CISWH Project Resources

The Shared Care Planning Handbook describes the process of creating a Shared Plan of Care, and is designed to be used alongside the Pediatric to Adult Care Transition workbook. 

This study aimed to explore the experiences of Oregon families of YAMC who had recently transitioned to adult health care providers, and obtain recommendations for transition from family members, to inform the development of the CoIIN quality improvement project.

AMCHP newsletter ‘Pulse’ interview 2021 of Oregon CoIIN Implementation team members.

Root Cause Analysis using CoIIN Environmental Scan findings.
The Oregon team created the following problem statement to focus its QI work: “Young adults with medical complexity (YAMC) and their families are not adequately prepared for, or supported in, the transition from pediatric to adult healthcare.” We used a fishbone diagram tool to guide a root cause analysis of our problem statement. A root cause analysis seeks to identify the primary reasons underlying a problem. The results of our analysis appear on page 1.

AMCHP 2019 presentation on creating meaningful settings to strengthen family involvement. – CMC CoIIN Team Oregon

State Medicaid programs are required to provide Medicaid enrollees under age 21 with comprehensive and preventive health care services through the Early Screening and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Federal law requires states to cover “medically necessary services” under the EPSDT benefit “whether or not such services are covered under the State plan.”  The federal statute does not define “medical necessity” but instead describes a broad standard for coverage. States can, therefore, establish their own parameters for medical necessity decisions so long as those parameters are not more restrictive than the federal statute. In March 2021, with support from the Catalyst Center, The National Academy for State Health Policy (NASHP) conducted a 50-state scan of medical necessity definitions used by state Medicaid programs for their EPSDT benefit, updating a previous scan conducted in 2013. This resource presents definitions of medical necessity from all 50 states and the District of Columbia.

States are increasingly interested in care coordination as a strategy for improving systems of care for children with medical complexity (CMC) and their families. The Section 2703 Medicaid Health Home State Option and the new Advancing Care for Exceptional (ACE) Kids Act Health Home State Option present opportunities to enhance and expand care coordination for CMC in Medicaid. This new brief compares the two approaches and presents key considerations for states as they explore implementing health home options. Additionally, the brief presents New York as a case study in implementing the Section 2703 Medicaid Health Home State Option to provide care coordination for CMC. 

Employment and economic self-sufficiency play a key role in health. With the effectiveness of early antiretroviral treatment (ART), many people with HIV can (and do) participate in the country’s workforce. When community-based organizations, HIV/AIDS service organizations, and health care centers provide employment services to their clients, a thoughtful approach is required to address the potential barriers to employment on the individual, organizational, and structural levels. POWER (Pursuing Opportunities with Employment & Resources) is an innovative intervention developed in New Haven, CT, based on the job club model. It seeks to bridge the gap between barriers and employment through peer support and community partnerships to prepare participants for success. Learn how Liberty Community Services, Inc. successfully integrated employment into their existing services through the POWER intervention. 

Learn strategies to help Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS Program clients during the COVID-19 pandemic. These approaches are applicable today and many have broader application for hard-to-reach populations in need of social support services during times of uncertainty. Topics include food insecurity, telehealth, medication access, and more. 

This issue brief, written in partnership with the National Academy for State Health Policy (NASHP), describes how states define CYSHCN within Medicaid and Title V CYSHCN programs and explores the implications of these definitions. Federal and state program approaches to defining children and youth with special health care needs (CYSHCN) can impact how they determine eligibility for health care services and supports (e.g., care coordination), evaluate the impact of services, and measure outcomes.  The brief presents an analysis of data gathered through administrative and interview data from seven states (AZ, FL, NY, OH, OR, UT, and VA), and presents state considerations for establishing and implementing definitions of CYSHCN.