Shared Plans of Care for Children and Youth with Special Healthcare Needs
Setting: Clinical Community
Population: CYSHCN Families & Caregivers Medical & Public Health Professionals
Topic Area: Family & Youth Engagement Care Coordination
The Colorado Department of Public Health’s Title V program partners with Local Public Health Agencies to provide care coordination to children and youth with special health care needs (birth-21 years) and their families. The statewide care coordination program is called HCP - A Program for Children and Youth with Special Health Care Needs (CYSHCN). On average, the program provides care coordination to about 1,100 children, 74% of whom are eligible for Medicaid. In addition, Colorado has a Medicaid Managed Care System and contractors (Regional Accountable Entities or RAEs) are responsible for ensuring the members in their geographic area have access to a medical home and are paid per member / per month to provide members with short term, episodic, care coordination services. The Title V Medical Home priority has focused on the policy and system level coordination across the Title V-funded care coordination program (HCP) and the care coordination being provided by the RAEs (with a focus on CYSHCN). One key area of improvement identified through efforts to coordinate across systems is the need for a shared plan of care to reduce duplication of services, align priorities in the care plan with the families’ capacity, and strengthen communication across other services provided to the family. In 2013, Colorado was the recipient of a D-70 grant that focused on strengthening and integrating systems of care for CYSHCN. Colorado’s Title V team leveraged the Medical Home priority policy strategies in the state action plan together with the D-70 grant implementation plans, to focus on creating a process for sharing care plans for CYSHCN across local public health, the RAEs, and Children’s Hospital Colorado. The HCP program policy was revised to read: “Local Public Health Agencies implementing the HCP model of care coordination will jointly develop a care plan with the family and share the plan with the family and at least one other member of the health care team.” While HCP had an existing program policy to share a printed copy of the care plan that was developed with the family, the care plan was not being shared with community partners who were also providing support to the family around goals in the care plan.
Back to Database