1. Vermont Department of Health
Maternal and Child Health Division
Children with Special Health Needs
CoP Call October 2, 2013

2. New Definition for CSHN Eligibility Effective January 1, 2013
“CSHN serves those Vermont children and youth aged birth to 21, who have a chronic physical or developmental condition and who also require health and related services of a type or amount beyond that required by children generally.”

3. Infrastructure building
Re-envisioning CSHN: Moving down the MCHB pyramid – a sustainability model
Direct
care
services
Enabling
Population-based
Infrastructure building
child development clinic  craniofacial team  nutrition network  Physiatry
care coordination  resource & referral  respite  financial technical assistance  supplemental financial assistance (POLR)  Vermont Family Network family support programming  pediatric palliative care  children’s personal care  hi-tech nursing
newborn screening  system-wide educational materials on CSHN: transition, immunizations, environmental health  community-based integration  liaison to specialty care  birth information network
medical home capacity  performance-based contracting  CSHN specialty care certification  children’s health and support services  autism SIG  university autism center pilot  Medicaid advisory panel  systems integration w/ other state services (CIS & Blueprint)  IT integration

4. Children with Special Health Needs-Overview
Child Development Clinic
Care coordination
Medical Home pilot
Pediatric Hi-Tech
Personal Care (ADL Assistance)
Children’s Palliative Care
Cleft Palate Clinic
Rehabilitation Clinic
Respite
Financial Technical Assistance
Community Nutrition
Birth to age 21

5. Care Coordination: Integrating with a Statewide System of Care
Care Coordinators: SWs & RNs
Support and resource to families with CYSHN
Member of regional CIS team
Connected to (co-located in) PCP offices
Liaison to health system Specialty Clinic teams
Member of CSHN-hosted CDC team
Liaison to Blueprint Medical Home initiative
Co-located in Health Dept District offices
Children’s Integrated Services (CIS) is a statewide resource for pregnant or postpartum women and families with children from birth to age six and Includes: Early Intervention, Nursing & Family Support, and Children’s Mental Health
The Vermont Blueprint for Health (Medical Home initiative) is a vision, a plan, and a statewide partnership to improve health and the health care system for Vermonters. The goals are: 1) To implement a statewide system of care that enables Vermonters with, and at risk of, chronic disease to lead healthier lives; 2) To develop a system of care that is financially sustainable; and 3) To forge a public-private partnership to develop and sustain the new system of care.

6. Pediatric Collaborations in Chittenden County

7. Pediatric Hi-Tech Nursing
Previously overseen by the Department of Aging and Independent Living (DAIL)
Integrated into CSHN in January 2012, recognizing that most children were also enrolled with CSHN
Public-private partnership providing skilled nursing, durable medical equipment, and care coordination

8. Children’s Personal Care Services (CPCS)
Previously overseen by the Department of Aging and Independent Living (DAIL)
Provides direct assistance with Activities of Daily Living to Medicaid eligible children, under the age of 21
Serves approximately 2,000 children, statewide
Survey of participants found that 50% were also enrolled with CSHN
Integrated into CSHN in January, 2012

9. Pediatric Palliative Care Program
Part of the Chronic Care Initiative (DVHA)
Close partnership with CSHN Nursing and Social Work
Program eligibility:
Under age 21
Medicaid eligible
Diagnosed with life-limiting illness and not expected to live into adulthood
Services include:
Care coordination
Family training
Expressive therapy
Skilled in-home respite
Grief/bereavement counseling

10. Contact us: Steve Brooks – 802-865-1312 Carol Hassler – 802-865-1324
Carol Hassler –
Janet Kilburn –
CSHN – P.O. Box 70, Burlington, VT 05402