Why Shared Plans of Care Are Critical to Coordinated Care and How States Are Implementing Them
This blog and the issue brief describe how states are using Shared Plans of Care to improve care coordination for children, particularly those with special health care needs.
Structuring Care Coordination Services for Children and Youth with Special Health Care Needs in Medicaid Managed Care: Lessons from Six States
State Medicaid agencies are strengthening care coordination programs as part of their health care delivery transformation efforts to improve health care quality and outcomes and reduce costs. States are increasingly enrolling CYSHCN into their Medicaid managed care delivery systems. As this shift occurs, it is critical to identify how managed care systems provide effective care coordination to CYSHCN.
Physical and Behavioral Health Integration: State Policy Approaches to Support Key Infrastructure
NASHP reviewed emerging areas of consensus in what makes for a successful integrated care model and highlights how leading states have supported infrastructure development using diverse policy strategies
Integrating Maternal and Child Health Data Systems
This blog and report describes information from state officials in Illinois, New Jersey, Rhode Island, and Utah–and a state contractor in Connecticut— in their experiences integrating maternal and child health data systems.
Improving Care Coordination, Case Management, and Linkages to Service for Young Children: Opportunities for States
States can use primary care practice-based strategies, service provider linkage strategies, and systems change and cross-system strategies to improve linkages to services for young children. This paper uses a framework that illustrates the various roles that states can play to facilitate and support improved linkages: 1) maximizing the use of personnel; 2) undertaking quality improvement initiatives; 3) supporting data, information and technology; and 4) supporting individualized care plans and cross systems planning.
Improving Care Coordination and Service Linkages to Support Healthy Child Development: Early Lessons and Recommendations from a Five-State Consortium
This report summarizes early findings from the current Assuring Better Child Health and Development (ABCD III) learning collaborative of five states. Arkansas, Illinois, Minnesota, Oklahoma, and Oregon are testing models to strengthen linkages and care coordination between pediatric primary care providers and community-based providers of early intervention, mental health, public health, and early care and education services. The states’ early experiences piloting communication tools, facilitating data sharing, implementing quality improvement processes, and involving families are relevant for efforts to engage multi-sector stakeholders to improve state policy, primary care practice, and population health.
Policies for Care Coordination Across Systems: Lessons from ABCD III
How can states help primary care providers (PCPs) and community service providers coordinate care? In NASHP’s third Assuring Better Child Health and Development learning collaborative (ABCD III), five state teams (AR, IL, OK, OR, and MN) have piloted projects to systematize care coordination between PCPs of young children with potential developmental delay and community providers, particularly early intervention services. Drawing on eleven years of ABCD experience, these state teams offer model policies and protocols to implement cross-system care coordination.
Improving the Lives of Young Children: Opportunities for Care Coordination and Case Management for Children Receiving Services for Developmental Delay
This brief examines states’ Medicaid and CHIP policy choices and new opportunities under health reform and other federal legislation to develop a well-coordinated system of care for children receiving Early Intervention and other ongoing services. State examples in the paper draw significantly from ABCD III.
Care Coordination and Linkages to Services
Building on previous ABCD efforts, these projects will seek to identify existing assessment and treatment resources, remove policy barriers to accessing those services, and facilitate referrals to these resources. States play an important role in removing barriers and providing support as communities move toward more integrated services. This section focuses on resources designed to assist states working to address the health and developmental needs of children and families.
50-State Chart of Medicaid Policies on Maternal Depression Screening during Well-Child Visits
Thirty-six states recommend, require, or allow maternal depression screening during well-child visits and 11 states capture positive and negative screens using modifiers or codes. These policies recognize the interdependent relationship between the health of mothers and children by providing families with necessary resources that support the health of mothers and their children’s’ healthy development.
State Strategies for Shared Plans of Care to Improve Care Coordination for Children and Youth with Special Health Care Needs
The issue brief identifies approaches and strategies states can use to promote the use of shared plans of care (SPoC) as part of care coordination. It also features case studies showcasing how Iowa, Oregon, Utah, and West Virginia are implementing SPoC for CYSHCN.
Measuring and Improving Care Coordination: Lessons from ABCD III
As states and providers move away from siloed health care systems and toward integrated systems of care, care coordination has become a key area of focus. Through the Assuring Better Child Health and Development (ABCD) III initiative, Arkansas, Illinois, Minnesota, Oklahoma and Oregon piloted and evaluated strategies to improve care coordination among primary care providers and community service providers serving Medicaid-eligible children, aged birth to three with or at risk of developmental delays. This report describes states’ evaluation methods, summarizes the results, and highlights lessons learned about evaluating care coordination.
Supporting Healthy Child Development through Medical Homes: Strategies from ABCD III States
Through Assuring Better Child Health and Development (ABCD) III, Arkansas, Illinois, Minnesota, Oklahoma, and Oregon have developed and tested models to improve care coordination for children with or at risk of developmental delay. The medical home has been a key mechanism in their improvement efforts. This brief draws from these states’ experiences to outline opportunities and lessons for state policy makers to consider in order to strengthen medical home initiatives by explicitly addressing the needs of children.
Policies for Care Coordination Across Systems: Lessons from ABCD III
How can states help primary care providers (PCPs) and community service providers coordinate care? In NASHP’s third Assuring Better Child Health and Development learning collaborative (ABCD III), five state teams (AR, IL, OK, OR, and MN) have piloted projects to systematize care coordination between PCPs of young children with potential developmental delay and community providers, particularly early intervention services. Drawing on eleven years of ABCD experience, these state teams offer model policies and protocols to implement cross-system care coordination.
Engaging Parents as Partners to Support Early Child Health and Development
Ensuring and coordinating services that support young children’s healthy development requires strong and effective partnerships between families and health care providers. This brief puts forth a three-part framework for engaging parents in supporting healthy child development: parents engaging with: 1) their child, 2) the services and programs they receive, and 3) the larger systems and policies that govern those services. It describes each level of engagement, explains why each is critical to improving care coordination and services for young children, and gives examples of how states can incorporate parent partnerships into their work. The framework represents a dynamic structure in which the three types of partnership support and inform each other.
State Strategies for Care Coordination, Case Management, and Linkages for Young Children: A Scan of State Medicaid. Title V, And Part C Agencies
NASHP conducted this scan of states in order to better identify and understand what states are doing through variously funded early child health and development agencies to promote better care coordination, case management, and linkages to services for young children. The scan was designed to elicit strategies used by the three state agencies to improve healthcare and community linkages in three areas: within primary care practices; between primary care practices and other child and family service providers; and through systems or statewide strategies. This paper describes state models that may help policy makers become more aware of the potential resources and tools available to promote healthy development for young children and can provide states with strategies to more effectively coordinate resources and achieve better outcomes for their children.
National Standards for Systems of Care for Children and Youth with Special Health Care Needs Version 2.0
The National Standards for Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN) define the core components of a comprehensive, coordinated, and family-centered system of care for CYSHCN. Since its release in 2014, many Medicaid and Children’s Health Insurance Program (CHIP) agencies, other government programs, health care systems, consumers, and others have used these standards as guideposts to improve systems of care for CYSHCN in an ever-changing health care landscape.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
