1. 1 CYSHCN Colorado: Where We’ve Been, Where We Are and Where We’re Going Presented by: Rachel Hutson, MSN, RN, CPNPJennie Munthali, MPH Children, Youth and Families Branch ChiefCYSHCN Section Manager rachel.hutson@state.co.us jennie.munthali@state.co.us rachel.hutson@state.co.us jennie.munthali@state.co.us

2. 2 Learning Objective: 1) Participants will be able to describe the past, present and future MCH/HCP public health efforts to support the CYSHCN population.

3. 3 Colorado’s CYSHCN Population Children and youth who have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions and require health and related services beyond that of the overall population of children and youth Across Colorado, nearly 14% of the overall population of children and youth have special health care needs. Many more are at risk for having needs beyond that of a typical child.

4. 4 Public Health Strategies to Support CYSHCN Information and resources Care coordination Specialty clinics Medical Home Policy/Systems Change

5. 5 Evolution of MCH/HCP Services and Supports for CYSHCN 2011 2016 2021

6. 6 Information and Resources for CYSHCN Where we were: Information and resources was considered to be part of the continuum of HCP care coordination services. Broad range of need, as well as staff and agency capacity/resources In FY13, smallest agencies able to opt out of care coordination and provide “information only” for CYSHCN and their families

7. 7 Information and Resources for CYSHCN Where we are: Information and resources for CYSHCN continues to be provided through local public health agencies statewide as part of the core public health services CYSHCN data system enables agencies to track “information only” contacts to capture need, with over 2,000 encounters statewide in FY15 Care coordination for CYSHCN continues to be provided in the vast majority of counties where 98% of the population resides, with over 1,000 clients served statewide in FY15

8. 8 Information and Resources for CYSHCN Where we are going: Explore partnerships and opportunities with statewide efforts to streamline information and resources, such as Help Me Grow-Hybrid, No Wrong Door and 211 Locally using information and resources data from the CYSHCN data system to guide outreach strategies for HCP and identify service gaps in the community Strengthening the referral process by providing warm hand offs and closing the referral feedback loop

9. 9 Care Coordination for CYSHCN Where we were: Variability in type and range of HCP care coordination across the state In FY12 and 13, intentional focus on the standardized components that are core to the HCP care coordination model

10. 10 Care Coordination for CYSHCN Where we are: Consistently delivering a high quality HCP model of care coordination Striving to improve the cost effectiveness of delivering HCP care coordination Collecting and summarizing high quality data from the CYSHCN data system that more comprehensively describes the children and families served by HCP Utilizing data collected through the CYSHCN data system to identify and inform program improvements

11. 11 Care Coordination for CYSHCN Where we are going: Strengthening communication and coordinated care among providers serving HCP clients through the use of shared plans of care and inter-agency case conferencing Using our experience in delivering services to HCP clients to highlight and inform the need for systems improvements Stratifying between medical complexity and other data points in order to measure progress on care plan goals and the impact of HCP care coordination

12. 12 Specialty Clinics for CYSHCN Where we were: Neuro, ortho and rehab clinics offered in rural/underserved areas of the state Wide range of implementation practices Paper-based reporting and data collection No consistent way of funding agencies to host clinics

13. 13 Specialty Clinics Where we are: Specialty clinic sites consistently host over 100 clinics annually Standardized policies and processes for hosting clinics in partnership with the six regional specialty clinic coordinators Electronic dashboard and reporting through the CYSHCN data system High family satisfaction rates (96%) and low no show rates (5-6%)

14. 14 Specialty Clinics Where we are going: Engaging Health Care Policy and Financing, RCCOs/RAEs, Children’s Hospital Colorado and other specialty care providers in regional discussions to fill gaps in target areas and leverage resources Locally using specialty clinic data, such as waitlists, to identify needs and gaps in pediatric specialty care Expand/enhance the use of technology, such as telehealth, to improve access

15. 15 Medical Home Policy/Systems Change Where we’ve been: Of local public health agencies that have contracts managed directly by the MCH Program: Many selected the integrated Medical Home/ABCD local action plan Remaining agencies selected other areas of focus for medical home policy/systems change

16. 16 Medical Home Policy/Systems Change Where we are: Mesa: bolstering cross-program coordination for shared clients within the health department; now exploring opportunities for collaboration with the RCCO Weld: strengthening resource and referral processes for indigent populations, with an emerging collaboration with the RCCO San Juan Basin: working directly with the RCCO and delegated practices to provide complementary care coordination services for CYSHCN Tri-County: establishing formal mechanisms of communication and data sharing with the RCCO to support inter agency collaboration around plans of care

17. 17 Medical Home Policy/Systems Change Where we are going: State logic model and action plan includes four areas of focus for policy/systems change specific to the CYSHCN population: care coordination, specialty care, transition and information and resources Facilitating conversations with RCCOs to identify opportunities to strengthen and support the interface with local public health agencies specific to CYSHCN Local logic model and action plan for FY16 includes two areas of focus for policy/systems change: care coordination and specialty care Exploring local strategies for FY17 for transition and information and resources

18. 18 The Next Chapter Continue to use HCP 1:1 client delivery service experiences to inform policy and systems change for the CYSHCN population As the health care system evolves, so will our MCH/HCP efforts to support CYSHCN Work force development at state and local level to strengthen systems to support the CYSHCN population