CHW National Library

The transition workbook includes information about 1) Introduction to the Medical Home; 2) Discussion of Medical Conditions and Medications; and 3) Transferring Care to use as a resource and workbook with the primary care provider on an ongoing basis during transition preparation, and to support a new patient visit with an adult primary care physician.

The Collaborative Improvement and Innovation Network to Advance Care for Children with Medical Complexity (CMC CoIIN) had the unique opportunity to study the experiences of health care providers and families of CMC in 2020 as care delivery quickly transitioned to telehealth. Now, as in-person services have returned, reflecting on what we have learned can help shape the future of telehealth for CMC.

This package includes:

1. A short podcast interview with the Kentucky CMC CoIIN Team about their experience expanding telehealth during the COVID-19 shut down and the benefits of telehealth for children and families they serve.
   1. Podcast Producer/Host: Candace Jarzombek, Graduate Research Fellow
   2. Featuring:
      1. Donna Croslin, Nurse Administrator
      2. Davenna Bales, Nurse Administrator
      3. Sondra Gilbert, Director, Family 2 Family Information Center & Parent Consultant

The infographics share the experiences of families in the CMC CoIIN focus groups related to the impact of COVID-19 on their child and family and the benefits and challenges of telehealth. 

Panelists from the 10 CMC CoIIN state teams reflect on their learnings from their quality improvement projects in an interactive panel conversation. 

National Care Coordination Academy teams presented their project’s goals, accomplishments, challenges, and next steps in this final meeting.

A brief look at the benefits of Peer Family Navigation, who may support building it in the community and potential costs.

Reflections on barriers observed for families of color, with cultural and language differences, and ways to mitigate the disparities in care observed based on the interventions tried.

This paper introduces a number of existing Medicaid policy instruments and explains how to use them more effectively for programs and providers dedicated to serving CMC. Because Medicaid programs are so variable across the nation, we also provide a diagnostic approach to understanding each state’s Medicaid policy and service delivery system environment. Finally, we offer strategies of different scale to demonstrate how to change policy incrementally from the targeted to transformative.

The federal Advancing Care for Exceptional (ACE) Kids Act became law in 2019 and aims to provide access to a high quality, well-coordinated system of care for children with medical complexity (CMC) and their families. This policy brief describes the background on the need for the ACE Kids legislation and outlines three benefits for states that choose to implement it. We focus on patient-centered health home models of care coordination with a comprehensive care plan that addresses all service needs.

This brief presents evidence on the cost effectiveness of comprehensive service delivery models to improve care for children with medical complexity (CMC) and describes the unique challenges in cost effectiveness evaluations for this population. It also points to Medicaid policy opportunities that provide financial support for a developmental period, whether focused on model development or systems building expansion. This information is offered as a resource to help make the financial case for further development and expansion of service delivery models for CMC.