1. What can we do for the Maltreated Child or child at-risk?  Can we Try to prevent this?  Who can help?  How do they help?

2. Who are Children with Special Healthcare Needs?  Children and Youth with Special Health care Needs (CYSHCN) those who have or are at increased risk for a chronic physical, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally

3. Medical Home Initiative Southwest CT Medical home is an approach to providing health care services in a high quality, comprehensive, coordinated, continuous, compassionate and cost-effective manner.

4. CYSHCN are about 16% of the population and account for 80% of pediatric health care expenditure

5. How does Medical Home (MH) help? MH has trained coordinators who understand the child and family’s needs Coordinators are aware of the existing services in the community They know how to procure resources

6. Who decides what is required? Plan of care is developed by the Physician/Advocate, Youth and the family. It is shared by the other providers involved in the care of the patient. Care among multiple providers is coordinated Families are linked to support services and advocacy groups. Transition of care is planned

7. How does a Coordinator help?  Coordinator will attempt to: Recognize such situations Try to prevent it from happening Seek professional help Seek solutions for the family Reach family support networks

8. Potential problems I encounter?  Potential stressful scenarios: Family with a CYSHCN Family with financial/other stress Abusive relationship

9. How will the coordinator relieve stress? Seek solutions for the family’s stresses Find an after school program/mentor Find camps Work with connecting with DVCC Help mother out of a stressful situation if possible Parenting classes Introduce to support group

10. What else can we do?  Refer child and family to therapy Crisis Management Services Child Advocacy Mental Health Counseling Social Skills/Mentoring/Recreation Parent Education Program Parent Support Groups Camps

11. How else can a coordinator help? Help with insurance Connect children to specialists Help connect patients with Child Guidance, Birth to three, School personnel Contact Social Service agencies Apply for Respite/Extended care funds Educate families about their rights Transition of youth

12. Who is part of the Medical Home?  Medical Home Team Primary care provider Family Child/Youth Pediatric office staff Pediatric specialists Allied health care professionals Community organizations/Schools

13. Tools of Medical Home Release Screener – 5 questions address the need for additional services or treatment (Title V) Complexity Index – how much assistance does the child need regardless of the diagnosis Portable Health Care Plan Directions Manual

14. Case Study -Physician needs help  Autism 10 year old boy demands excessive attention Dad walks out Physically hurts 8 years sister who breaks her arm A year later child dies with viral cardiomyopathy Mom and sister deeply distressed left alone

15. Case Study -Physician needs help  KIDS in Crisis Obese-raised by GM GM obese, hypertensive, diabetic with arthritis Child craves approval Mom does jail time for drug usage  Mother disgusted with obesity, inactive child- slob  Dad: Pizza/coke/movie

16. Prevention How?

17. Prevention-Medical Home Childhood Blueprint 0-8 years Organized delivery of care to help those at-risk rather than wait for them to be diabetic or school failures CYSHCNChildhood obesity AsthmaMental Health ReadingDental care

18. Obesity effort in Stamford Stamford Hospital Stamford Youth Foundation Community Centers Childcare Learning Centers Stamford Schools Stamford Tables Community Gardens Cooking classes Department of Health

19. The YSCHN is growing up? What now? Barriers and challenges abound Frustration mounts Parents worry Adults providers clueless of past and challenges Youth need services to help cross this bridge to adulthood

20. What do we strive for? Financial independence Positive peer group and relationships Independent living Transition helps youth achieve a meaningful productive life

21. Medical Home Initiative Southwest Region 1351 Washington Boulevard 4 th Floor Stamford, CT 203-276-7552