1. Transition for Youth with Special Health Care Needs: How Do We Get this Done? Richard C. Antonelli, MD, MS Medical Home Advisor Healthy & Ready to Work National Resource Center Topical Call: May, 2008

2. What Are The Issues? Capacity Training Communication Changing Roles of Youth Financing Mechanisms Professional Culture and “Traditions”

3. Youth Pediatric PCP Pediatric SP Medical Dental Behavioral Family Community Based Partners Title V Vocational Rehabilitation Avocation Education (K-12 & post secondary) National Family to Family KASA Pediatric Model for YSHCN

4. Youth Pediatric PCP Adult PCP Pediatric SP Medical Dental Behavioral Adult SP Medical Dental Behavioral Family Community Based Partners Title V Vocation Avocation Education Pediatric to Adult Systems of Care: Current Family to Family KASA

5. Youth Pediatric PCP Adult PCP Pediatric SP Medical Dental Behavioral Adult SP Medical Dental Behavioral Family Community Based Partners Title V Vocation Avocation Education Pediatric to Adult Systems of Care: Possibilities Co-Management Family to Family KASA

6. Strategies Outreach and Education –Youth, families, pediatric, and adult providers –Primary Care and Subspecialty Advocacy - Title V and Other Policy Makers - Link with payers (incentives including P4P)

7. Remember These Strategies!!!!! Encourage use of Care Plan Oversight CPT Codes –You can use administrative data to track progress and may lead to reimbursement Remove Administrative and Financing Barriers for cross-specialty co-management –This will support education, capacity-building, and sustainability

8. The Ultimate Outcome: Transition to Adulthood Richard C. Antonelli, MD, MS, FAAP Medical Home & Transition HRTW Medical Advisor Chief, Division of Primary Care Dept of General Pediatrics Connecticut Children's Medical Center Head, Division of Academic General Pediatrics Univ of Conn, School of Medicine richantonelli@hrtw.org

9. Resources-01 HRSA/MCHB funded National Centers (6) 1.HEALTH & TRANSITION www.hrtw.orgwww.hrtw.org Healthy & Ready to Work National Resource Center 2. MEDICAL HOME www.medicalhomeinfo.orgwww.medicalhomeinfo.org National Center on Medical Home Initiatives 3. FAMILY PARTNERSHIP www.familyvoices.orgwww.familyvoices.org National Center on Family and Professional Partnerships

10. Resources-02 HRSA/MCHB funded National Centers (6) 4. CULTURAL COMPETENCE http://www11.georgetown.edu/research/gucchd/nccc/ http://www11.georgetown.edu/research/gucchd/nccc/ National Center for Cultural Competence 5. HEALTH INSURANCE http://www.hdwg.org/cc/ http://www.hdwg.org/cc/ Catalyst Center – for Improving Financing of Care for CYSHCN 6. DATA www.cshcndata.org www.cshcndata.org Data Resource Center National Survey for CSHCN

11. Resources - 03 HEALTHY & READY TO WORK www.hrtw.orgwww.hrtw.org HRTW Portable Medical Summary - One page summary of health needs that youth or others can carry. Information contains medical history, current medication, name of health surrogate, health insurance numbers, contact information for treating doctors, pharmacy, home health and other vendors. Understanding Health Insurance - Web links to Choosing a Plan, Paying for Care, Public Insurance, Private Insurance, Policy / Advocacy Centers and Insurance Regulations, Laws and Statutes. Decisions & Making Choices - Web section contains information of Informed Decision Making, Assent-Consent, Guardianship, Living Wills and Advance Directives.

12. Resources - 04 HRTW Portal - Laws that Affect CYSHCN http://www.hrtw.org/tools/laws_leg.html  The Term Special Health Care Needs or Disability  Disability Rights Portals  Education Issues  Employment & Disability  Equal Opportunity Access (504, 508 & ADA)  Family Medical Leave Act  HRSA/MCHB – Title V Legislation  Health Insurance Benefits  SSI/SSDI