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)
Michigan CSHCS Michigan CSHCS eligibility criteria for children and youth focuses almost exclusively on physical health conditions and services provided by pediatric subspecialists. ----WHY?
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
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.
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
CSHCS Chapter Medicaid Manual Criteria for approval of hospitals Criteria for approval of physicians Criteria for medical eligibility
Criteria for Medical Eligibility Diagnosis Severity of Condition Chronicity of Condition Need for Treatment by a Physician Specialist
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.
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 individual’s normal capacity for education and self-support.
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.
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.
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.
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.
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.
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;
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
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.
System of Care Challenge 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.
System of Care Medical 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.”
CSHCS System of Care Infrastructure Approval of facilities, medical specialists, other providers. Regulation of the conduct of clinics Pediatric Regional Centers Children’s Multidisciplinary Clinics Medical Home Primary Care Practices Local Health Department Case Management & Care Coordination Telemedicine reimbursement Family Support Network
New Directions Cooperate with the Feds –Pursue their Goal—System 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
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, Children’s Hospitals, Academic Departments Pediatrics and Family Medicine, MI Acad. Ped Dent
Children’s 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.