System Principles, Standards and Key Questions for Assessment of Systems of Care for CYSHCN DOMAIN: SCREENING, ASSESSMENT, AND REFERRAL Children are screened early and continuously for special health care needs. ___________________________________ Date: _____________________ Type of Agency Completing this Tool: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify _________) Family/Consumer Other (please specify: _____________________________) When providing answers in this assessment tool, please do so from the perspective of the organization or system in which you work or are affiliated. Column A System Standards (Structure and Process) Column B Within my organization, there are policies and procedures in place for this standard: Column C What agencies/entities in your have the authority to implement and/or ensure this standard? (Check all that apply.) Column D Please rate your organization’s authority to implement or improve policies and procedures that support this standard. Screening and Assessment: Upon enrollment and transfer between insurance coverage (e.g., public and private), a consistent and culturally and linguistically appropriate mechanism for identifying CYSHCN, including children with significant health conditions, is in place to ensure that these children are referred to appropriate types and sources of enhanced care. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score:
Promptly after enrollment in a health plan, all CYSHCN are provided a documented initial assessment that is conducted in collaboration with the child’s family or caregiver. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: Title V Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: State newborn screening information is delivered to providers and parents in a timely fashion and arrangements made for necessary follow-up services are documented. If indicated, the need for repeat screening and follow-up is communicated to the health plan and providers by the hospital or state program. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score:
The child’s health plan and medical home have a documented plan and process to demonstrate how they follow-up with a hospital or state health department when newborn screening results are not received. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: All children, including CYSHCN, receive periodic, developmentally appropriate, and recommended comprehensive screenings (to include screening for physical health, oral health, mental health, developmental, and psychosocial needs, and cultural and linguistic needs, preferences or limitations) as part of a well-child visit or other preventive visit and in response to triggering events such as hospitalization, trauma, or sudden onset of new symptoms, in accordance with Bright Futures Guidelines. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score:
Screening efforts, results and referrals for further assessment are documented, relayed to the child’s medical home and family, and, to the extent feasible, coordinated among all screening entities, including but not limited to clinical care settings, medical homes, child care settings, and schools. Yes (IF YES) How effective are policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: Referral/Follow-up: Following a screening and assessment, the CYSHCN and their family are referred to needed services including pediatric specialists, therapies, other service systems such as Early Intervention, Special Education, family organizations and community-based agencies, and follow-up is provided to ensure such referrals are completed. In turn, those services and systems should ensure follow-up to the child’s medical home and other members of the child’s care team after referral visits. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Score:
Regardless of the entity conducting a screening and referral, protocols and documentation methods are in place for the primary care provider, medical home or other such entity to with the child and family in areas including: assessment of follow-up received, barriers to care, and, where feasible, assistance in addressing barriers to obtaining needed follow-up. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: SUMMARY: SCREENING, ASSESSMENT and REFERRAL Effectiveness Indicator: Organizational Influence Indicator: Additional Notes: ENDNOTES: