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Transition for Youth with Special Health Care Needs: How Do We Get this Done?. Richard C. Antonelli, MD, MS Medical Home Advisor Healthy & Ready to Work National Resource Center Topical Call: May, 2008. What Are The Issues?. Capacity Training Communication Changing Roles of Youth

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Transition for youth with special health care needs how do we get this done

Transition for Youth with Special Health Care Needs: How Do We Get this Done?

Richard C. Antonelli, MD, MS

Medical Home Advisor

Healthy & Ready to Work

National Resource Center

Topical Call: May, 2008


What are the issues
What Are The Issues?

  • Capacity

  • Training

  • Communication

  • Changing Roles of Youth

  • Financing Mechanisms

  • Professional Culture and “Traditions”


Pediatric Model for YSHCN

Family

National

Family to Family

KASA

Youth

Pediatric

PCP

Community Based Partners

Title V

Vocational Rehabilitation

Avocation

Education

(K-12 & post secondary)

Pediatric

SP

Medical

Dental

Behavioral


Pediatric to Adult Systems of Care: Current

Family

Family to Family

KASA

Youth

Pediatric

PCP

Adult

PCP

Pediatric

SP

Medical

Dental

Behavioral

Adult

SP

Medical

Dental

Behavioral

Community Based Partners

Title V

Vocation

Avocation

Education


Pediatric to Adult Systems of Care: Possibilities

Family

Family to Family

KASA

Youth

Pediatric

PCP

Co-Management

Adult

PCP

Pediatric

SP

Medical

Dental

Behavioral

Adult

SP

Medical

Dental

Behavioral

Community Based Partners

Title V

Vocation

Avocation

Education


Strategies
Strategies

  • Outreach and Education

    • Youth, families, pediatric, and adult providers

    • Primary Care and Subspecialty

  • Advocacy

    - Title V and Other Policy Makers

    - Link with payers (incentives including P4P)


Remember these strategies
Remember These Strategies!!!!!

  • Encourage use of Care Plan Oversight CPT Codes

    • You can use administrative data to track progress and may lead to reimbursement

  • Remove Administrative and Financing Barriers for cross-specialty co-management

    • This will support education, capacity-building, and sustainability


The Ultimate Outcome: Transition to Adulthood

Richard C. Antonelli, MD, MS, FAAP

Medical Home & Transition

HRTW Medical Advisor

Chief, Division of Primary Care

Dept of General Pediatrics

Connecticut Children's Medical Center

Head, Division of Academic General Pediatrics

Univ of Conn, School of Medicine

[email protected]


Resources 01

HRSA/MCHB funded National Centers (6)

HEALTH & TRANSITION www.hrtw.org

Healthy & Ready to Work National Resource Center

2. MEDICAL HOME www.medicalhomeinfo.org

National Center on Medical Home Initiatives

3. FAMILY PARTNERSHIP www.familyvoices.org

National Center on Family and Professional Partnerships

Resources-01


Resources 02

HRSA/MCHB funded National Centers (6)

4. CULTURAL COMPETENCEhttp://www11.georgetown.edu/research/gucchd/nccc/

National Center for Cultural Competence

5. HEALTH INSURANCE http://www.hdwg.org/cc/

Catalyst Center – for Improving Financing of Care for CYSHCN

6. DATAwww.cshcndata.org

Data Resource Center National Survey for CSHCN

Resources-02


Resources 03

HEALTHY & READY TO WORKwww.hrtw.org

HRTW Portable Medical Summary - One page summary of health needs that youth or others can carry. Information contains medical history, current medication, name of health surrogate, health insurance numbers, contact information for treating doctors, pharmacy, home health and other vendors.

Understanding Health Insurance - Web links to Choosing a Plan, Paying for Care, Public Insurance, Private Insurance, Policy / Advocacy Centers and Insurance Regulations, Laws and Statutes.

Decisions & Making Choices - Web section contains information of Informed Decision Making, Assent-Consent, Guardianship, Living Wills and Advance Directives.

Resources - 03


Resources 04
Resources - 04

HRTW Portal - Laws that Affect CYSHCN

http://www.hrtw.org/tools/laws_leg.html

  • The Term Special Health Care Needs or Disability

  • Disability Rights Portals

  • Education Issues

  • Employment & Disability

  • Equal Opportunity Access (504, 508 & ADA)

  • Family Medical Leave Act

  • HRSA/MCHB – Title V Legislation

  • Health Insurance Benefits

  • SSI/SSDI


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