CSHCS Strategic Planning Michigan Issues George Baker, MD

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CSHCS Strategic PlanningMichigan IssuesGeorge
Baker, MD

• I. CSHCN Definition
• II. System of Care

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CSHCS Strategic Planning

• CSHCN Definition

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Federal Definition

• Children with special health care needs are
  those who have or are at increased risk for a
  chronic physical, developmental, behavioral, or
  emotional condition and who also require health
  and related services of a type or amount beyond
  that required by children generally.
• - The federal Maternal and Child Health Bureau
  (July 1998)
• - Definition adopted by AAP (October 1998)

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Michigan CSHCS

• Michigan CSHCS eligibility criteria for
  children and youth focuses almost exclusively on
  physical health conditions and services provided
  by pediatric subspecialists. ----WHY?

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Michigan Law PUBLIC HEALTH CODE Defines
Crippled Child

• (1) As used in this part, crippled child or
  child means a single or married individual
  under 21 years of age whose activity is or may
  become so restricted by disease or deformity as
  to reduce the individual's normal capacity for
  education and self-support.
• Sec 5801

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Program Purpose

• The program shall be carried out for the purposes
  of providing medical and physical care for
  crippled children and for making them
  self-sustaining in whole or in part rather than
  dependent on the public for support.

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Program Responsibilities

• The department shall establish and administer a
  program of services for crippled children and
  children who are suffering from conditions which
  lead to crippling.
• Make a determination of eligibility
• Sec. 5815

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CSHCS Chapter Medicaid Manual

• Criteria for approval of hospitals
• Criteria for approval of physicians
• Criteria for medical eligibility

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Criteria for Medical Eligibility

• Diagnosis
• Severity of Condition
• Chronicity of Condition
• Need for Treatment by a Physician Specialist

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Diagnosis

• The individual must have a CSHCS qualifying
  diagnosis where his activity is or may become so
  restricted by disease or deformity as to reduce
  his normal capacity for education and
  self-support.
• Psychiatric, emotional and behavioral disorders,
  attention deficit disorder, developmental delay,
  mental retardation, autism, or other mental
  health diagnoses are not conditions covered by
  the CSHCS Program.

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Severity of Condition

• The severity criteria is met when it is
  determined by the MDCH medical consultant that
  specialty medical care is needed to prevent,
  delay, or significantly reduce the risk of
  activity becoming so restricted by disease or
  deformity as to reduce the individuals normal
  capacity for education and self-support.

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Chronicity of Condition

• A condition is considered to be chronic when it
  is determined to require specialty medical care
  for not less than 12 months.

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Need for Treatment by a Physician Specialist

• The condition must require the services of a
  medical and/or surgical subspecialist at least
  annually, as opposed to being managed exclusively
  by a primary care physician.

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CSHCS Source FY 08
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Cooperate with the Feds

• (c) Cooperate with the federal government, under
  title V of the social security act, chapter 531,
  49 Stat. 620, 42 U.S.C. 701 to 716, through its
  appropriate agency or instrumentality, in
  developing, extending, and improving services,
  provided by this part and in the administration
  of the plans.

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Dilemma

• To meet MCHB expectations for coverage of CSHCN
  population, i.e., add developmental, behavioral,
  or emotional conditions, CSHCS would go beyond
  its legislative mandate.

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Recommendation

• As part of its MCH Block Grant activities MCH
  could establish a collaborative effort among
  CSHCS, mental health, NBS/Genetics, EHDI and
  others as identified, to develop a system of care
  for CSHCN.

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CSHCS Strategic Planning

• System of Care

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Title V Social Security Act

• (D) to provide and to promote family-centered,
  community-based, coordinated care (including care
  coordination services, as defined in subsection
  (b)(3)) for children with special health care
  needs and to facilitate the development of
  community-based systems of services for such
  children and their families

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Program Responsibilities

• The department shall establish and administer a
  program of services for crippled children and
  children who are suffering from conditions which
  lead to crippling.
• Sec. 5815

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CSHCS Now

• A statewide system of care to assure access to
  and to guide families to appropriate medical and
  surgical subspecialty services for children who
  meet CSHCS medical eligibility criteria. The
  system offers assistance in care coordination
  through multidisciplinary clinics and local
  health departments and family support through the
  Family Center.

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System of CareChallenge

• In a state of 10 million people with driving
  times ranging to 10 hours to subspecialty care,
  and major budgetary constraints
• Morph the system so it incorporates primary care
  to accomplish screening and care coordination in
  the medical home
• Broaden the system to meet the 6 objectives on
  behalf of the CSHCN population, not just those
  who are medically eligible for CSHCS.

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MANAGED CARE

• SHPs

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RESOURCES FOR PEDIATRIC SPECIALTY
CAREConfiguration of Regions
Region 10
Reg 9
8
5
7
Childrens Hospital
Pediatric Regional Center
Referring Hospital
2
4
1
6
3
January 2004
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(No Transcript)
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System of CareMedical Home

• The Medical Home Collaborative Team recommended
  that There will be a regionalized system of
  Medical Home support to recruit, train and mentor
  new Medical Home practices.

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CSHCS System of CareInfrastructure

• Approval of facilities, medical specialists,
  other providers.
• Regulation of the conduct of clinics
• Pediatric Regional Centers
• Childrens Multidisciplinary Clinics
• Medical Home Primary Care Practices
• Local Health Department Case Management Care
  Coordination
• Telemedicine reimbursement
• Family Support Network

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New Directions

• Cooperate with the Feds
• Pursue their GoalSystem of Care
• Pursue their objectives-the Six
• Reconcile CSHCN definition through partnerships
• Create a new organizational structure to replace
  the Special Health Plans
• Regional Systems
• Information Technology
• Telemedicine
• Epidemiologically sound database for
  accountability

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New Partners

• CSHCS,
• Medicaid, managed care
• Newborn Screening, Early Hearing Screening
• Genetics,
• Children's Mental Health,
• Early On and Special Ed,
• Emergency Medical Services for Children.
• MI Chapter American Academy of Pediatrics
• MAFP, Childrens Hospitals, Academic Departments
  Pediatrics and Family Medicine, MI Acad. Ped Dent
•  

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Childrens Special Health Care Services 2010

• A system of care for children with special health
  care needs with regionalized subspecialty and
  multidisciplinary services organized to support a
  regional system of practices qualified as medical
  homes for CSHCN, collaborating with local health
  to provide care coordination with a written plan
  of care.