1. Community Linkages, Referrals, & Referral Tracking CHIPRA CONNECT

2. AAP Defines Medical Home  Accessible  Family-Centered  Continuous  Comprehensive  Coordinated  Compassionate  Culturally competent

3. Children with Special Health Care Needs (CSHCN) Particular need for: Continuity – longitudinal relationship with Primary Care Provider (PCP) Communication – among PCP, specialists Collaboration - linkages to community resources Transition – planned process which starts early for youth; need for responsibilities for health care to shift as possible over time

4. Systemic Challenges oIntegration of Family-Centered Principles: e.g. continuity, comprehensiveness, coordination, cultural sensitivity. oFacilitation of networking between community resources that have historically been in “silos.” oPaucity of mental health services, especially for 0 – 5 year olds.

5. Systemic Challenges (cont.) oAdditional risks for children living in poverty or in foster care (continuity especially important). oLack of reimbursement for care coordination. oUninsured and underinsured. Many insurance/HMO plans have inadequate or deny coverage for services for CSHCN

6. Challenges for the Primary Care Practice Treating the “whole” child: in the context of the family, the school, the community. Adopting an Office Systems approach Operationalizing family feedback as part of the practice system Considering family needs as well as office needs for scheduling and logistics Enhanced processes for CSHCN: registries, scheduling tailored for longer visits, linkages to community resources, assistance with referrals

7. Challenges for the Primary Care Practice o“Knowing the system” of public and private providers locally oNetworking with community partners effectively oMaintaining continuity and communication with specialists, child care, school, …(Wraparound) oAssuring child and family role in care planning for a child/adolescent who has a chronic/complex condition

8. Referral, Community Linkages, and Feedback Relationships & Communication

9. Sustaining Change New kind of communication with community  Relationship with key partners  Networking to facilitate process beyond practice  Agreements on how to exchange information, e.g. standardized referral process/form

10. Establishing Relationships Invite community resource representative(s) to the practice for lunch & learn re processes for communication and referrals. Have periodic meetings with partners who provide “wraparound” services for patients and families. Have evening “mixer” for primary providers and community mental health providers to establish contacts. Compile contact information and identify staff to be the liaison for the practice.

11. Partner with Parents to Do Screening & Surveillance Important linkages for Medical Home: Head Start, Early Head Start, Child Care, Preschools, Schools Part C, Part B Childcare/school nurses CC4C Home visiting nurses Nurse-Family Partnership Family support Community mental health providers LME

12. Family Contributions Gather reviews from families regarding referral experiences Engage families in providing information about family resources they recommend Become familiar with family support program(s)

13. Tracking Referrals Tickler system: manual or electronic? Whose role? Reminders to families Standardized communication and feedback with specialists Communication processes with mental health providers and the LME ROI specifics for CDSA and schools