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Community Linkages, Referrals,Referral Tracking

CHIPRA

CONNECT

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AAP Defines Medical HomeAccessible

Family-Centered

Continuous

Comprehensive

Coordinated

CompassionateCulturally competent

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Children with Special HealthCare Needs (CSHCN)Particular need for:

Continuitylongitudinal relationship with

Primary Care Provider (PCP)

Communicationamong PCP, specialists

Collaboration - linkages to community resources

Transitionplanned process which starts early

for youth; need for responsibilities for health careto shift as possible over time

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Systemic Challengeso Integration of Family-Centered Principles: e.g.

continuity, comprehensiveness, coordination,cultural sensitivity.

o Facilitation of networking betweencommunity resources that have historicallybeen in silos.

o Paucity of mental health services, especiallyfor 05 year olds.

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Systemic Challenges (cont.)o Additional risks for children living in poverty or

in foster care (continuity especiallyimportant).

o Lack of reimbursement for care coordination.

o Uninsured and underinsured. Manyinsurance/HMO plans have inadequate or

deny coverage for services for CSHCN

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Challenges for thePrimary Care Practice Treating the whole child: in the context of the

family, the school, the community.

Adopting an Office Systems approach Operationalizing family feedback as part of the

practice system

Considering family needs as well as office needs for

scheduling and logistics

Enhanced processes for CSHCN: registries, schedulingtailored for longer visits, linkages to communityresources, assistance with referrals

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Challenges for thePrimary Care Practiceo Knowing the system of public and private

providers locally

o Networking with community partners effectively

o Maintaining continuity and communication withspecialists, child care, school, (Wraparound)

o Assuring child and family role in care planning for a

child/adolescent who has a chronic/complexcondition

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Referral, Community Linkages,and Feedback

Relationships

&Communication

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Sustaining ChangeNew kind of communication with community

Relationship with key partners Networking to facilitate process beyond practice

Agreements on how to exchange information, e.g.

standardized referral process/form

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Establishing Relationships Invite community resource representative(s) to

the practice for lunch & learn re processes forcommunication and referrals.

Have periodic meetings with partners whoprovide wraparound services for patients andfamilies.

Have evening mixer for primary providers andcommunity mental health providers to establish

contacts. Compile contact information and identify staff to

be the liaison for the practice.

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Partner with Parents to DoScreening SurveillanceImportant linkages for Medical Home: Head Start, Early Head Start, Child Care, Preschools,

Schools Part C, Part B

Childcare/school nurses CC4C Home visiting nurses Nurse-Family Partnership Family support Community mental

health providers LME

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Family Contributions Gather reviews from families regarding

referral experiences

Engage families in providing information

about family resources they recommend

Become familiar with family support

program(s)

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Tracking Referrals Tickler system: manual or electronic?

Whose role?

Reminders to families Standardized communication and feedback

with specialists

Communication processes with mental healthproviders and the LME

ROI specifics for CDSA and schools