None A transfer package including a Yes Title V 0 final transition readiness (IF YES) How effective are those State Medicaid 1 Weak assessment, plan of care with policies and procedures? CHIP 2 Moderate transition goals, and medical 1 Not effective Health Plan/Insurer 3 Strong summary and emergency plan is 2 Somewhat effective Provider (please specify) prepared and communicated 3 Very effective Family/Consumer with the new adult medical Other (please specify) home, prior to the transfer of a YSHCN from a pediatric to an OPTIONAL: adult medical home. Why? No for score, above ) (Select “0” Not applicable to my organization Enter Score: Enter Score: The pediatric medical home is Yes Title V 0 None available for consultation (IF YES) How effective are those State Medicaid 1 Weak assistance with the adult policies and procedures? CHIP 2 Moderate Not effective Strong medical home, as needed. 1 Health Plan/Insurer 3 2 Somewhat effective Provider (please specify) 3 Very effective Family/Consumer Other (please specify) OPTIONAL: Why? No for score, above) (Select “0” Not applicable to my organization Enter Score: Enter Score:
A transfer package including a final transition readiness assessment, plan of care with transition goals, and medical summary and emergency plan is prepared and communicated with the new adult medical home, prior to the transfer of a YSHCN from a pediatric to an adult medical home. 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: The pediatric medical home is available for consultation assistance with the adult medical home, as needed. 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:
7_Transition%20to%20Adulthood_In%20DepthFINAL.docx