System Principles, Standards and Key Questions for Assessment of Systems of Care for CYSHCN DOMAIN: SCREENING, ASSESSMENT, AND REFERRAL Children are screened early and continuously for special health care needs. ___________________________________ Date: _____________________ Type of Agency Completing this Tool: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify _________) Family/Consumer Other (please specify: _____________________________) 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. 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 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.) Screening and Assessment: Yes Title V 0 None Upon enrollment and (IF YES) How effective are those State Medicaid 1 Weak transfer between insurance policies and procedures? CHIP 2 Moderate coverage (e.g., public and 1 Not effective Health Plan/Insurer 3 Strong private), a consistent and 2 Somewhat effective Provider (please specify) culturally and linguistically 3 Very effective Family/Consumer appropriate mechanism for Other (please specify) OPTIONAL: identifying CYSHCN, Why? including children with significant health conditions, No (Enter for score, below.) “0” is in place to ensure that Not applicable to my organization these children are referred to appropriate types and sources of enhanced care. Enter Score: Enter Score:
System Principles, Standards and Key Questions for Assessment of Systems of Care for CYSHCN DOMAIN: SCREENING, ASSESSMENT, AND REFERRAL Children are screened early and continuously for special health care needs. ___________________________________ Date: _____________________ Type of Agency Completing this Tool: Title V State Medicaid CHIP Health Plan/Insurer Provider (please specify _________) Family/Consumer Other (please specify: _____________________________) 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. Column A System Standards (Structure and Process) Column B Within my organization, there are policies and procedures in place for this standard: Column C What agencies/entities in your have the authority to implement and/or ensure this standard? (Check all that apply.) Column D Please rate your organization’s authority to implement or improve policies and procedures that support this standard. Screening and Assessment: Upon enrollment and transfer between insurance coverage (e.g., public and private), a consistent and culturally and linguistically appropriate mechanism for identifying CYSHCN, including children with significant health conditions, is in place to ensure that these children are referred to appropriate types and sources of enhanced care. 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