Medical Homes in Wisconsin
This page is designed to keep you informed about events and activities happening in
Wisconsin 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.

Wisconsin Medical Home Contact:

Name: Loraine Lucinski - Family Centered Care Consultant
Contact: Phone: 608-267-0329 | Email: LucinLA@DHFS.State.WI.US

The Wisconsin Department of Health and Family Services has been awarded an MCHB State Implementation Grant for Integrated Community Systems of Services for CSHCN - Abstract
Duration of Program: Project period May 1, 2005- April 30, 2008.
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

MCHB Medical Home Grant: National Medical Home Autism Initiative
www.medicalhomeinfo.org/grant/states/MCHB Grants/WI Updated Abstract 8-3-04.DOC
Project Period: 4 years from July 1, 2004 to June 30, 2008
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.

Wisconsin Statewide Medical Home Implementation Plan: Promise to the State (www.medicalhomeinfo.org/grant/states/WisconsinPromise.pdf)

Wisconsin was selected to be part of the National NICHQ Medical Home Learning Collaborative - A fifteen-month collaborative activity to improve care for the growing population of CSHCN. This initiative focuses on 3 practices in the state and assists them in completing a quality improvement process to provide medical homes to their patients with special needs. It also assists in building the capacity of Wisconsin's CSHCN and other health department programs to support and extend this approach after the completion of the project period.

Update: Expanding the Learning Collaborative to 9 practices. Facilitator from the Regional CSHCN Center to do quality improvement work with the practices.
First Session May 7th & 8th | Second Session September 10th | Third Session December 3rd

Wisconsisn Medical Home Special Needs Rotation Presentations
Children's Hospital of Wisconsin (CHW) Special Needs Program: A Primary Care/ Tertiary Care Medical Home Partnership - Holly Colby, RN, MS

• Evolution of the Special Needs Program
• Care coordination at Children’s Hospital of Wisconsin
• Reimbursement strategies
• Issues/Challenges

Together Everyone Achieves More: A Children with Special Health Care Needs Rotation for Third Year (PL-3) Residents at CHW - Anne K. Juhlmann RN, BSN

• Focus of the Rotation
• Assessing Resident Learning
• Family Views

Presentations from the CATCH and Medical Home National Conference - July 16, 2004

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.

Transitions Champions Incentive Grant - Incentive Award FAQs
Goal:To establish a formalized, ongoing mechanism for gathering and utilizing youth input about resources and services they need for successful transition, including adult health care, vocational training, post secondary education, recreational opportunities, and gainful employment.
For more information contact: Daniel Bier, Associate Director
University Center for Excellence in Developmental Disabilities - Waisman Center
Phone: (608) 262-5254 | Email: BIER@Waisman.Wisc.Edu

Dyson Community Pediatrics Training Grant
Medical College of Wisconsin: Department of Pediatrics - Pediatric Training Program
Through The Initiative, the Department of Pediatrics at the Medical College of Wisconsin balances training in the growth and development of well and sick children in traditional inpatient and outpatient settings. The newly created Multi-Dimensional Education Program (MDEP) systematically expands the traditional training program to a more comprehensive community education paradigm. Specifically, it incorporates community-based, collaborative interactions to enhance residents' effectiveness in providing family-centered, community-based, coordinated care.

The ultimate goal of the Dyson Initiative is the development of pediatric professionals with greater skills and interest in community-based medicine, advocacy, and the capacity to improve the health of children in their communities. Here you can learn how diverse programs around the country are educating residents about community pediatrics and fostering practical community experiences.www.aap.org/commpeds/cpti/grantees.htm


Healthy & Ready to Work
Project Period: June 1, 2001 through May 31, 2005
Purpose: Develop, implement and evaluate an asset based approach to promote and support the transition of adolescents with special health care needs from pediatric to adult health care and related services, employment and independence. The goals are to assure a medical home for all children with special health care needs, train service providers to provide person centered services, promote self-determination and self sufficiency for all youth with special health care needs.
Web site: www.waisman.wisc.edu/hrtw/index.html

MCHB Hemophilia Grant
Purpose: Provide access to comprehensive care, develop culturally-appropriate, coordinated, and family-centered services, provide outreach to undeserved populations, prevent complications and morbidity associated with hemophilia and provide collaborative services in coordination with local, state, and federal programs.

MCHB Financing for CSHCN Grant - Covering Kids with Special Needs:
Purpose: The purpose of this project is to expand coalition-building efforts focused on CSHCN and to link with the
larger coalitions looking at access/ coverage/ and enrollment issues in health care. Working with Wisconsin's Title V CSHCN Program and their five Regional CSHCN Centers to initiate new local HealthWatch committees, which will gather information on issues facing CSHCN, provide resources and strategies to address the issues, and promote networking and collaboration between parents and a spectrum of service providers across Wisconsin. Other objectives include: Promote public policy strategies and initiatives to decrease uninsured and/or increase coverage of underinsured; Providing direct health benefits counseling services and tracking client encounters to identify systemic problems; Creating training and educational materials around the 2010 six core outcome measures.
E-mail: bobbyp@safetyweb.org

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.wisaap.org/
The Wisconsin AAP is a organized group of over 700 pediatricians located across the state of Wisconsin.

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

Title V Children with Special Health Care Needs Program (CSHCN) Program:
www.dhfs.state.wi.us/dph_bfch/cshcn/index.HTM

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, link newborns to a medical home and strive to eliminate geographic and financial
barriers to service access.

Name: Sharon Fleischfresser; MD, MPH
Contact: Phone: 608-266-3674 | Fax: 608-267-3824 | E-mail: fleissa@dhfs.state.wi.us

State Genetics Program: www.slh.wisc.edu/genetics/
This web site features links to many other web sites that may be helpful to families and professionals, genetics educational materials, and also introduces the Genetic Services Plan for Wisconsin and the accompanying family stories. The family stories are an especially important part of the web site as they give a face to those of us in the state who benefit from genetic services.

Birth to Three - 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: David Sorenson
Contact: Phone: (608) 267-3270 | Fax: (608) 261-6752
Web Site: dhfs.wisconsin.gov/bdds/birthto3/index.htm

Section 619/ Preschool Grants Program of the Individuals with Disabilities Education Act (IDEA). This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities:

Name: Mary Peters, Education Consultant
Contact: Phone: (608) 267-9625 | Fax: (608) 266-2529 | Email: mary.peters@dpi.state.wi.us
Web site: www.dpi.state.wi.us/dpi/dlsea/een/index.html
Web Site: www.dpi.state.wi.us/dpi/dltcl/bbfcsp/ecspedhm.html

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: Sandra Butts
Contact: Phone: (414) 289-5944 | Fax: (414) 289-8570 | Email: sbutts@milwcnty.com

Wisconsin Katie Beckett Program: dhfs.wisconsin.gov/bdds/kbp/

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.

The 2006 Circles of Life Conference
Wisconsin's Annual Conference for Families of Children with Disabilities and Their Providers

Date: May 4 & 5, 2006
Location: County Spring Hotel (formerly Holidome), Stevens Point
For more information, go to: www.wfv.org/circle/

To see information from the 2005 conference, go to: www.wfv.org/circle/2005/index.html

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
Programs
Wisconsin Department of Health and Family Services Web site: www.dhfs.state.wi.us/dph_bfch/index.htm

Wisconsin Regional CSHCN Centers:
Northeastern Region--(800) 236-3030 ext. 8296
Northern Region---------(888) 266-0028
Southeastern Region--(800) 234-KIDS (5437)
Southern Region---------(800) 532-3321
Western Region----------(800) 400-3678

Wisconsin First Step Hotline (800) 642-7837 www.dhfs.state.wi.us/DPH_BFCH/cshcn/CntrsFrstStep.htm
Information and referral hotline for children birth to age 21 with special needs. Serves families and professionals. Direct referrals are provided to Birth to 3 Programs and Regional Children With Special Health Care Needs (CSHCN) Centers across the State of Wisconsin

Wisconsin Oral Health Program Web site: www.dhfs.state.wi.us/health/Oral_Health/
The Oral Health Program promotes and seeks to improve oral health for all citizens in Wisconsin through policy development, technical assistance, needs assessment, training, and education. In addition, the Oral Health Program plans, implements, and evaluates the effectiveness of preventive oral health programs in Wisconsin.

Healthy Smiles Program: www.dhfs.state.wi.us/health/Oral_Health/HealthySmiles.htm
Healthy Smiles for Wisconsin is dedicated to realizing a statewide effort to improve the oral health of Wisconsin children. This program offers resources, education, coalition-building efforts, and is working on a variety of dental access projects.

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

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!

Advocacy and Support Organizations
Family Voices web site: www.familyvoices.org/st/WI.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 Wisconsin (National Voice on Mental Health): www.namiwisconsin.org/
Education, advocacy and support for persons with brain disorders (mental illnesses) and their families.

Parent to Parent of Wisconsin www.familyresourceconnection.org/ptpow.htm
Parent to Parent of Wisconsin provides parent matching by connecting a parent new to having a child with special needs, experiencing a time of stress or simply seeking emotional support, resources and information with an experienced, trained "Support" parent. (888) 266-0028

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 /wisconsin.html