Regardless of the entity Yes Title V 0 None conducting a screening and (IF YES) How effective are those State Medicaid 1 Weak referral, protocols and policies and procedures? CHIP 2 Moderate documentation methods are 1 Not effective Health Plan/Insurer 3 Strong in place for the primary care 2 Somewhat effective Provider (please specify) provider, medical home or 3 Very effective Family/Consumer other such entity to Other (please specify) OPTIONAL: Why? with the child and family in areas including: assessment of follow-up No (Enter for score, below.) “0” received, barriers to care, Not applicable to my organization and, where feasible, assistance in addressing barriers to obtaining needed follow-up. Enter Score: Enter Score: Effectiveness Indicator: Organizational Influence Indicator: SUMMARY: SCREENING, ASSESSMENT and REFERRAL Additional Notes: ENDNOTES:
Regardless of the entity conducting a screening and referral, protocols and documentation methods are in place for the primary care provider, medical home or other such entity to with the child and family in areas including: assessment of follow-up received, barriers to care, and, where feasible, assistance in addressing barriers to obtaining needed follow-up. 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: SUMMARY: SCREENING, ASSESSMENT and REFERRAL Effectiveness Indicator: Organizational Influence Indicator: Additional Notes: ENDNOTES:
1_Screening%20Assess%20Referl_In%20DepthFINAL.docx