The child’s health plan and Yes V 0 None medical home have a (IF YES) How effective are those State Medicaid 1 Weak documented plan and policies and procedures? CHIP 2 Moderate process to demonstrate how 1 Not effective Health Plan/Insurer 3 Strong they follow-up with a 2 Somewhat effective Provider (please specify) hospital or state health 3 Very effective Family/Consumer department when newborn Other (please specify) OPTIONAL: Why? screening results are not received. No (Enter for score, below.) “0” Not applicable to my organization Enter Score: Enter Score: All children, including Yes Title V 0 None CYSHCN, receive periodic, (IF YES) How effective are those State Medicaid 1 Weak developmentally appropriate, policies and procedures? CHIP 2 Moderate and recommended 1 Not effective Health Plan/Insurer 3 Strong comprehensive screenings 2 Somewhat effective Provider (please specify) (to include screening for 3 Very effective Family/Consumer physical health, oral health, Other (please specify) OPTIONAL: mental health, Why? developmental, and psychosocial needs, and No (Enter for score, below.) “0” cultural and linguistic needs, Not applicable to my organization preferences or limitations) as part of a well-child visit or other preventive visit and in response to triggering events such as hospitalization, trauma, or sudden onset of new Enter Score: symptoms, in accordance Enter Score: with Bright Futures Guidelines.
The child’s health plan and medical home have a documented plan and process to demonstrate how they follow-up with a hospital or state health department when newborn screening results are not received. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) Not applicable to my organization Enter Score: 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: All children, including CYSHCN, receive periodic, developmentally appropriate, and recommended comprehensive screenings (to include screening for physical health, oral health, mental health, developmental, and psychosocial needs, and cultural and linguistic needs, preferences or limitations) as part of a well-child visit or other preventive visit and in response to triggering events such as hospitalization, trauma, or sudden onset of new symptoms, in accordance with Bright Futures Guidelines. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Enter “0” for score, below.) 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:
1_Screening%20Assess%20Referl_In%20DepthFINAL.docx