outcome #2: CSHCN who receive coordinated, ongoing, comprehensive care within a medical home
OCSHCN staff will continue to advocate for the concept of a medical home and provide support to existing providers in communities. OCSHCN is participating in the CoIIN Grant on Children with Medical Complexity and although the program will end in the coming year OCSHCN is looking to apply for a 5th year to look at other program improvements. One of the goals of the CoIIN grant is to increase the number of families reporting having a medical home. In its own direct services, the use of nursing care plans supports the measurement of individual outcomes and interventions through care coordination. OCSHCN has received positive feedback from the CoIIN team and has the second highest patient population count among all the states working in the grant. In addition, the University of Kentucky’s infant complex care team will continue to collaborate with OCSHCN as part of the CoIIN grant will continue to enable OCSHCN to reach even more of the CYSHCN population. The expansion of transitions services from only focusing on OCSHCN clinic patient to all adolescents in the state, with or without special health care needs, will assist all adolescents in the state to receive appropriate care into adulthood.
MCHB Core Outcome #3: CSHCN have consistent and adequate public or private insurance
OCSHCN remains committed to enrolling families in one-on-one education or application assistance. OCSHCN front-line staff and support parents will continue participation with Kentucky’s Health Benefits Exchange (Kynect), Healthcare.gov, and other trusted resources. Kentucky re-launched its Kynect portal for Kentuckians to access health plans and has expanded to include benefits and resources. OCSHCN “kynectors” will receive continued education on the Kynect portal and the available health coverage, benefits, and resources and will continue to provide assistance to patient and families in navigating the system.
MCHB Core Outcome #4: CSHCN who are screened early and continuously for special health care needs
OCSHCN has been working to improve services to youth with autism and staff continue to meet with and develop plans in accordance with the University of Missouri’s ECHO Autisms Collaboration project. OCSHCN is developing an ECHO Autism program with a wealth of Pediatric Autism Specialist to offer education, resources and referral information to pediatricians throughout the state of Kentucky. This will provide improved access to services in the care of children with Autism. In the coming year the new service in FY20 of doing remote autism assessment will continue to expand and ECHO autism provider meetings will begin.
OCSHCN’s dietitians and other clinical staff will continue to administer the agency’s Healthy Weight Plan, focusing on how to collect healthy weight data with an ever-changing population, possibly initiating chart reviews of individual longer-term patients to determine whether the agency’s processes positively or negatively affect outcomes in any way, and will continue to collaborate with the Partnership for a Fit Kentucky and coalitions locally and statewide
OCSHCN audiology is committed to supporting and promoting periodic hearing screenings throughout childhood. The EHDI program will continue to use and develop as needed it’s “Risk Factor Fact Sheet” which is disseminated to physicians when an infant on their caseload is identified as having a risk factor for late onset or progressive hearing loss. The fact sheet includes pertinent information regarding appropriate follow up protocols that should be initiated. As part of OCSHCN audiology services loaner audiometers are made available to school systems for use in their hearing conservation programs. Our outreach to Head Start and Early Head Start Programs, previously limited to service delivery and staff training has been supplemented by making loaner Otoacoustic Emissions (OAE) test equipment available to agencies whose own equipment is malfunctioning. By policy OCSHCN makes diagnostic audiologic follow up (in the event of a “failed” hearing screening) available at no cost to the family through any one of OCSHCN regional offices.
MCHB Core Outcome #5: CSHCN who can easily access community-based services
As described in the Detail Sheet (Form 10-B) for SPM #3, OCSHCN will work on its new Access to Care Plan (see attached documents) over the next year. The Access to Care Plan has been revised this year based on the 5-year needs assessment. OCSHCN is working towards more integrated and coordinated care, and increased access, considering well-planned telemedicine expansion informed in part by the recent expansion of telehealth due to COVID-19, replication of the Spanish-speaking support group programs outside of the Louisville pilot area and subsequent Lexington program, and administration of the F2F, care coordination, and social work programs to assist with navigation of services. The hybrid clinic model put into place and modified due to the pandemic will continue to develop.
In the coming year, OCSHCN will have a new initiative called the telehealth lending library in which the equipment needed for telehealth will be loaned to families. With the delivery will be instructional videos on telehealth and some items they can keep.
Continuous education of both OCSHCN contracted and some non-contracted medical providers occurs through the OCSHCN Medical Director, implementation of the ECHO Autism project, and expansion of our video library postings.
OCSHCN is working with the state’s two Hemophilia Treatment Centers to provide more flexibility and support for operations. To further the goal of collecting better data, OCSHCN will explore how to refine the non-clinical data tool to more effectively measure the numbers of non-OCSHCN enrolled CYSHCN who may receive enabling or public health services through partnerships.
OCSHCN’s Executive Director chairs Kentucky’s State Interagency Council for Services and Supports to Children and Transition Aged Youth that focuses on improving the systems of care for those with behavioral health needs.
MCHB Core Outcome #6: CSHCN youth receive services needed for transition to adulthood
Transitions continues to be a priority need. OCSHCN intends to ensure conformity with Got Transition and AAP guidelines/best practices as described in the State Action Plan Table. OCSHCN will begin with surveying pediatricians on their transition’s awareness and processes. Results will inform OCSHCN’s education efforts.
F2F will continue to work with the Midwest Genetics Collaborative on updating videos and other materials on understanding Genetic Telehealth Medicine done in previous years. OCSHCN will continue working with families and professionals to understand the importance of transition for children with special needs.
OCSHCN works with Regional Interagency Transition Teams (“RITTs”) that are based off the 9 Special Ed Co-op districts across the state, (that were designed to help agencies collaborate better at the regional level to support youth). F2F and OCSHCN staff will continue to participate in the Regional Interagency Transition Teams to collaborate with schools with planning for transition activities, such as local transition fairs.
OCSHCN staff will continue to utilize the transition checklist to work with patients and their families on transition issues to assist patients to plan for transitioning to adulthood. As appropriate staff communicate/collaborate with community service providers (Vocational Rehabilitation, the Department of Community Based Services, Behavioral Health, and others) in order to connect patients/families with services/resources to assist them with transitioning to adulthood to the optimum ability of the patient. As appropriate OCSHCN staff attend community resource fairs to give information to families.
OCSHCN partially funds a social work position at the UofL Sickle Cell and Hemophilia pediatric program to ensure their successful transition to adult providers.
The Transition Administrator will continue to complete transition checklist audits twice a year to verify that OCSHCN staff are continuing to provide transitions services. In the coming year the physician’s referral list that OCSHCN uses will receive a thorough review and update to facilitate staff helping a wider population of adolescents in transitioning to adult health care providers.
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