Spreadsheet: 070f38ed-6488-42b7-ae00-a6b8c47f7fd0
Sheet: Sheet1

Maternal and Child Health Planning Form October 1, 2013 - June 30, 2014 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6
 |  |  |  | July 1, 2013 - June 30, 2014
Form Instructions and Recommendations:
DIRECTIONS:  Please submit this form along with the Maternal Child Health Planning Form by August 1, 2013 to [NAME] at [EMAIL] or FAX: [PHONE]
PURPOSE: This form is intended to guide the planning for FY14 local HCP Care Coordination Services. CDPHE HCP staff will use information provided in this planning form to learn more about your agencies plan to provide HCP care coordination and identify areas of support your agency may need. Thank you for taking time to provide the CDPHE staff with this information.
Questions Regarding this form?  Please contact [NAME] at [EMAIL] or [NAME] at [EMAIL]
Planning Questions:
1. What is the estimated population of CYSHCN in your county?
FY12 CYSHCN estimated population by county located on |  |  |  |  |  | www.hcpcolorado.org
2. If your agency implemented HCP Care Coordination Services in FY13, How many children received HCP care coordination services by your agency in FY13?  TIP: This information can be obtained by reviewing report 102 from the CYSHCN data system.
3.  Staffing:  When considering how your agency will staff the HCP Care Coordination Services, HCP recommends 1.0 FTE for approximately 50 children that will be supported with an HCP care coordination action plan.  This FTE can be split across multiple staff or from different disciplines.  Your agency may need to adjust this ratio depending on the unique characteristics of your county including non-english speaking population, rural geography etc. which may use more staff time.
4. What are some of the challenges you anticipate in providing HCP care coordination services? How do you plan to address those challenges? (staffing, referrals, communication with PCPs, encouraging a medical home approach etc.)
5. Does your agency need any training or technical assistance related to the provision of HCP care coordination services? CDPHEHCP unit staff will utilize the responses to this question in the development and prioritization of a training and technical assistance plan.
If yes, please describe:
6. Would your agency like to receive CRCSN notifications? If your agency received CRCSN notifications in FY13, HCP recommends reviewing report 020 for FY13 from the CYSHCN data system to help inform your agency’s decision to receive CRCSN notifications in FY14.
Agencies receiving CRCSN notifications will meet the following expectations:
• Agree to follow the CRCSN policy and guidelines located at |  |  |  |  |  | www.hcpcolorado.org
• Are required to enter responses into the CYSHCN data system.
• Are required to make efforts to contact the families and assess whether care coordination services are            needed at that time.  Notifications contain PHI (including medical information) are not sent to agencies for           informational purposes.
• Notifications will be sent to agencies one time per child.  For example if an agency has already received a           notification for that child they will not receive another.
In alignment with the HCP Care Coordination Model and based on the responses to the above planning questions, please answer the following for FY14:
7. For FY14, estimate the number of children that will be supported with an HCP care coordination action plan:
8. For FY14, estimate the number of children/families who will receive information only: