Medical Homes in Texas

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»Related Grant Initiatives	»Educational Initiatives
»Partners in the State	»Screening Initiatives
	»Autism State Plan

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.

Texas Medical Home Contact:

Name: Lesa Walker, MD, Title V CSHCN Director
Contact: Phone: 512/458-7111 ext. 2567
Email: Lesa.Walker@dshs.state.tx.us
State Team Roster

Name: Beverly MacCarty, Texas Medical Home Workgroup Staff
Contact: Phone:(512) 458-7111, Ext. 6436 | Fax: (512) 458-7238
Email: Beverly.MacCarty@dshs.state.tx.us

Texas Department of State Health CSHCN Services Program Medical Home webpage has been revised: http://www.dshs.state.tx.us/cshcn/medicalhome/default.shtm
The revised webpage is organized in 4 sections: Medical Home Basics, Medical Home Workgroup, Medical Home Resources, Medical Home Supports in Texas, Related Initiatives

Introduction to Medical Home online module
Texas Health Steps Online provider education – The Texas Department of State Health Services and the Texas Health and Human Services Commission have collaborated to develop a FREE, online education program designed to educate health care providers about Texas Health Steps (Medicaid for children) and other health care services. The comprehensive program offers FREE continuing education credits, and its courses are accredited by the Texas Medical Association, the American Nurses Credentialing Center, the National Commission for Health Education Credentialing, the Texas State Board of Social Work Examiners, the Accreditation Council of Pharmacy Education, and the Academy of General Dentistry. Topics include Introduction to Medical Home and many others!
To view a course online, please visit www.txhealthsteps.com

Notice of Open Enrollment for Medical Home Supports: March 2008-March 2009
The Department of State Health Services (DSHS), Children with Special Health Care Needs (CSHCN) Services Program, within the Purchased Health Services Unit, issues this Notice of Open Enrollment (the “Notice”) requesting applications from Texas pediatric or family physician practices to implement practice-level supports to help improve the provision of a Medical Home for children and youth with special health care needs (CYSHCN) and their families. To be enrolled as a Contractor for Medical Home Supports, the applicant must meet the eligibility requirements described in the Notice and complete, sign, and submit the application attached to the Notice.  The enrollment period begins March 1, 2008 and ends March 1, 2009. For more information on this Open Enrollment opportunity, please click on the following link to the posting on the Electronic State Business Daily (ESBD): http://esbd.cpa.state.tx.us/bid_show.cfm?bidid=74328

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.

Family-Centered Care Champions Incentive Grant - Incentive Award FAQs
Goal: To organize a Parent Group Network designed to promote family-centered care by providing information and support to parent groups at the local level. This includes the identification, production and dissemination of family-centered and practical tools/methods for families to use in order to build partnerships with health care providers that promote both family centered care and effective medical coordination within the medical home.
For more information contact: Laura J. Warren, Executive Director
Phone: (512) 458-8600 | Email: laura@txp2p.org

Healthy Tommorrows Program for Children Grant 2002-2007
Montwood Wellness Center
Texas Tech University Health Science Center Department of Pediatrics - El Paso, TX
The mission of the Montwood Wellness Center is to improve the health and quality of life within the community by integrating the education system, the health care system, and community groups to provide comprehensive care with dignity and respect. The project provides comprehensive pediatric care for children in the Socorro Independent School District area, a community with 38.6% of the population at or below the federal poverty level. This collaboration between Texas Tech University Health Science Center Department of Pediatrics and Socorro Independent School District establishes a medical home for children who face many barriers to access health care.
Program goals include: establish a medical home for children who have no primary care provider; increase and enhance each student's academic potential through health maintenance and education; create a new system of community support individuals that will work as a link between individual homes, parents, families, and the wellness center; and develop continuous evaluation, feedback, and research based on the results of the program.

Healthy Tommorrows Program for Children Grant 2005-2010
Behavioral Developmental Primary Care Program
People’s Community Clinic, Austin, TX
Program goals include: provide an improved system of behavioral/mental health/developmental screening, assessment, and care coordination for school- aged (3-19) patients and to offer an improved, formalized resource to the larger Central Texas community by providing diagnostic assessments, case coordination, and a medical home to youth and families referred specifically to the program by schools, youth serving agencies, and individuals because of behavioral/developmental/mental health concerns. Click here for more information on this project. Click here for more information on this project.

For more information on the Healthy Tomorrows Grant Program click here. For more information on this HTPCP project, please e-mail your name, address, telephone, and fax numbers with your specific request to healthyt@aap.org.

Texas participated in the National Initiative for Child Health Quality (NICHQ) Medical Home Learning Collaborative (October 2004 - September 2005)
The Medical Home Learning Collaborative was a 15-month project committed to helping primary care practices become accessible, family-centered, and provide care that is continuous, comprehensive, coordinated, compassionate, and culturally effective. A particular emphasis was placed on care coordination and family involvement in decision-making for children with special health care needs (CSHCN). Project Overview.

Genetics MCHB Grant: Abstract
Purpose: This cooperative agreement provides for a National Newborn Screening and Genetics Resource Center (NNSGRC) to: (1) provide a forum for interactions between the Genetic Services Branch (GSB) and others regarding policy initiatives and emerging issues in newborn screening (NBS) and genetics by enhancing timely, interactive communication and information sharing with key stakeholders (including community leaders, policy makers, consumers, health care professionals, government officials, and researchers); (2) provide consultation and technical assistance to GSB grantees and state and territory public health agencies in their NBS and genetics activities (including integrating genetic services into public health programs at the community level) through expert technical assistance teams and to provide consultative services on developing and implementing integrated data management for newborn and child health information; (3) implement a dissemination and education strategy for providing educational opportunities in NBS and genetics, particularly for the public health community; (4) standardize, maintain, and analyze quantitative information to monitor and evaluate the impact of State and Territory NBS programs; (5) support unique projects that translate genetic technological advances into public health practice; and (6) support activities to strengthen genetics planning at the State and local levels, including coordination of regional genetics networks information sharing and working with the Coalition of State Genetics Coordinators (CSGC).

Hemophilia MCHB Grant: Abstract
Purpose: The purpose of this project is to provide comprehensive care to any individual with a congenital bleeding disorder in the states of Arkansas, Louisiana, Oklahoma and Texas. This area is designated as Hemophilia Region VI by MCHB.

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.txpeds.org/
The Texas Pediatric Society, the Texas Chapter of the American Academy of Pediatrics, is a state professional nonprofit organization of 2,800 Texas pediatricians and 600 medical students. The goal of the Society is that all children in the State attain their full potential for physical, emotional, and social health.

American Academy of Family Physicians (AAFP) Chapter: www.tafp.org/
The Texas Academy of Family Physicians is a medical specialty organization dedicated to the delivery of quality health care made up of ten local chapters in the state.

Title V Children with Special Health Care Needs Program Information and Overview: www.dshs.state.tx.us/cshcn/default.shtm | CSHCN Inquiry Line: 1-800-252-8023

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: Gwen Lewis
Contact: Phone:(512) 458-7111 extension 2600 | Fax: (512) 458-7125
E-mail: gwen.lewis@dshs.state.tx.us

State Genetics Program: http://www.dshs.state.tx.us/genetics/default.shtm

Early Childhood Intervention/Part C Coordinator:
Early childhood Intervention (ECI) is a coordinated system of services available in every Texas county for families of children, birth through 2 years, with disabilities and developmental delays. ECI is federally
and state funded through the Individuals with Disabilities Education Act (IDEA.) The Division for Early Childhood Intervention Services is a division of the Department of Assistive and Rehabilitative Services.

Name: Kim Wedel, Assistant Commissioner
Texas Early Childhood Intervention Program
Department of Assistive and Rehabilitative Services
Contact: Phone: (512) 424-6754  | Fax: (512) 424-6749
Email: kim.wedel@dars.state.tx.us
Web Site: www.dars.state.tx.us/ecis/index.shtml

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: Dotty Goodman, 619 Contact, Texas Education Agency
Contact: Phone: (512) 463-9362 | Fax: (512) 463-9560 |
Email: Dotty.Goodman@tea.state.tx.us
Web Site: www.tea.state.tx.us/

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: Laura Logan Kender, ICC Chair
DEBT ECI Program
1628 19th Street
Lubbock, TX 79401-4895
Contact: Phone: (806) 766-1172 | Fax: (806) 766-1286
Email: lkender@lubbockisd.org
Web Site: http://www.dars.state.tx.us/ecis/advisorycommittee.shtml

Resources/Documents

The 2008 Texas Medicaid Provider Procedures Manual is now available. 
The 2008 CSHCN Services Program Provider Manual is now available

The Primary Care Medical Home for the Chronically Ill Child, April 2007
A powerpoint presentation delivered by Robert W. Warren, M.D., Ph.D., M.P.H. of the Texas Children’s Hospital, Houston, TX and Cynthia Lopez, M.D., F.A.A.P. Su Clinica Familiar, Harlingen, TX

Texas Medical Home Toolkit for Families Toolkit
Information for families on the concept of Medical Home and how to get one set up for your child or clients who have special health care needs. Includes:  information to take to my child’s doctor about the help I need from him/her, and information on how to provide support to families who would like to have a medical home.

Emergency Preparedness for Children with Special Needs
The Children with Special Health Care Needs (CSHCN) Services Program of the Texas Department of State Health Services recently published a bilingual booklet titled, “Emergency & Disaster Planning for Children with Special Health Care Needs".  Click here to download the booklet.
The booklet contains a bilingual Emergency Information Form for Children with Special Needs. The form was developed by the American Academy of Pediatrics and adapted by DSHS. The Emergency Information Form can also be downloaded for free from http://www.dshs.state.tx.us/cshcn/Newspage.shtm

Web-based Transitions Training for Case Managers Information
The Texas Department of State Health Services and the Center for Health Training created a web-based continuing education for case managers to learn more about transition to adulthood for young adults with health conditions or disabilities. Case managers will learn about:

• Why early planning for transition is important
• The stages of transition
• Who may need assistance with transition
• Health care transition and other transition issues such as education and independent living
• Resources in the state of Texas for transition

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.

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.

Developmental Surveillance and Screening Policy Implementation Project (D-PIP)
Midland Community Healthcre Services from Midland, TX is participating in the Developmental Surveillance and Screening Policy Implementation Project (D-PIP). The D-PIP has selected 17 practices from across the United States to implement the AAP policy statement (scheduled for publication in July 2006) “Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening” to 1) determine if the algorithm is efficiently and effectively implemented into pediatric practice; 2) recognize strategies for implementing the algorithm; and 3) examine outcomes of implementation. Following the project, information and outcomes will be shared with pediatric clinicians and other health care professionals who are seeking to improve the delivery of developmental surveillance and screening.

Click here for additional information on the D-PIP.

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

Texas Autism State Plan
Interagency Council on Autism and other Pervasive Developmental Disorders: The Interagency Council on Autism and Pervasive Developmental Disorders (Council) was established by legislation in 1987 that added Chapter 114 to the Human Resources Code. The Council is composed of seven public members who are family members of a person with autism or pervasive developmental disorder (PDD), appointed by the governor, and one representative from each of the following state agencies, appointed by the commissioner of the respective agency: Texas Department of Mental Health and Mental Retardation; Texas Department of Health; Texas Department of Human Services; Texas Education Agency; and Texas Rehabilitation Commission, and the Interagency Council on Early Childhood Intervention.
http://www.autismcouncil.org/stateplan/FY04_StatePlanForAutism.pdf

State Resources on the Internet

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.

Last Updated January 9, 2008