None A process for confirming the Yes Title V 0 transfer between the pediatric (IF YES) How effective are those State Medicaid 1 Weak and adult medical home is in policies and procedures? CHIP 2 Moderate place to assist the YSHCN with 1 Not effective Health Plan/Insurer 3 Strong ongoing care management and 2 Somewhat effective Provider (please specify) referral to adult specialists and 3 Very effective Family/Consumer other community supports and Other (please specify) elicit feedback about their experience of care. OPTIONAL: Why? No for score, above ) (Select “0” Not applicable to my organization Enter Score: Enter Score: Effectiveness Indicator: Organizational Influence Indicator: SUMMARY: TRANSITION TO ADULTHOOD Additional Notes: ENDNOTES:
A process for confirming the transfer between the pediatric and adult medical home is in place to assist the YSHCN with ongoing care management and referral to adult specialists and other community supports and elicit feedback about their experience of care. Yes (IF YES) How effective are those policies and procedures? 1 Not effective 2 Somewhat effective 3 Very effective No (Select “0” for score, above ) 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: TRANSITION TO ADULTHOOD Effectiveness Indicator: Organizational Influence Indicator: Additional Notes: ENDNOTES:
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