Family strengths, including Yes Title V 0 None cultural and ethnic identities, 1 Weak (IF YES) How effective are those State Medicaid are respected in the delivery policies and procedures? CHIP 2 Moderate of care. 1 Not effective Health Plan/Insurer 3 Strong 2 Somewhat effective Provider (please specify) 3 Very effective Family/Consumer Other (please specify) OPTIONAL: Why? No for score, above ) (Select “0” Not applicable to my organization Enter Score: Enter Score: Care is delivered in culturally Yes Title V 0 None appropriate ways, respecting (IF YES) How effective are those State Medicaid 1 Weak family desires for inclusion policies and procedures? CHIP 2 Moderate of extended family members 1 Not effective Health Plan/Insurer 3 Strong in decision making. 2 Somewhat effective Provider (please specify) 3 Very effective Family/Consumer Other (please specify) OPTIONAL: Why? No for score, above) (Select “0” Not applicable to my organization Enter Score: Enter Score:
Family strengths, including cultural and ethnic identities, are respected in the delivery of care. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: Care is delivered in culturally appropriate ways, respecting family desires for inclusion of extended family members in decision making. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above) Not applicable to my organization Enter Score: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify) Family/Consumer Other (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: