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MCHB Medical Home & Integrated Services
Grant Initiatives - Current
State
Implementation Grants for Integrated Community Systems of
Services for CSHCN, FY 2005 -
News
Release
Duration of Program: Project period May
1, 2005- April 30, 2008.
Program Objective: Priority # 5:
"The President's New Freedom Initiative: State Implementation
Grants for Integrated Community Systems of Services for
CSHCN". The purpose of this initiative is to support
statewide implementation of the HRSA component of the President's
New Freedom Initiative (NFI) to create inclusive Community-Based
Systems of Services for Children with Special Health Care
Needs. Under the NFI initiative, HRSA's Maternal and Child
Health Bureau has the lead in developing and implementing
a plan to achieve appropriate Community-Based Service Systems,
as defined by the following components: 1) family/professional
partnership; 2) comprehensive health care through a medical
home; 3) access to adequate health insurance/financing;
4) early and continuous screening; 5) organization of community
services for easy use by families; and 6) transition to
adult health care, work, and independence. This program
replaces previous initiatives which addressed each of these
systems components separately. Applicants must: 1) be, or
work closely with, the State Title V Program for Children
with Special Health Care Needs; 2) have a complete statewide
needs assessment that addresses the State's status in each
of the 6 systems components; 3) implement a specific plan
to achieve Community-Based Systems of Services incorporating
each of these components, but may have a focus on two or
more; 4) integrate the plan into the Title V Block Grant
and other public/private programs serving CSHCN and their
families, and 5) define a comprehensive evaluation plan
using national, state, and community data.
Other Participating Organizations: Applicants
must be, or work closely with, the State Title V Program
for CSHCN, and describe experience in working across state
and local level agencies, organizations and families on
implementing the core components of a system of care.
Resources: (Type/Amount/Project Period):
12-15 Grants. Approximately $300,000 per year for 3 years
subject to availability of funds. Successful projects are
expected to demonstrate existing state and local commitment
to this initiative, have established partnerships, and leverage
other sources of support which will maximize resources and
initiate a sustainability plan, post grant funding. Applicants
for Priority #5 are encouraged to have approximately 25%
of their grant award as direct or in-kind contributions
from state and local agencies and organizations and/or foundations,
and to indicate these as line items in the budget.
Guidance
for Integrated Services for Children with Special Health
Care Needs (CSHCN) funding opportunities through HRSA-05-014.
Catalog of Federal Domestic Assistance (CFDA) No. 93.110
Fiscal Year 2005
Grants were awarded to:
- Arizona Department
of Health Service - Abstract
Contact Person: Joan Agostinelli, Acting Office Chief, 602-542-2584
Goals and
Objectives:
A major goal is the creation a statewide forum where stakeholders
from governmental and state agencies, as well as local,
and community level providers, children and youth with
special health care needs (c/yshcn), and their families
can review activities of the various agencies and communities,
plan needs assessments, and study alternative funding
for services for c/yshcn within the state of Arizona.
Several task-specific subcommittees will conduct needs
assessments, develop educational materials, and provide
input and evaluation of quality improvement activities.
Each committee will involve yshcn and their families.
Three groups will consist primarily of youth and families
who will be charged with integrating the family perspective
into every agency and community service organization.
The second major goal of this proposal is to study the
impact of providing screening and care coordination to
different clinical settings, including school-based clinics
with the intent of evaluating the cost-effectiveness of
this service in reducing redundancy, enhancing access,
and ensuring higher quality of care outcomes. The impact
of insurance coverage will be evaluated in each of the
clinical settings. The culmination of all of the activities
will result in a white paper that will be sent to the
governor.
- Children’s
Hospital Los Angeles - Los Angeles, California
Goals and
Objectives:
1) family/professional partnership at all levels of decision
making; 2) access to comprehensive health and related
services through medical homes; 3) adequate public and/or
private financing of needed services; 4) early and continuous
screening and evaluation and diagnosis; 5) organization
of community services so that families can use them easily;
and 6) successful transition to all aspects of adult health
care, work and independence.
These components will be achieved by convening a statewide,
diverse group of key stakeholders to serve as a planning
and oversight body; identifying service delivery strengths,
gaps and barriers; and identifying and developing a statewide
strategic plan to improve the system of care for CSHCN
and their families, and to address performance shortfalls.
Given the size, budgetary challenges and population of
California, this project will be implemented incrementally,
in three phases.
Phase 1: establish a presence through
the development of the Key Stakeholder Group, finalizing
the statewide plan for C/YSHCN, establishing a family
advisory board to our State Title V program, and creating
a Youth Advisory Committee; Phase 2:
implement systems integration in two large, diverse regions
of the state, including identifying planning/service regions;
identifying existing regional or local coalitions that
focus on service systems for C/YSHCN that address specific
core components; and, mobilizing existing regional coalitions
to work together to achieve the six core components;
Phase 3: develop implementation capacity
in additional regions in the state, including establishing
and mentoring new coalitions in areas currently without
active local or regional coalitions; assisting in the
development of local plans in these areas to achieve core
outcomes; and facilitating information and resource sharing
to assure uniform progress throughout the participating
regions.
- State of Florida
- Abstract
- State of Hawaii
Department of Health -
Abstract
Contact Person:
Patricia Heu, MD, MPH.
Phone: (808)733-9058 | E-mail: pat.heu@fhsd.health.state.hi.us
Goal 1:
Establish,
document and implement family-centered best practices,
protocols, and standards to coordinate care between programs
and agencies that serve CYSHCN within the State through
the One Stop/Transition Certification Program.
Goal 2: Provide families with training
opportunities specifically providing practical insight
and approaches on “Navigating the System”
Goal 3: Provide families with access
to information and the opportunities for training regarding
resources for family support and leadership development,
by bringing together and augmenting community resources
based upon identified family needs, and compiling the
information into a centralized directory.
Goal 4: Increase the level of participation
of families of CYSHCN in program and policy activities.
Goal 5: Implement a Residency Curriculum
which extends teaching the knowledge, skills, and attributes
of the Medical Home to include the role of the Medical
Home in an integrated service system for Community Pediatric
and Family Physician Residents.
Goal 6: Implement the best practices,
protocols and standards developed by the project into
targeted application of transitioning youth within the
Medicaid Developmental Disabilities/Mental Retardation
Waiver from pediatric to adult health care.
Goal 7: Implement and evaluate a statewide
integrated developmental screening and referral process
for children served in community pediatric, family physician,
and community health center sites.
- University of Iowa
- Abstract
Contact Person: Brenda Moore. brenda-moore@uiowa.edu
Goals and
Objectives:
Goal 1: Community-based services will
be organized so that families can use them easily. Obj
1.1: Iowa’s primary care providers (pediatrics and
family practice) will assess their CYSHCN for care coordination
and case management (cc/cm) needs. Obj 1.2: Iowa’s
primary care providers (pcp’s) will be linked to
a designated “external” care coordination
resource. Obj 1.3: Iowa’s pcp’s will have
a structure and procedures for providing “internal”
cc/cm services. Obj 1.4: Title V CYSHCN Program care coordinators
will be competent in cc/cm knowledge and skills. Obj 1.5:
Children (0-21) with severe behavioral disorders will
be served in their communities using innovative cc/cm
methods. Obj 1.6: CYSHCN will have access to Title V care
coordinators to help transition to a life of self-determination.
Goal 2: All CYSHCN will have access to
comprehensive health and related services through a medical
home. Obj 2.1: Thirty pcp’s per year will participate
in a learning collaborative dedicated to quality improvement
in the medical home model. Obj 2.2: Sustainability of
medical homes will be assured through relationships with
organizations dedicated to performance improvement. Obj
2.3: Formal recognition will be applied to pcp’s
that achieve progress toward building a medical home.
Goal 3: All children will receive early
and continuous screening for special health care needs.
Obj 3.1: Standardized early childhood developmental screening
procedures will be available in all pcp’s. Obj 3.2:
Children, 0-3, identified as at-risk through screening
will be tracked by a database in a statewide public agency
- Commonwealth of
Massachusetts - Abstract
Contact Person: Nicole Roos, MBA. nicole.roos@state.ma.us
Goals and Objectives:
Goal 1: Build system capacity for family-professional
partnerships statewide
Goal 2: Enhance medical provider capacity
for providing medical homes for CYSHCN
Goal 3: Assure children receive early
and continuous screening and referral to appropriate services
Goal 4: Build system capacity for ensuring
YSHCN receive services necessary to make successful transitions
to adult life
Goal 5: Strengthen collaboration of youth,
families, providers, and state agencies in enhancing systems
of care for CYSHCN
Goals 6: Enhance advocacy skills of youth
and families
- Minnesota Department
of Health - Abstract
Contact Person: Ann Ricketts, MS, MPH.
ann.ricketts@health.state.mn.us
Objectives:
Objective 1: The development and mobilization
of policy and practice partners among physicians, state
level government program leaders, youth and families of
CYSHCN who will all effectively promote changes and advance
adoption of best practices in systems for care of CYSHCN.
Objective 2: Expansion of Medical Home
in Minnesota both in breadth and depth, including adoption
of transition best practices.
Objective 3: The assurance that medical
care practices providing coordinated, comprehensive, family
centered care to CYSHCN are reimbursed appropriately for
care coordination, care plans, preventive services and
coordination with community services.
Objective 4: The elimination of disparities
in access and outcomes between CYSHCN and their same age
peers without health care needs and elimination of disparities
among CYSHCN because of linguistic, cultural or financial
barriers.
- Board of Regents,
University of Oklahoma
- Abstract
Contact Person: Louis Worley louis-worley@ouhsc.edu
Goals
and Objectives: The project will build community-based infrastructure with regional and state level supports that coordinates the efforts of the health, mental health, social and education systems in a rural and metropolitan region. Similar rural and metropolitan regions where the model is not implemented will be compared to document the results of the intervention for CSHCN. These activities will establish a foundation for a sustainable statewide spread strategy of an integrated community-based system of services.
Objective 1: Strengthen and integrate Oklahoma’s Champions for Progress Incentive Award: Family Partnership in Decision-Making outcomes into all other performance outcomes, the Title V CSHCN program and other public/private services.
Objective 2: Provide ongoing coordination of existing initiatives working on improvement of access and availability of screening, evaluation and referral mechanisms for CSHCN.
Objective 3: Strengthen and spread, statewide, current Oklahoma Medical Home Initiative for CYSHCN
Objective 4: Identify gaps in public/private funding for needed services,
Objective 5: Establish a mechanism for statewide replication of the Sooner SUCCESS integrated services model.
Objective 6: Identify gaps in transition services and develop a strategic plan for filling those gaps.
- Oregon Health &
Sciences University
- Abstract
Contact Person: Robert E. Nickel, M.D.
nickelr@ohsu.edu
Goals
and Objectives: This project
will address all 6 Title V Block Grant performance measures,
will focus on “adequate public and/or private financing
of needed services,” “early and continuous
screening, evaluation and diagnosis,” and “family-professional
partnerships,” and will build on current Title V
activities. The project’s objectives for these 3
measures are:
Objective 1: Families and youth are informed
consumers of health care
Objective 2: Communities plan to assure
adequate financing of health services for CYSHN
Objective 3: Children are screened early
and continuously for developmental/ behavioral differences
Objective 4: Family/professional partnerships
are developed in health care practices and communities
Objective 5: Providers design services
to meet the needs of culturally diverse groups
- South Carolina. Dept.
of Health and Environmental Control -
Abstract
Contact Person: Sarah Cooper coopers@dhec.sc.gov
Goals and
Objectives: The project's overarching
goal is
the creation of an inclusive, community-based systems
of care for CYSHCN. Six goals address the six core outcomes
for CYSHN. Comprehensive grant objectives support the
integration of state and community based systems of services
through the careful collection and analysis of primary
and secondary data designed to support policy development,
the creation of innovative partnerships across agencies
and disciplines to implement needed organizational change,
and comprehensive training strategies that include participant
input designed to support and guide policy analysis and
change.
- Utah Department of
Health - Abstract
Contact Person: Barbara Ward, RN bward@utah.gov
Goals and Objectives:
The Project’s overall goal is the systematic integration
of community-based services for CYSHCN and their families
throughout Utah. Component Goals include:1) Design and
implement the leadership and infrastructure to accomplish
and sustain this integration; 2) Using the Learning Collaborative
model, integrate the six core components into Utah community
systems; 3) Provide and continually enhance statewide
resources and information to support the integration of
the 6 Core Components into communities.
- Wisconsin Department
of Health - Abstract
Contact Person: Sharon Fleischfresser,
MD fleissa@dhfs.state.wi.us
Goals:
Goal 1: Enhance participation in and
decision-making capability of parents of children and
youth with special needs (CYSHCN) in their child's own
health care
Goal 2:Improve health care service delivery
for CYSHCN by increasing health care access and implementing
the medical home concept in primary care practices across
the state i collaboration with tertiary care centers.
Goal 3: Develop a collaborative and supportive
network for health providers, community partners, parents
and youth with special health care needs regarding transitioning
to adult services
Current
MCHB Medical Home Grants
For primary care practices and communities
Project Period: 4 Years From: July 1, 2004 to June
30, 2008
Definitions & Explanations of Grant Terms: www.hrsa.gov/grants/preview/definitions.htm
Medical Home Implementation through
Community-Based, Primary Care Practices.
Grants to primary care practices/networks to improve
the ability of community primary care practices to become
medical homes and to promote and support community inclusion
for children and youth with special health care needs by
better linking medical homes with early intervention, child
care, Head Start, schools, and other community programs.
Eligible applicants are: (a) networks of medical home providers
including but not limited to State primary care professional
organizations and other existing networks of primary care
practices: and (b) individual primary care practices.
Funds available: $800,000 for grants up
to $50,000 for individual practices, or up to $250,000 for
Network applications supporting at least five pediatric
primary care practices.
Grants are for four years.
Awarded Grants:
- Illinois: Illinois Medical Home Project
Abstract
Purpose: The IMHP supports development
of community-based medical homes for CYSHCN by informing
primary care providers about the medical home model; providing
access to quality improvement (QI) processes involving
partnerships with parents, linkages to community resources,
and reimbursement; facilitating QI Teams at practices;
and sponsoring Leadership Forums to develop statewide
action plans.
- New Hampshire: Beyond the Medical Home: Cultivating
Communities of Support for Children with Special Health
Care Needs Abstract
Purpose: Beyond the Medical Home (BMH)
extends previous CMHI efforts beyond the boundaries of
childhood and the walls of the Medical Home by improving
transitions to adult services and by establishing effective
methods of communication and coordination among families,
community-based organizations and the Medical Home.
- New York: Suffolk Medical Home Network
Abstract
Purpose: The purpose of this project is to combine
resources of several agencies that specialize in caring
for CSHCN to develop a care coordination model, and to
provide medical home training for pediatric residents;
to create effective linkages to educational and social
services; to increase the access of Suffolk County families
to medical homes; and to provide services for families
such as parent training, support groups and advocacy coaching
for parents.
- Ohio: Medical Home Implementation - PrimeCare
Pediatrics Abstract
Purpose: The purpose of this project is to further
implement the concept of the medical home into this primary
care practice. The goals of this project are to: continue
to identify CSHCN in the practice; continue education
efforts regarding community resources, disease processes,
and practice guidelines; provide care coordination through
the use of care plans; establish a timeline and resources
for transitioning for CSHCN; and investigate proper coding
for services for CSHCN an lobby for more appropriate reimbursement.
- Massachusetts: Stringing the Pearls: Families
and Providers as Partners Abstract
Purpose: The purpose of the project
is to demonstrate how existing medical home (MH) practices
can enhance the care delivered to children and youth with
special health care needs (CYSHCN). By integrating families
as formal quality improvement (QI) advisors, and including
community-based organizations (CBO’s) in the process
of QI, enhancement and spread of MH will occur. The most
recent National Survey of CSHCN revealed that 52% of CYSHCN
have medical homes. In MA, 48% of parents of CSHCN report
receiving effective care coordination (CC).
- Pennsylvania: Educating Practices in Community
Integrated Care Abstract
Purpose: The purpose of EPIC IC is to improve
the quality of life for children with special health care
needs (CSHCN) and their families by continuing to build
sustainable MH teams in primary care practices and health
care systems throughout Pennsylvania. EPIC IC will focus
on providing MH and care coordination (CC) services for
families in underserved communities, increasing the integration
of family advisors into the practice team, and assuring
the availability of care coordination for children and
families, especially youth in transition.
Subspecialty
Capacity-Building. Grants to develop
strategies for partnership between State Title V agencies,
subspecialty networks, and the medical home to improve access
and availability of health/medical services to support children
and youth in their community. Funds will support: (a) comprehensive
Statewide, contiguous State, or national needs assessments
of workforce capacity for specialists and sub- specialists
serving CSHCN; (b) development and implementation of a plan
to improve workforce capacity; and (c) strengthen subspecialty
relationships with the medical home. The plan must define
and articulate the role of subspecialty networks, the medical
home, and Title V in improving access to and availability
of appropriate health and related services to support inclusion
of children and youth in their community.
Funds available: $400,000 for 2 grants
up to $200,000.
Grants are for four years.
Awarded Grant:
- MCHB Medical Home Grant:
Medical Home in the Safety Net: Building Infrastructure
for CSHCN in Community Health Centers Abstract
Purpose: To link two cornerstones of
Florida’s health-care system – Florida’s
Title V program (Children’s Medical Services; CMS)
and local community health centers (CHC) – to implement
a model of the medical home in the “safety net”
that capitalizes on community-based care, and enhances
access to specialty care through telemedicine. The project
specifically addresses the MCHB priority of subspecialty
capacity building and improving service delivery to children
from communities with limited access to comprehensive
care. Our goal is to ensure that each CSHCN served by
community health centers has a medical home that is accessible,
family-centered, continuous, comprehensive, coordinated,
compassionate, and delivered in culturally competent environment.
Early Identification
and Intervention for Children with Autism. A cooperative
agreement to improve the capacity of the medical home and
the early intervention community to identify, appropriately
serve, and integrate children with autism into their communities.
The cooperative agreement will: (a) work with MCHB, family
leaders, and pediatric primary care providers to improve
medical home capacity for early identification of young
children with autism; (b) support the work of HRSA on the
Interagency Autism Coordinating Council; (c) collaborate
with CDC’s national awareness campaign to ensure that
medical homes are well-prepared to support identified children;
and (d) implement community-based strategies to link the
medical home with early intervention programs for children
identified as having autism.
Funds available: $300,000 for one cooperative agreement.
The scope of Federal involvement with respect to all cooperative
agreements is included in the Application Kit. The
cooperative agreement is for four years.
Awarded Grant:
- Wisconsin: National
Medical Home Autism Initiative Abstract
Purpose:To develop a National Medical
Home Initiative on Autism in collaboration with the federal
Maternal and Child Health Bureau and the National Center
on Medical Home Initiatives within the American Academy
of Pediatrics. The Initiative will serve as a model that
demonstrates and promotes how the principles of the medical
home can be applied to achieve early identification and
intervention for children with ASD, with an additional
benefit to show how the approach can assist in the developmental
surveillance of all children, and thereby increasing the
identification of children with other developmental delays.
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Last Updated
July 6, 2007
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