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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?
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
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.
CYSHCN are about 16% of the population and account for 80% of pediatric health care expenditure
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
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
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
Potential problems I encounter?
Potential stressful scenarios:
Family with a CYSHCN Family with financial/other stress Abusive relationship
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
What else can we do?
Refer child and family to therapy
Crisis Management ServicesChild AdvocacyMental Health CounselingSocial Skills/Mentoring/RecreationParent Education ProgramParent Support Groups Camps
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
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
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
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
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
PreventionHow?
Prevention-Medical HomeChildhood Blueprint 0-8 years
Organized delivery of care to help those at-risk rather than wait for them to be diabetic or school failures
CYSHCN Childhood obesityAsthma Mental HealthReading Dental care
Obesity effort in Stamford
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
What do we strive for?
Financial independence Positive peer group and relationships Independent living Transition helps youth achieve a
meaningful productive life
Medical Home Initiative
Southwest Region
1351 Washington Boulevard4th Floor
Stamford, CT
203-276-7552