Screening efforts, results Yes Title V 0 None and referrals for further (IF YES) How effective are State Medicaid 1 Weak assessment are policies and procedures? CHIP 2 Moderate documented, relayed to the 1 Not effective Health Plan/Insurer 3 Strong child’s medical home and 2 Somewhat effective Provider (please specify) family, and, to the extent 3 Very effective Family/Consumer feasible, coordinated among (please specify) OPTIONAL: Why? all screening entities, including but not limited to clinical care settings, No (Enter for score, below.) “0” medical homes, child care Not applicable to my organization settings, and schools. Enter Score: Enter Score: Referral/Follow-up: Yes Title V 0 None Following a screening and (IF YES) How effective are those State Medicaid 1 Weak assessment, the CYSHCN policies and procedures? CHIP 2 Moderate and their family are referred 1 Not effective Health Plan/Insurer 3 Strong to needed services 2 Somewhat effective Provider (please specify) including pediatric 3 Very effective Family/Consumer specialists, therapies, other (please specify) OPTIONAL: service systems such as Why? Early Intervention, Special Education, family No (Enter for score, below.) “0” organizations and Not applicable to my organization community-based agencies, and follow-up is provided to ensure such referrals are completed. In turn, those services and systems should ensure follow-up to the child’s medical home Score: and other members of the Enter Score: child’s care team after referral visits.
Screening efforts, results and referrals for further assessment are documented, relayed to the child’s medical home and family, and, to the extent feasible, coordinated among all screening entities, including but not limited to clinical care settings, medical homes, child care settings, and schools. Yes (IF YES) How effective are 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 (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Enter Score: Referral/Follow-up: Following a screening and assessment, the CYSHCN and their family are referred to needed services including pediatric specialists, therapies, other service systems such as Early Intervention, Special Education, family organizations and community-based agencies, and follow-up is provided to ensure such referrals are completed. In turn, those services and systems should ensure follow-up to the child’s medical home and other members of the child’s care team after referral visits. 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 (please specify) 0 None 1 Weak 2 Moderate 3 Strong OPTIONAL: Why? Score:
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