<p>National Standards for Systems of Care for CYSHCN: IN-DEPTH State Systems Assessment Tool for Community-Based Services and Supports</p><p>System Principles, Standards and Key Questions for Assessment of State Systems of Care for CYSHCN DOMAIN: COMMUNITY-BASED SERVICES AND SUPPORT </p><p>CYSHCN and their families are provided access to comprehensive and community-based supports, provided by their health plan and/or in partnership with other community agencies including family organizations, public health, education, Early Intervention (Part C), Special Education welfare, mental health, and home health care organizations.</p><p>State: ______Date: ______</p><p>Type of Agency Completing this Tool:  Title V State Medicaid  CHIP Health Plan/Insurer </p><p>Provider (please specify ______) Family/Consumer Other (please specify: ______) </p><p>When providing answers in this assessment tool, please do so from the perspective of the organization or system in which you work or are affiliated. </p><p>Column A Column B Column C Column D System Standards Within my organization, there are What agencies/entities in your Please rate your organization’s (Structure and Process) policies and procedures in place for state have the authority to authority to implement or improve this standard: implement and/or ensure this policies and procedures that support standard? (Check all that this standard. apply.) 1. Agreements are in place  Yes  Title V 0 None 1 Weak between the health systems and (IF YES) How effective are those  State Medicaid various community agencies policies and procedures? 2 Moderate  CHIP and programs serving CYSHCN 1 Not effective 3 Strong and are structured to: 2 Somewhat effective  Health Plan/Insurer o promote family 3 Very effective  Provider (please specify) support through linking families to family  Family/Consumer organizations and other OPTIONAL: services and supports  Other (please specify) Why?  No (Select “0” for score, above ) promote shared o  Not applicable to my organization financing</p><p> o establish systems for timely communications and appropriate data sharing </p><p> o ensure access and </p><p>1 National Standards for Systems of Care for CYSHCN: IN-DEPTH State Systems Assessment Tool</p><p> coordination of services for individual children and their families</p><p> o promote collaboration between community-based organizations and agencies, providers, health care systems, and families</p><p> o specify responsibilities across the Enter Score: various providers, and Enter Score: community-based agencies serving children and their families1 RESPITE CARE (as part of the community based services)</p><p>1. Respite services, both planned  Yes  Title V 0 None 1 Weak and emergency, are available to (IF YES) How effective are those  State Medicaid all families and caregivers of policies and procedures? 2 Moderate  CHIP CYSHCN. 1 Not effective 3 Strong 2 Somewhat effective  Health Plan/Insurer 3 Very effective  Provider (please specify) </p><p> Family/Consumer OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above )  Not applicable to my organization </p><p>Enter Score: Enter Score:</p><p>2 National Standards for Systems of Care for CYSHCN: IN-DEPTH State Systems Assessment Tool for Community-Based Services and Supports</p><p>2. Families are informed about  Yes  Title V 0 None 1 Weak available respite services and (IF YES) How effective are those  State Medicaid helped to access them. policies and procedures? 2 Moderate  CHIP 1 Not effective 3 Strong 2 Somewhat effective  Health Plan/Insurer 3 Very effective  Provider (please specify) </p><p> Family/Consumer OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above )  Not applicable to my organization </p><p>Enter Score: Enter Score: 3. When out-of-home respite  Yes  Title V 0 None 1 Weak services are needed, (IF YES) How effective are those  State Medicaid transportation is available to policies and procedures? 2 Moderate  CHIP help a child and family access 1 Not effective 3 Strong these services. 2 Somewhat effective  Health Plan/Insurer 3 Very effective  Provider (please specify) </p><p> Family/Consumer OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above )  Not applicable to my organization </p><p>Enter Score: Enter Score:</p><p>3 National Standards for Systems of Care for CYSHCN: IN-DEPTH State Systems Assessment Tool</p><p>4. Health providers and plans  Yes  Title V 0 None 1 Weak screen families and caregivers (IF YES) How effective are those  State Medicaid of CYSHCN for respite care policies and procedures? 2 Moderate  CHIP needs, make them aware of 1 Not effective 3 Strong available respite services in their 2 Somewhat effective  Health Plan/Insurer community, and provide them 3 Very effective  Provider (please specify) with appropriate and timely referrals to providers that are  Family/Consumer qualified to serve CYSHCN. OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above)  Not applicable to my organization </p><p>Enter Score: Enter Score: 5. Health providers and plans have  Yes  Title V 0 None 1 Weak a system in place for ensuring (IF YES) How effective are those  State Medicaid timely referrals for families of policies and procedures? 2 Moderate  CHIP CYSHCN with emergency respite 1 Not effective 3 Strong needs. 2 Somewhat effective  Health Plan/Insurer 3 Very effective  Provider (please specify) </p><p> Family/Consumer OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above)  Not applicable to my organization </p><p>Enter Score: Enter Score:</p><p>4 National Standards for Systems of Care for CYSHCN: IN-DEPTH State Systems Assessment Tool for Community-Based Services and Supports</p><p>PALLIATIVE AND HOSPICE CARE (as part of the community based services) 1. Curative and palliative care (also  Yes  Title V 0 None 1 Weak known as concurrent care) is (IF YES) How effective are those  State Medicaid available and offered at the policies and procedures? 2 Moderate  CHIP same time. 1 Not effective 3 Strong 2 Somewhat effective  Health Plan/Insurer 3 Very effective  Provider (please specify) </p><p> Family/Consumer OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above)  Not applicable to my organization </p><p>Enter Score: Enter Score: 5 National Standards for Systems of Care for CYSHCN: IN-DEPTH State Systems Assessment Tool</p><p>2. Palliative and hospice care  Yes  Title V 0 None 1 Weak utilizes family-centered models (IF YES) How effective are those  State Medicaid of care that respect individual’s policies and procedures? 2 Moderate  CHIP preferences, value, and cultural 1 Not effective 3 Strong beliefs, and provide family 2 Somewhat effective  Health Plan/Insurer access to psychosocial 3 Very effective  Provider (please specify) screening and referrals to needed supports and services.  Family/Consumer OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above )  Not applicable to my organization </p><p>Enter Score: Enter Score: 3. The child and family plays an  Yes  Title V 0 None 1 Weak active role in decision making (IF YES) How effective are those  State Medicaid regarding goals and plans of policies and procedures? 2 Moderate  CHIP care. 1 Not effective 3 Strong 2 Somewhat effective  Health Plan/Insurer 3 Very effective  Provider (please specify) </p><p> Family/Consumer OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above )  Not applicable to my organization </p><p>Enter Score: Enter Score: HOME-BASED SERVICES (as part of the community based services)</p><p>6 National Standards for Systems of Care for CYSHCN: IN-DEPTH State Systems Assessment Tool for Community-Based Services and Supports</p><p>1. Home health care is a covered  Yes  Title V 0 None 1 Weak benefit for CYSHCN that (IF YES) How effective are those  State Medicaid includes health care for the child policies and procedures? 2 Moderate  CHIP and supportive care for the 1 Not effective 3 Strong family, and is provided in the 2 Somewhat effective  Health Plan/Insurer family's home by licensed 3 Very effective  Provider (please specify) professionals who have experience in pediatric care.2  Family/Consumer OPTIONAL:  Other (please specify) Why?  No (Select “0” for score, above )  Not applicable to my organization </p><p>Enter Score: Enter Score: Effectiveness Indicator: Organizational Influence Indicator: SUMMARY: COMMUNITY-BASED SERVICES AND SUPPORT </p><p>Additional Notes:</p><p>7 National Standards for Systems of Care for CYSHCN: IN-DEPTH State Systems Assessment Tool</p><p>ENDNOTES:</p><p>8 1 See framework presented by Richard C. Antonelli (2012). “Integration for Children with Special Health Needs: Improving Outcomes and Managing Costs.”Presentation for the National Governors Association, July 12, 2012. Unpublished.</p><p>2Libby RC, Imaizumi SO. American Academy of Pediatrics, Committee on Child Health Financing, Section on Home Care. Policy Statement: Financing of Pediatric Home Health Care (Second Edition). Available at: http://pediatrics.aappublications.org/content/118/2/834.full.pdf. Updated 2009. Accessed October 2013.</p>