The Maryland Title V CSHCN Program (OGCSHCN) and Parents’ Place of Maryland (PPMD) are partnering with and the Maryland Chapter of the American Academy of Pediatrics to implement strategies to achieve integrated, community-based systems of care for children and youth with special health care needs (CYSHCN) and their families. This includes providing statewide leadership in creating the needed infrastructure and processes to involve all key stakeholders in creating a shared vision and strategic plan for action across the state. Special focus is being given to service system elements of medical home, early and continuous screening, and planning and services to facilitate transition of care from pediatric to adult medicine for young people with special health needs.
A broad alliance of concerned stakeholders — the Community of Care (COC) Consortium — is involved in shared planning, implementation and evaluation. The COC Consortium will oversee and spread the use of evidence-based and best practice strategies both at the state and local levels, using mini-grants to support implementation. In addition, the project will engage medical homes, families/youth, and community partners in quality improvement efforts to improve systems of care at both the practice and community levels. This project will support Learning Collaboratives in diverse communities; provide regional training in developmental screening and referral; and support strategies to promote health care transition within existing programs/processes for young people with special health needs. Family-professional partnerships, youth involvement, and cultural competency will be incorporated within practices and systems.
The WCHPC also is a partner in this effort, with responsibility for designing and conducting the outcomes evaluation of the project. The scope and intensity of partnerships, service integration, and implementation of core outcomes of a family-centered system of care (family-professional partnerships, medical home, adequate insurance, early and continuous screening, community-based services, transition) are the elements that form the basis of the outcomes evaluation. These outcomes will be measured from the perspectives of families, youth, public agencies, community organizations, and pediatric providers. Baseline data collection is occurring in 2008-09, with follow-up data collection and reporting in 2011.
Holly Grason and Cynthia Minkovitz are the WCHPC Faculty Investigators.