CYSHCN will be identified Care team Identification of and a data base will be Tool to identify, follow and documentation i.e as an population of established to adequately collect outcome data on activity log, or Care CYSCHN report activities affecting CYSHCN Coordination health outcomes Measurement Tool Costs of care Reduced emergency Baseline of emergency or Activity log, or Care department visits urgent care usage Coordination Increase in measures of health % decrease in usage of Measurement Tool emergency or urgent care Function(addressing Ease of access to Baseline Family Reports Patient, family, PCP, the improved resource information (CMHI Family Survey) and specialist report function of the CYSHCN or the Achieve % Increase in family and Patient, family, PCP, family of management skills professional access to and specialist report CYSHCN) information about resources Care plans Enhance Functional assessments communication among % Increase in documentation Standardized screening providers, family, of care plan or medical community partners summary use establish baseline Family report, plan and compare % increase in any report, school reports. Increase functional of following: abilities improved functional Center for Medical assessment, increase in and Home Improvement Support achievement number of care developed survey tools ( see links of optimal and shared; improved school and resource page the developmental attendance and or school AAP file has examples) trajectory success; improved ability to perform activities of daily living. Additional examples of strategies that grantees may undertake to influence change may include:
Identification of population of CYSCHN Tool to identify, follow and collect outcome data on CYSHCN CYSHCN will be identified and a data base will be established to adequately report activities affecting health outcomes Care team documentation i.e as an activity log, or Care Coordination Measurement Tool Costs of care Reduced emergency department visits Increase in measures of health Baseline of emergency or urgent care usage % decrease in usage of emergency or urgent care Activity log, or Care Coordination Measurement Tool Function(addressing the improved function of the CYSHCN or the family of CYSHCN) Ease of access to resource information Achieve skills Enhance communication among providers, family, community partners Increase functional abilities Support achievement of optimal developmental trajectory Baseline Family Reports (CMHI Family Survey) % Increase in family and professional access to information about resources % Increase in documentation of care plan or medical summary use establish baseline and compare % increase in any of following: improved functional assessment, increase in and number of care developed and shared; improved school attendance and or school success; improved ability to perform activities of daily living. Patient, family, PCP, and specialist report Patient, family, PCP, and specialist report Care plans Functional assessments Standardized screening Family report, plan report, school reports. Center for Medical Home Improvement survey tools ( see links and resource page the AAP file has examples) Additional examples of strategies that grantees may undertake to influence change may include: management
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