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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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Quality Assurance and Improvement

  1. The state, health plans, providers, and insurers have a specific and ongoing quality assurance (QA) and quality improvement (QI) process in place. This includes:
    • families of CYSHCN are represented on the primary care provider QI teams and health plan QI teams
    • periodic monitoring of network provider capacity to ensure the full continuum of children’s physical, oral, and mental health needs are met on a timely basis
    • promotion of geographic accessibility to needed services 1
    • periodic monitoring of utilization of care, appropriateness of care, and compliance with all system standards for CYSHCN 2
    • conducting experience of care surveys with families of CYSHCN and youth (including targeted feedback from relevant racial/ethnic and language groups) to obtain feedback and assess their experiences with care 3
    • assessment of out of pocket expenses, lost work burden, and other sources of stress on families, and
    • assessment of child outcomes, including measures of health and functional status.
  2. Child medical record reviews include a representative sample of CYSHCN so that the experiences of this population are reflected in QA and QI activities.
  3. The utilization review and appeals processes for CYSHCN includes members of a child’s integrated care team when requested by the family. 4

2013 Special Needs Plans Structure and Process Measures (SNP Element 2), National Committee for Quality Assurance (NCQA) 5

  1. 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 Unpublished.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.
  2. The George Washington University Center for Health Services Research and Policy. Purchasing specifications related to pediatrics services: A User’s guide. Available at: http://sphhs.gwu.edu/departments/healthpolicy/CHPR/newsps/peds-user-guide/Pediatric_Guide.pdf. Updated July 2002. Accessed March 10, 2013.
  3. National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2011, Appendix 2: NCQA’s PatientCentered Medical Home (PCMH) 2011 and CMS Stage 1 Meaningful Use Requirements.
  4. The George Washington University, Center for Health Services Research and Policy. Optional purchasing specifications: Medicaid managed care for children with special health care needs – A technical assistance document [Rev. Ed.]. Available at: http://sphhs.gwu.edu/departments/healthpolicy/CHPR/newsps/ccs/ccs.pdf. Washington, DC: GWU Center for Health Services Research and Policy, 2002.
  5. National Committee for Quality Assurance. 2013 Special Needs Plans Structure & Process Measures. https://www.cms.gov/Medicare/Health-Plans/Medicare-Advantage-Quality-Improvement-Program/Downloads/SandP_2012_SNP_Performance-Report_09_20_2013.pdf