Services and Models of Care Issue Narrative Transition from youth to adulthood is a vulnerable stage in life, especially for CYSHCN. Often these adolescents and young adults lose some or all of their health care services and support when they transition from pediatric to adult health care. As a result, their care is interrupted and their health may be affected. Transition support is essential to navigating a new complex health care system and other aspects of adult life. IV. Youth, families, and providers will have access to community-based resources necessary to facilitate and achieve successful health care transition. A. Transition support will be provided for youth, families, and providers. 1. CMSN will identify navigators to assist providers in the development of transition policy and establishing transition-specific medical homes related to the Six Core Elements of healthcare transition for their practices (gottransition.org) and provide assistance with the care coordination process specific to transition assessments, care planning and resources (Year 1-2). 2. CMSN will provide an individualized, client specific transition staffing for CMSN enrollees ages 18-21 using the existing multidisciplinary staffing model that includes oversight by a regional transition physician (Year 2). 3. Explore utilizing telehealth to provide transition services when necessary (Year 2). 4. Promote utilization of the FloridaHATS Health Services Directory for Young Adults in Florida (Year 1). 5. Leverage the state Memorandum of Agreement between CMSN and the Florida Association of Community Health Centers to establish community-based partnerships between CMSN area offices and Federally Qualified Health Centers (Year 2). 6. Under the CMSN transition program, FloridaHATS will strengthen and continue to build regional transition coalitions throughout the state (Years 1-5). a. Percentage of youth who receive transition support. b. Percentage of CMSN regional offices who have transition navigators. c. Percentage of CMSN area offices who establish a transition team. d. Increase in regional coalition activity and outcomes. e. Increase in use of telehealth to provide transition services. f. Significant increases in transition metrics on CMSN Satisfaction Surveys.
Infrastructure Issue Narrative Based on the National Performance Measure for transition and Healthy People 2020 Objective 5, transition is a high priority for all youth. Identifying a separate transition program under Title V will provide centralized coordination, advocacy and a standardized approach to transition that encompasses Got Transitions’ 6 Core Elements. The development of a strategic plan and specific performance measures will ensure accountability by holding stakeholders responsible for V. Transition is recognized as a priority for Department of Health’s Title V Program. A. CMSN implements a transition program within the CMSN organizational structure that includes specific programmatic outcomes related to quality improvement, measurable performance expectations, maintaining a transition registry and ensuring provider adequacy. 1. Identify a transition program consultant(s) and staff support for the state that are responsible for the development of the transition program and identify and implement a transition registry to collect information necessary to assess pre- and post-transition data (Years 1-2). 2. Explore more robust documentation and reporting options in the CMS data system to document and track anticipatory guidance and transition readiness based on age (Years 1-2). 3. Establish the Adolescent Health Program as a transition program partner to support transition policy and practice as a process for all youth with and without SHCN (Year 2). 4. FloridaHATS becomes a formal component of the CMSN transition program to develop and maintain (Years 1-2) Transition registry Transition provider network database Webinars/teleconferences for families 5. CMSN will identify necessary resources for transition navigators, youth ambassadors, and programmatic operations (Year 1). 6. Measure above activities (Years 3-5). a. Transition implemented as a formal priority by CMSN (central consultant and office established). b. Increase in utilization of transition registry and provider database. c. Increase in number of providers listed in database. d. Significant increases in transition metrics on CMSN Satisfaction surveys.