Improving Care Coordination, Case Management, and Linkages to

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Table of Contents
Acknowledgements 1
ex e c u t i v e su m m A ry 2
Table 1: Linkage and CC/CM strategies to promote coordination between medical providers
and community referral and resource agencies ........................................................................................3
Areas for state action: ..........................................................................................................................4
Ab o u t t h e Au t h o r s 5
in t r o d u c t i o n A n d bAc kg ro u n d 6
Access to developmental services is uneven and inequitable ....................................................6
States are poised to improve linkages to promote healthy child development .....................7
Table 2: Ages for events related to identification and enrollment in Part C ......................7
Barriers hinder effective linkages .......................................................................................................9
Care coordination/case management (CC/CM) provides an opportunity to assure
children and families are connected to needed services ............................................................11
key FederAl/stAt e Pr o g r A m s Fi nA n c i n g he A lt h A n d relAted services 13
Medicaid and EPSDT ..........................................................................................................................13
Figure 1: EPSDT Participation Ratios, Children ages 1-3 FY 2006 ..................................14
Figure 2: EPSDT Referral Rates, Children ages 1-3 FY 2006 .............................................14
State Children’s Health Insurance Program (CHIP) .....................................................................15
Title V Programs ..................................................................................................................................16
IDEA Programs for Young Children .................................................................................................17
st rAt e g i e s t h At Pr o m o t e eFFective li n kAg e s between PediAtric Pr i mA ry cA r e A n d ot h e r services 19
Maximizing the use of personnel in linkages and CC/CM ........................................................ 19
Table 3: Linkage and CC/CM strategies to promote coordination between medical
providers and community referral and resource agencies ...................................................20
Quality improvement initiatives and other mechanisms for assuring and
monitoring quality ..............................................................................................................................25
Data, Information, and Technology that facilitate linkages and communication
between families and multiple providers .......................................................................................27
Individualized care plans and cross-systems planning ...............................................................29
co n c l u s i o n s 31
Recommendations to Improve Care Coordination and Linkages among Services
that Promote Healthy Child Development ................................................................................... 32
Examples of Financing Strategies to Drive Change ..................................................................... 33
Next steps ............................................................................................................................................34
APPendix A: ABCD III Planning Committee 36
en d no t e s 38
Improving Care Coordination, Case Management, and Linkages to Service for Young Children: Opportunities for States
National Academy for State Health Policy