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Identification, Screening, Assessment, and Referral

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Eligibility and Enrollment in Health Coverage

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Access to Care

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Medical Home

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Community-Based Services and Supports

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Transition to Adulthood

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Health Information Technology

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Quality Assurance and Improvement

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Identification, Screening, Assessment, and Referral

Children are screened early and continuously for special health care needs.

Identification

  1. The state system should have a definition for CYSHCN. 1
  2. Upon enrollment and transfer between insurance coverage (e.g., public and private), a mechanism for identifying CYSHCN is in place. 2

Screening

  1. CYSHCN receive periodic, developmentally appropriate, and recommended comprehensive screenings according to the Bright Futures guidelines. 3
  2. Screening results are documented and coordinated with the medical home. 4
  3. State newborn screening information is delivered to providers and parents in a timely fashion, and arrangements for necessary follow-up services are documented. If indicated, repeat screening results and follow-up are communicated by the hospital or state program to the newborn’s health plan, medical home, and specialty providers. 5
  4. The child’s health plan and medical home have a documented plan and process to demonstrate follow-up with a hospital or state health department when newborn screening results are not received. 4

Assessment

  1. CYSHCN are provided a documented initial health assessment within 90 days of enrollment in a health plan. 6
  2. Screening efforts, results, and referrals for further assessment are documented and coordinated with the child’s medical home and health plan. 4

Referral/Follow-up

  1. Following a screening and assessment, CYSHCN are referred to needed services including pediatric specialists, therapies, and other service systems. 7
  2. Protocols and documentation methods are in place for the child’s medical home to follow-up with the child and family to ensure referred services were accessed and to provide any assistance in accessing needed care, regardless of the original entity conducting a screening and referral. 7

  • Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, American Academy of Pediatrics. 3
  • Draft Structure and Process Measures for Integrated Care for People with Dual Eligibility for Medicare and Medicaid, National Committee for Quality Assurance. 8

  1. McPherson M, Arango P, Fox H. A new definition of children with special health care needs. Pediatrics. 1998;102: 137-140.
  2. Rosenbaum S., Wilsensky S. EPSDT at 40: Modernizing a pediatric health policy to reflect a changing health care system. Washington, DC: Center for Health Care Strategies, Inc., 2008. http://www.chcs.org/media/EPSDT_at_40.pdf
  3. Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition. Elk Grove Village, IL: American Academy of Pediatrics, 2017. Accessed March 2017
  4. National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017. Available at: http://www.ncqa.org. Accessed May 9, 2017.
  5. Rhode Island Department of Human Services, Rhode Island Medicaid Managed Care Letter of Intent to Bidders, Certification Standards: Appendix D, Rhode Island EPSDT Periodicity Schedule, p. 211. Unpublished. Accessed March 2013.
  6. Rhode Island Department of Human Services. Rhode Island Department of Human Services Care Management Protocol for Children with Special Health Care Needs. Rhode Island RIte Care Contract. Unpublished. Accessed March 2013.
  7. Massachusetts Child Health Quality Coalition. Care Coordination, Key Elements Framework. V3 (4.21.14). http://www.masschildhealthquality.org/wp-content/uploads/2014/06/care-coordination-framework.pdf
  8. National Committee for Quality Assurance. Draft Structure and Process Measures for Integrated Care for People with Dual Eligibility for Medicare and Medicaid. Revised Draft Measures for Testing. Updated October 2012. Unpublished.