Promote an integrated, Yes Title V 0 None based model of care 1 Weak (IF YES) How effective are those State Medicaid coordination. policies and procedures? CHIP 2 Moderate 1 Not effective Health Plan/Insurer 3 Strong 2 Somewhat effective Provider (please specify) 3 Very effective Family/Consumer Other (please specify) OPTIONAL: Why? No Not applicable to my organization Enter Score: Enter Score: Develop, maintain, and update a Yes Title V 0 None comprehensive, integrated plan (IF YES) How effective are those State Medicaid 1 Weak of care that has been developed policies and procedures? CHIP 2 Moderate with the family and other 1 Not effective Health Plan/Insurer 3 Strong members of a team, addresses 2 Somewhat effective Provider (please specify) family care clinical goals, 3 Very effective Family/Consumer encompasses strategies and Other (please specify) actions needed across all settings, and is shared OPTIONAL: effectively with families and Why? among and between providers No (See standards for care Not applicable to my organization coordination). Enter Score: Enter Score:
Promote an integrated, model of care coordination. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No 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: Develop, maintain, and update a comprehensive, integrated plan of care that has been developed with the family and other members of a team, addresses family care clinical goals, encompasses strategies and actions needed across all settings, and is shared effectively with families and among and between providers (See standards for care coordination). Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No 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: based
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