January 2015: An Interview with Healthy Tomorrows Partnership for Children Program Grantees
The Children’s Medical Services and Advocacy Center (The Center) is a Healthy Tomorrows Partnership for Children Program (HTPCP), which provides high quality, comprehensive health care to children in foster care programs. Administered through Children’s Aid and Family Services, the Center integrates a medical home model of care within a child welfare organization.
The Center ensures coordinated and comprehensive team-based care for the children it serves. By hosting weekly medical rounds with the behavioral/mental health team (Licensed clinical social workers and a psychiatrist) and the primary care team, the Center is able to successfully integrate these services into the medical home. In a recent interview with the National Center for Medical Home Implementation, Anne Armstrong-Coben, MD, FAAP, medical director at the Center stated that integrated “behavioral/mental health services with primary care provides a holistic, team approach, which improves health outcomes.”
Since the Center’s HTPCP started in 2012, the Center has seen a significant increase in referrals to its services from Children’s Aid and Family Services. The Center has built powerful relationships within the community, including those with schools and other caregivers, to ensure a true medical home neighborhood for the children they serve. For more information visit the Healthy Tomorrows Partnership for Children Program Web site.
An Interview with Healthy Tomorrows Partnership for Children Program Grantees
The Newark School-Based Health Center Program is a Healthy Tomorrows Partnership for Children Program (HTPCP) that provides coordinated, team-based care for some of Newark’s most vulnerable youth and families. The project supports two school-based health centers administered by Jewish Renaissance Medical Center (JRMC), a Federally Qualified Health Center and serves a growing African American and Latino population. The health centers serve as medical homes for students and work to connect appropriate community resources to the families that need them the most.
The health center team consists of front desk and registration staff, a licensed clinical social worker, two family nurse practitioners, a pediatric nurse practitioner, and a family physician. In addition to daily communication between all team members, the health center team meets on a monthly basis with JRMC leadership, including the Chief Medical Officer Nancy Tham, MD. In a recent interview with the National Center for Medical Home Implementation (NCMHI), Dr Tham recommended that any pediatric practice interested in implementing team based care should “include both clinical and non-clinical staff” on the healthcare team. Family and caregiver input is crucial in a pediatric medical home, and these needs are communicated to the health care team with the assistance of the social worker, who serves as a liaison between the families and the clinicians.
The Newark School-Based Health Center Program assures sustainability of programs and resources by maximizing and leveraging community partnerships with organizations such as the Living Cities Foundation and the Greater Newark Healthcare Coalition. The program also works to engage national child health leaders and stakeholders, such as the American Academy of Pediatrics. In a recent interview with the NCMHI, Jorge Cruz, the director of planning and development at JRMC, emphasized the importance of partnership, collaboration, and teamwork to achieve optimal child health outcomes.
For more information on the Newark School-Based Health Center program, visit the Healthy Tomorrows Partnership for Children Program Web site.
National Academy for State Health Policy —New Jersey 2014 CHIP Fact Sheet
This fact sheet provides key information describing each state’s CHIP program at a time when states are both immersed in implementing the Children’s Health Insurance Program Reauthorization Act and Affordable Care Act.
Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield of New Jersey launched its Patient-Centered Pediatric Program on January 1, 2014. This is Horizon Blue Cross Blue Shield of New Jersey’s first patient-centered program targeted at the pediatric population and will benefit over 100,000 pediatric patients. The program focuses on improving care coordination and quality outcomes for its participants and reimburses providers with outcome-based payments.
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Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis
Through the support of the Allergy & Asthma Network Mothers of Asthmatics (AANMA), the Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis facilitates the dissemination of best practices, evidence-based guidelines and resources in asthma and allergy care to pediatricians in their states, and supports pediatricians in serving as advocates for change at local, state and national levels. The program seeks to support a successful, national chapter champion network model, initiate a team-based, care coordination and co-management quality improvement learning community; and cultivate an enhanced focus on advocacy and policy. If you are interested in more information about the project, fill out the Contact Us form.
Maternal, Infant, and Early Childhood Home Visiting Program (2012)
The US Department of Health and Human Services (HHS) has announced the awarding of grants to 10 states including the New Jersey Department of Health and Senior Services to provide early childhood supports and home visits to families. The funding has been awarded for the purpose of expanding or establishing home visiting programs that will provide for effective coordination and delivery of critical health, development, early learning, child abuse and neglect prevention, and family support services to at-risk children and families.
Healthy Tomorrows Partnerships for Children Grants—Children’s Medical Services & Advocacy Center (2012 - 2016)
The Children’s Medical Services & Advocacy Center provides intake assessments/exams, medical triage, acute care and medical consultation, along with comprehensive health care case management serving children in agency foster care programs. The purpose is to improve the health of these children by implementing the medical home model, integrating health care with mental health services, providing acute care, coordinating comprehensive preventive care and health education, and ensuring high quality coordination of medical care in a safe and supportive environment, consistent with the AAP’s Bright Futures Guidelines. Children in foster care have high rates of chronic health conditions and special needs.
State Implementation Grant for Improving Services for Children and Youth with ASD and Other DD—Statewide Parent Advocacy Network of New Jersey
Grant Period: September 1, 2010 - August 31, 2013
35 Halsey St., Newark, NJ 07102-3047
Program Director: Jennifer B Pitre | Phone: 856/649-4420 | E-mail: firstname.lastname@example.org
Medical Home Director: Malia Corde | Phone: 908/537-4673 | E-mail: email@example.com
The purpose of this project is to improve access to a quality, comprehensive, coordinated community-based system of services for CYSHCN with Autism Spectrum Disorders (ASD) and other Developmental Disabilities and their families that are family-centered and culturally competent. The initiative supports grants to assist State Title V CSHCN programs, family organizations, providers, and other partners to implement the six core outcomes of a system of services based on evidence based practices for CYSHCN.
Innovative Evidence Based Models for Improving the System of Services for CYSHCN
Grant Period: September 1, 2011 - August 31, 2014
35 Halsey St., Newark, NJ 07102-3047
Program Director: Mercedes Rosa | Phone: 973/642-8100 x 191 | E-mail: firstname.lastname@example.org
Medical Home Director: Malia Corde | Phone: 908/537-4673 | E-mail: email@example.com
The purpose of this project is to improve access to a quality, comprehensive, coordinated community-based system of services for underserved CYSHCN and their families that are family-centered and culturally competent. The initiative supports grants to assist State Title V CSHCN programs, family organizations, providers, and other partners to implement the six core outcomes of a system of services based on evidence based practices for CYSHCN. The focus of SPAN's project is working with immigrant families served by Federally Qualified Health Centers in three high-immigrant, high-poverty counties.
Monmouth County Pilot of the AAP New Jersey Chapter/Pediatric Council on Research and Education (PCORE)
As part of the Family to Family Health Information Center (F2F HIC), Family Voices-NJ at the Statewide Parent Advocacy Network (SPAN) has recruited parent partners to participate in medical home site visits under the Monmouth County pilot of the AAP - New Jersey Chapter/PCORE. In June 2009, SPAN commenced their Integrated Community Systems for CYSHCN project funded by HRSA in collaboration with the state Departments of Health, Human Services, and Children and Families and the NJ AAP chapter. A major component of the project is to expand the current Monmouth County medical home pilot, involving one hospital, one federally qualified health center, and six other pediatric practices, to five additional counties within the three-year project period. A full-day statewide training has been conducted. F2F HIC parent partners have been participating in medical home visits for 30 diverse parents of children and youth with a range of special health care needs.
State Initiatives in Patient-Centered Medical Homes
The Council of State Governments
The majority of state Medicaid programs are testing models of coordinated medical care to improve quality and reduce costs, particularly for patients wit h multiple chronic illnesses. This brief includes descriptions of eleven states' pilot programs or authorizing legislation including New Jersey.
The Assuring Better Child Health and Development (ABCD) Program
The ABCD Program was funded by The Commonwealth Fund, administered by National Academy for State Health Policy (NASHP), and designed to assist states in improving the delivery of early child development services for low-income children and their families by strengthening primary health care services and systems that support the healthy development of young children, ages 0-3. The program focused particularly on preventive care for children enrolled in state health care programs, especially Medicaid. The ABCD program ran from 2001-2013 and helped twenty-seven states create models of service delivery and financing through a laboratory for program development and innovation.
- The Enduring Influence of the ABCD Initiative
In May 1999, NASHP and The Commonwealth Fund launched the ABCD project. New Jersey is one of the states included in this initiative. This report offers lessons, strategies, and policies learned over the past 12 years through this initiative.
Health Resources and Services Administration (HRSA) in Your State
HRSA in Your State offers overviews of HRSA programs and current information, such as the number and amount of grants awarded down to the County level. It also provides state-specific information about health centers, National Health Service Corps members and the communities they serve, and the number of participating providers through the 340B program.
Early Childhood Comprehensive Systems (ECCS) State Contacts
The Maternal and Child Health Bureau (MCHB) launched the State Maternal and Child Health Early Childhood Comprehensive Systems (ECCS) Initiative to implement the MCHB Strategic Plan for Early Childhood Health. The purpose of ECCS is to support states and communities in their efforts to build and integrate early childhood service systems that address the critical components of access to comprehensive health services and medical homes; social-emotional development and mental health of young children; early care and education; parenting education, and family support. For additional information, you can look up your state's ECCS Grantee Contact or Grantee Web site.
AAP: Community Pediatrics Grant Database
The Community Pediatrics Grant Database archives previously funded Community Pediatrics grant projects, including those funded through the CATCH Program, the Healthy Tomorrows Partnership for Children Program, the Community Pediatrics Training Initiative, and the Healthy People 2010 Chapter Grants. The database is searchable by seven major categories: target population; health topic; state/territory; project activity; AAP program; AAP district; and project year. Members of the AAP can obtain grantee contact information by searching through the Member Center. If you are not an AAP member, but have questions please contact firstname.lastname@example.org.
Comprehensive Primary Care Initiative (CPCi)
New Jersey is one of seven markets participating in CPCi. In this initiative, Medicare is collaborating with public and private insurers in the selected states or regions with the goal of strengthening primary care. In New Jersey, CPCi launched in November 2012, bringing together five payers, as well as 71 participating primary care practices with 272 providers across the state. For more information, visit the NASHP New Jersey Medicaid Medical Home Demonstration Project.
New Jersey Medicaid Accountable Care Organization (ACO) Demonstration Project
New Jersey’s PL 2011, Ch 114 was signed into law in August 2011 creating the New Jersey Medicaid ACO Demonstration Project. Under the 3-year demonstration program, ACOs will assume responsibility for Medicaid/CHIP populations within a designated area. For more information about ACOs in New Jersey, visit the NASHP ACO New Jersey page.
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This section provides information on state organizations that play a role in implementing various aspects of medical home, and includes links to their Web sites and contact information.
American Academy of Pediatrics (AAP) Chapter—New Jersey
AAP chapters are organized groups of pediatrician members and other health care professionals working to achieve AAP goals in their communities. Please contact your local chapter for additional state resources.
- The Pediatric Council on Research and Education (PCORE)
The PCORE is the charitable arm of the AAP New Jersey Chapter that is dedicated to improving the health and well-being of children in the state of New Jersey. PCORE's mission is accomplished by working to improve health policies and practices, and to educate parents and primary care providers on preventative health topics within the context of a medical home framework. PCORE and its successful partnerships with local and state agencies help promote wellness and prevent illness, abuse, and neglect among children in New Jersey.
American Academy of Family Physicians (AAFP) Chapter—New Jersey
AAFP represents more than 94,000 family physicians, family medicine residents, and medical students.
Family Voices Chapter—New Jersey
Family Voices aims to achieve family-centered care for all children and youth with special health care needs (CYSHCN) and/or disabilities. Through a national network of chapters, they provide families with tools to advocate for improved public and private policies, and build partnerships among professionals and families.
Family-to-Family Health Information Centers (F2F HICs)
F2F HICs are non-profit organizations that help families of CYSHCN and the professionals who serve them. F2F HICs are typically staffed by parents of CYSHCN who understand the issues that families face, provide advice, offer resources, and tap into a network of other families and professionals for support and information.
Statewide Parent Advocacy Network (SPAN)
Address: 35 Halsey Street, 4th Floor, Newark, NJ 07102
Phone: 973/642-8100 ext 110 | Toll free: 800/654-7726
Primary Contacts: Diana Autin at email@example.com and Mercedes Rosa at Mercedesrosa1@yahoo.com
Title V Maternal and Child Health (MCH) Director & Children with Special Health Care Needs (CSHCN) Director
Title V of the Social Security Act is the nation's oldest federal program to improve the health of all mothers, infants, children, adolescents, and CSHCN. Title V is administered by the Federal Maternal and Child Health Bureau (MCHB) as a block grant to states to support core public health functions, such as care coordination and rehabilitation services.
Early Hearing Detection & Intervention (EHDI) Contact(s)
State EHDI programs promote universal newborn hearing screening, develop effective tracking and follow-up as a part of the public health system, promote appropriate and timely diagnosis of hearing loss, prompt enrollment in appropriate early intervention, ensure a medical home for all newborns, and strive to eliminate geographic and financial barriers to service access.
State Newborn Screening & Genetics Programs
Early Intervention/Part C Coordinators
The Program for Infants and Toddlers with Disabilities (Part C of IDEA) is a federal grant program that assists states in operating a comprehensive statewide program of early intervention services for infants and toddlers with disabilities, ages birth through 2 years, and their families.
State Section 619/Special Education for ages 3-5 Coordinators
This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities.
State Interagency Coordinating Council (ICC) Chairs
This program advises appropriate agencies on the unmet needs in early childhood special education and early intervention programs for children with disabilities, assists in the development and implementation of policies that constitute a statewide system, and assists all appropriate agencies in achieving full participation, coordination, and cooperation for implementation of statewide system.
Children's Health Insurance Program (CHIP)
CHIP is Title XXI of the Social Security Act and is a state and federal partnership that targets uninsured children and pregnant women in families with incomes too high to qualify for most state Medicaid programs, but often too low to afford private coverage. Within federal guidelines, each state determines the design of its individual CHIP program, including eligibility parameters, benefit packages, and administrative procedures. The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 re-authorized the program through FY 2013, and includes many incentives for states to find and enroll more eligible children in both Medicaid and CHIP. CHIPRA also includes quality provisions that aim to monitor and improve care delivered through the Medicaid and CHIP programs. Each state does have a CHIP program, and the names of these programs differ from state to state. To find information on health coverage programs in your state, visit the InsureKidsNow.gov Web site.
Medicaid State Directors
Medicaid is Title XIX of the Social Security Act and is a federal/state entitlement program that provides medical assistance to certain individuals and families with low incomes and/or special health care needs. Medicaid is of unique importance to children; together with the CHIP, Medicaid insures more than one in four children in the United States, with millions more eligible but currently unenrolled. The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is a critical component of Medicaid, which guarantees that children enrolled in Medicaid are screened for medical or developmental problems early, and that necessary treatments and services are provided. To find information on health coverage programs in your state, visit the InsureKidsNow.gov Web site.
Community Health Centers in the State
HRSA provides a searchable database of federally-funded health centers. Health centers provide care to those with or without health insurance including well-care check ups, treatment when sick, complete care during pregnancy, immunizations and checkups for children, dental care, prescription drugs, and mental health and substance abuse care.
Regional Extension Centers (RECs)
Health Information Technology RECs support and serve health care providers to help them quickly become adept and meaningful users of electronic health records (EHRs). RECs are designed to make sure that primary care clinicians get the help they need to use EHRs by providing training in adopting EHRs, guidance with implementation, and technical assistance as needed.
Help Me Grow
Help Me Grow (HMG) is a collaborative, cross-sector system that assists states in identifying at-risk children, then helping families find community-based programs and services. The organization and its affiliates do not provide direct services. Rather, it is a system for improving access to existing resources and services for children through age eight. States affiliated with the Help Me Grow National Center use the HMG system to implement effective, universal, early surveillance and screening for all children, and then link them to existing quality programs.
MOM2MOM Helpline Program
1/877-914-6662 (MOM2) is a 24 hour/7-day a week helpline coordinated by University of Medicine and Dentistry of New Jersey-University Behavioral HealthCare and New Jersey Medical School. The helpline features peer counseling, clinical assessments, and useful resources and referrals. The helpline provides Moms of special needs children in Essex and Union Counties of New Jersey access to a comprehensive support network of mental health professionals.
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Association of Maternal and Child Health Programs (AMCHP)—New Jersey State Profile
These state profiles provide a snapshot of how the Maternal and Child Health Block Grant (Title V) works in specific states. The profiles detail the federal funds appropriated to each state, state match, specific programs funded, numbers of people receiving services and state health needs.
Early Childhood State Policy Profiles
National Center for Children in Poverty (NCCP)
NCCP’s Early Childhood Profiles were produced as part of the Improving the Odds for Young Children project. These comprehensive profiles highlight states’ policy choices that promote health, education, and strong families alongside other contextual data related to the well-being of young children.
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Medical Home Data Portal—State Data Pages
Child and Adolescent Health Measurement Initiative
The Medical Home State Data Portal profiles provide a state’s medical home performance level for all children and children with special health care needs, based on data from the 2009/2010 National Survey on Children with Special Health Care Needs, 2007 National Survey on Children's Health and the 2005/2006 National Survey of Children with Special Health Care Needs.
State-at-a-Glance Chartbook on Coverage and Financing for Children and Youth with Special Health Care Needs
The Catalyst Center
The Online State-at-a-Glance Chartbook provides data on carefully selected indicators of health coverage and health care financing for CYSHCN. Using the online Chartbook, you can access data for your state and easily compare it with both national averages and other states' data.
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AAP Child Health Informatics Center—State and Territory Specific HIT Resources
This page on the AAP Child Health Informatics Center (CHIC) Web site allows you to identify pediatric specific HIT resources by state related to Meaningful Use, Regional Extension Centers, State Health Information Exchanges, and other important information.
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