Medical Homes in Rhode Island
 This page is designed to keep you informed about events and activities happening in Rhode Island that will help improve access to medical homes for children with special health care needs (CSHCN).

Medical Home Initiatives
This section provides information on state medical home initiatives/programs. States that are a part of the mentorship network will have a "Promise to the State" which outlines how they will achieve ensuring that all children have a medical home by 2010. This is based on the Healthy People 2010 goals which is a 10 year action plan to achieve and measure success for all CSHCN.

Rhode Island Medical Home Team Contact:

Name: Deborah Garneau - Division of Family Health
Contact: Phone: 401-222-5928 | Email: Deborah.Garneau@health.ri.gov
State Team Roster available at: www.medicalhomeinfo.org/model/downloads/State Teams/Rhode Island Medical Home Team.doc

Pediatric Practice Enhancement Project (PPEP)
This project provides parent support personnel to primary care physician who serve a large percentage of CSHCN and their families. Parent consultants are currently placed in seven primary pediatric offices statewide and assist the physician in providing a comprehensive coordinated medical home to about 300 families annually. Parent consultants link families with necessary community resources, assist physicians and families in accessing specialty services, and identify and resolve with the PPEP Steering Committee systems barriers to coordinated care. The PPEP is partnership between the Rhode Island Department of Health (DOH), Department of Human Service (DHS) and the Rhode Island Chapter of the American Academy of Pediatrics (AAP).

The PPEP funding sources include the DOH and State and Federal Medicaid. Oversight and monitoring of the PPEP is a collaborative effort among the DOH, DHS, Neighborhood Health Plan of RI, and the Rhode Island Parent Information Network (including Family Voices), with the DOH being the lead agency.

Project Goals: The PPEP aims to fully embrace the Medical Home model of care by fostering partnerships among families, pediatric practices, and available community resources, including CEDARR (Comprehensive Evaluation Diagnosis Assessment Referral Re-evaluation) Family Centers. The outcomes identified for the PPEP include:

  1. Pediatrics practices will provide coordinated and comprehensive care to CSHCN with greater operational efficiency within the practices
  2. Pediatric practices will have improved awareness and communication with available and appropriate community resources for their CSHCN
  3. Families of CSHCN will receive ongoing, comprehensive, and coordinated care, where the family is recognized as a critical decision maker, resulting in improved health outcomes for the child
  4. Families of CSHCN will have improved understanding of both the health care delivery system and the community resources available to them and demonstrate the ability to access those resources.

Project Evaluation: The evaluation plan is a two-tiered approach that includes assessment of the overall effectiveness of the PPEP and identification of key system barriers that limit the families' access to appropriate services and supports. Evaluation of the PPEP is accomplished through pre/post intervention surveys administered to families and practice staff. In addition, aggregate data is analyzed based on parent consultant activities. System barriers are identified through parent consultant documentation resulting from their work with the families. Several state and community agencies are anticipating this feedback from parent consultants to direct their quality improvement efforts

Form more information on PPEP contact: Deborah Garneau at Phone: 401-222-5929 | E-mail: Deborah.Garneau@health.ri.gov

Newport County CATCH/Medical Home Initiative
Purpose: facilitate the creation of medical homes for all children in Newport County.
Goals:

  • Develop and implement a care coordination system to support the medical home
  • Identify and reduce barriers to medical homes.
  • Provide medical home training to parents, medical and human service providers
  • Evaluate the impact of our interventions
  • Implement systems to sustain and ensure quality medical homes for all children.

Future Initiatives:

  • Collaborate with the PPEP to define access barriers and capacity issues & continue collaborative problem solving with providers and families
  • Collaborate with the RI Lung Association, Hasbro Children's Hospital and Newport Hospital to implement community needs assessment and training for asthma
  • Develop Neighborhood Training Teams in collaboration with the Newport Housing Authority
  • Provide medical home training to school educators, FSC(s) and health advocates as part of the Train the Trainer Initiative
  • Collaborate with mental health and special education services to integrate care into the medical Home
  • Develop a Newport County Medical Home web-site for families and providers
  • Maintain and build upon established medical home services and products
  • Obtain funding to sustain Newport County CATCH/Medical Home Initiative

Newport County CATCH/ Medical Home Initiative Presentation

Newport County CATCH/Medical Home Initiative 2005 Work Plan and Action Items

Newport County CATCH/ Medical Home Initiative Brochure
This brochure provides definitions, benefits and tips for families about having a Medical Home for your child, and includes a comprehensive listing of community and state resources

Newport, Middletown, and Jamestown Medical Home Transportation Map

Newport County CATCH/ Medical Home Initiative " Initiative Aims to Improve Children's Health Care"
Newspaper clip from the Newport Daily News. February 19-10, 2005

For more Information on the Newport County CATCH/ Medical Home Initiative Contact:
James Sattel
Newport County CATCH/Medical Home Coordinator
The Triplett School
435 Broadway
Newport, RI. 02840
(401) 847-2100; ext 223 | jsattel@ebcap.org

Related Grant Initiatives
This section provides information on current state grants that are working on medical home initiatives. This includes the grant abstract as well as key contacts for the grant.

Genetics MCHB Grant
Project Period: 3 years From: 6/1/2001-5/31/2004
The goals for this project focus on assuring identification of all children with genetic conditions, access to a medical home which coordinates primary and specialty care, improving vehicles for informing parents and professionals about genetic risks and tests, and strengthening HEALTH’s ability to respond to existing and evolving genetics issues.

Partners in the State
This section provides information on who in the state (individuals and agencies) are working together to create medical homes for children.

American Academy of Pediatrics (AAP) Chapter: www.riaap.org/

American Academy of Family Physicians (AAFP) Chapter: www.riafp.org/

Title V CSHCN Program: www.health.state.ri.us/family/disability/index.php

Title V Block Grant to States
Title V of the Social Security Act is one of the largest Federal block grant programs. It leads the nation in ensuring the health of all mothers, infants, children, adolescents, and children with special health care needs (CSHCN). Title V is administered by the Maternal and Child Health Bureau (MCHB) as part of the Health Resources and Services Administration, U.S. Department of Health and Human Services.

Title V and Children with Special Health Care Needs
MCHB Objective: Support development and implementation of comprehensive, culturally competent, coordinated systems of care for the estimated 18 million U.S. children who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally

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 the 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.

Name: Ellen Amore
Contact: Phone: 401-222-4601| Fax: 401-222-1442 | E-mail: ellena@doh.state.ri.us

State Genetics Program: www.healthri.org/genetics/screening.htm

Early Intervention/Part C Coordinator:
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 age 2 years, and their families.

Name: Deborah Garneau, Chief
Office of Families Raising Children with Special Health Care Needs
Contact: Phone: (401) 222-5929 | Fax: (401) 222-1442 | Email: Deborah.Garneau@health.ri.gov
Web Site: www.healthri.org/family/ei/Home.htm

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:

Name: Amy Cohen, Preschool Grant Coordinator
Contact: Phone: (401) 222-4600 x2408 | Fax: (401) 222-4979 | Email: abcohen@ride.ri.net
Web site: www.ridoe.net/child_family/earlychild/default.htm

State Interagency Coordinating Council (ICC) Chairs:
The ICC 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.

Name: Dawn Wardyga, ICC Chair
Contact: Phone: (401) 727-4144 x58 | Fax: (401) 727-4040 | Email: familyvoices@ripin.org
Web site: www.ripin.org/

Resources/Documents
State Waiver Information: www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/08_WavMap.asp
Waivers are the result of a process that allows state Medicaid agencies to apply for and receive permission from HCFA to provide services not otherwise covered by Medicaid and/or to do so in ways not described by the Social Security Act. Most Medicaid managed care programs require Waivers. The Waivers, which can differ greatly, are known by their numbers (1115, 1119), or as home-and community-based, or as Katie Beckett Waivers.

KIDSNET: www.health.ri.gov/family/kidsnet
Rhode Island's child health integrated system houses data from several public health programs, and for the last two years, has provided online access to pediatric providers and other users. The new public-facing site offers information for parents, providers, and other users, answers to frequently asked questions, our confidentiality policies, and program highlights. The KIDSNET system is available to Head Start, the home visiting nurses agencies, WIC, Comprehensive Child Care Service Programs, school nurses, Lead Centers, and Early Intervention sites. KIDSNET provides the immunization schedule for each child in the system.

Educational Initiatives
This section provides information on training initiatives on the medical home. Some states will discuss their outreach projects in relation to physicians, families, and the community.

No information is currently available for this category.

Screening Initiatives
This section provides information on surveillance and screening initiatives in the state.

State Newborn Screening & Genetics Programs: genes-r-us.uthscsa.edu/resources.htm

  • State Newborn Screening Program Links
  • State Genetics Program Links
  • Regional Genetics and Newborn Screening Collaborative Links
  • Newborn Screening State Contact Fact Sheet

Family Corner
Resources and Materials
Early Hearing Detection & Intervention (EHDI) Information for Parents:
Description of EHDI Program | Babies Diagnosed with Hearing Loss
www.medicalhomeinfo.org/screening/State/rhode_island.html

2003 Recreation Resource Guide: www.riddc.org/recguide.shtml
This guide lists a broad range of recreation, arts and entertainment and education programs and services for people who have a disability. It also lists other programs that have upgraded facilities to make them accessible and have inclusive policies that allow people with developmental disabilities to participate.

Family Village: www.familyvillage.wisc.edu/index.htmlx
A global community that integrates information, resources, and communication opportunities on the Internet for persons with cognitive and other disabilities, for their families, and for those that provide them services and support. This site offers informational resources on specific diagnoses, communication connections, adaptive products and technology,adaptive recreational activities, education, worship, health issues, disability-related media and literature, and much, much more!

The Rhode Island Developmental Disabilities Council: Provides national and local resources for people concerned about disabilities. Whether you are a person with a disability, a parent, teacher, social worker or other professional, you’ll find many useful links along with a brief site evaluation. Advocacy organizations, government agencies, research institutes, along with regional and local service agencies offer information that will help you close in on the answers to your questions. www.riddc.org/

Advocacy and Support Organizations
Family Voices: www.familyvoices.org/st/RI.htm
Partnering with professionals and families to advocate for health care services that are family-centered, community-based, comprehensive, coordinated and culturally competent.

NAMI of Rhode Island (National Voice on Mental Health): web.nami.org/about/amiri/
Education, advocacy and support for persons with brain disorders (mental illnesses) and their families
The Rhode Island Parent Information Network: www.ripin.org/
The Rhode Island Parent Information Network (RIPIN) is a statewide, nonprofit agency that provides information, training, support and advocacy to parents seeking help for their children. RIPIN is the home of five projects that are made up of 11 programs and services to families with children in RI, including families of children with special needs. The five projects include Family Voices, the Early Intervention Parent Consultant Program, the Family Health Parent Consultants, the Parent Information and Resource Center and the Parent Training and Information Center.

The Association for Retarded Citizen (Arc) Family Resource Guide www.thearc.org/familyguide/rhodeisland.doc
This guide is written for families raising children with mental retardation and related developmental disabilities. It tells families about benefits, supports and services in their state that might help their child.

State Resources on the Internet: www.medicalhomeinfo.org/states/index.html#res

Note: The information provided on the state pages was submitted by the state medical home teams.As this is not an exhaustive list, please let us know if you have additions for your state resource page. You can contact us at: medical home@aap.org.

http://www.medicalhomeinfo.org/states/state /rhode_island.html

Last Updated August 15, 2006