Services and IV. Youth, families, A. Transition support will be 1. CMSN will identify navigators to assist a. Percentage of youth Models of Care and providers will provided for youth, families, providers in the development of transition policy who receive transition have access to and providers. and establishing transition-specific medical support. Issue Narrative community-based homes related to the Six Core Elements of Transition from resources necessary healthcare transition for their practices b. Percentage of CMSN youth to adulthood to facilitate and (gottransition.org) and provide assistance with regional offices who have is a vulnerable achieve successful the care coordination process specific to transition navigators. stage in life, health care transition. transition assessments, care planning and especially for resources (Year 1-2). c. Percentage of CMSN CYSHCN. Often area offices who establish these adolescents 2. CMSN will provide an individualized, client a transition team. and young adults specific transition staffing for CMSN enrollees lose some or all of ages 18-21 using the existing multidisciplinary d. Increase in regional their health care staffing model that includes oversight by a coalition activity and services and regional transition physician (Year 2). outcomes. support when they transition from 3. Explore utilizing telehealth to provide e. Increase in use of pediatric to adult transition services when necessary (Year 2). telehealth to provide health care. As a transition services. result, their care is 4. Promote utilization of the FloridaHATS interrupted and Health Services Directory for Young f. Significant increases in their health may be Adults in Florida (Year 1). transition metrics on affected. Transition CMSN Satisfaction support is essential 5. Leverage the state Memorandum of Surveys. to navigating a new Agreement between CMSN and the Florida complex health Association of Community Health Centers to care system and establish community-based partnerships between other aspects of CMSN area offices and Federally Qualified adult life. Health Centers (Year 2). 6. Under the CMSN transition program, FloridaHATS will strengthen and continue to build regional transition coalitions throughout the state (Years 1-5).
Services and Models of Care Issue Narrative Transition from youth to adulthood is a vulnerable stage in life, especially for CYSHCN. Often these adolescents and young adults lose some or all of their health care services and support when they transition from pediatric to adult health care. As a result, their care is interrupted and their health may be affected. Transition support is essential to navigating a new complex health care system and other aspects of adult life. IV. Youth, families, and providers will have access to community-based resources necessary to facilitate and achieve successful health care transition. A. Transition support will be provided for youth, families, and providers. 1. CMSN will identify navigators to assist providers in the development of transition policy and establishing transition-specific medical homes related to the Six Core Elements of healthcare transition for their practices (gottransition.org) and provide assistance with the care coordination process specific to transition assessments, care planning and resources (Year 1-2). 2. CMSN will provide an individualized, client specific transition staffing for CMSN enrollees ages 18-21 using the existing multidisciplinary staffing model that includes oversight by a regional transition physician (Year 2). 3. Explore utilizing telehealth to provide transition services when necessary (Year 2). 4. Promote utilization of the FloridaHATS Health Services Directory for Young Adults in Florida (Year 1). 5. Leverage the state Memorandum of Agreement between CMSN and the Florida Association of Community Health Centers to establish community-based partnerships between CMSN area offices and Federally Qualified Health Centers (Year 2). 6. Under the CMSN transition program, FloridaHATS will strengthen and continue to build regional transition coalitions throughout the state (Years 1-5). a. Percentage of youth who receive transition support. b. Percentage of CMSN regional offices who have transition navigators. c. Percentage of CMSN area offices who establish a transition team. d. Increase in regional coalition activity and outcomes. e. Increase in use of telehealth to provide transition services. f. Significant increases in transition metrics on CMSN Satisfaction Surveys.
FINAL-Title-V-Medical-Transition-Strategic-Action-Plan-7-26-2016.docx