CSHCS Strategic Planning Michigan Issues I. CSHCN Definition II. System of Care

CSHCS Strategic Planning
Michigan Issues
George Baker, MD
I. CSHCN Definition
II. System of Care
CSHCS Strategic Planning
CSHCN Definition
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
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•
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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 selfsupport.
• 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.
CSHCS $ Source FY 08
CSHCS FY08 Appropriation = $199,420,300
Fees & Collections,
$2,295,000
MCH Block Grant,
$8,890,800
Title XIX (Federal),
$90,555,100
General Fund (Michigan)
General Fund
(Michigan),
$97,679,400
Title XIX (Federal)
MCH Block Grant
Fees & Collections
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.
CSHCS Strategic Planning
System of Care
Title V Social Security Act
• (D) to provide and to promote familycentered, 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.
MANAGED CARE
SHPs
RESOURCES FOR PEDIATRIC
SPECIALTY CARE
Configuration of Regions
Region 10
Reg 9
8
5
7
Children’s Hospital
Pediatric Regional Center
Referring Hospital
2
4
1
6
January 2004
3
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
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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
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Regional Systems
Information Technology
Telemedicine
Epidemiologically sound database for
accountability
New Partners
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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.