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. 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.

Findings from Oregon team’s CoIIN QI project presented at the Adolescent Health Initiative virtual meeting 2021.

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.

Part of a ‘new to program’ packet sent to new complex care program patients/families several weeks ahead of their first complex care program clinic visit.

A manual Word document that captures what parents identified as critical components of the shared plan of care. Team Minnesota considers this an ‘interim solution’ until an EMR-based application is built.

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. 

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. 

Part of a ‘new to program’ packet sent to new complex care program patients/families several weeks ahead of their first complex care program clinic visit.

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.

This document describes a family-centered goal-planning initiative, prior to the CMC CoIIN work. The learnings informed Team Minnesota’s work on the CoIIN.