System Principles, Standards and Key Questions for Assessment of State Systems of Care for CYSHCN DOMAIN: FAMILY PROFESSIONAL PARTNERSHIPS Families of CYSHCN will partner in decision making at all levels and will be satisfied with the services they receive. State: ___________________________________ 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 state 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. Families are active, core members of the medical home team. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) 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:
Family priorities and concerns are central to care planning and management. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) 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: Families are connected to family organizations, peer support and family support programs. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) 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:
Health systems that serve CYSHCN solicit feedback from the family and children on the experience of care that they receive. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) 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: Health systems that serve CYSHCN have a family advisory board or committee, inclusive of families of CYSHCN that guides their policies, programs and quality improvement activities and offers family members training, mentoring, and reimbursement for their participation as active members of these boards and committees. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) 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: