About the Initiative
Children and youth with special health care needs ("CYSHCN") are defined by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB) as"... those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” Children with special health care needs often require complex care across several medical specialties and are vulnerable to psychosocial and developmental difficulties.
The Mississippi State Department of Health, Children and Youth with Special Health Care Needs Program, collaborates with a diverse group of partners statewide to increase access to medical and dental homes for children with special needs from birth to 21 years of age, provide care coordination and empower families and caregivers to become champions for health equity and the elimination of health disparities.
The goal of the Care Coordination Model is to assure that all providers, institutions and patients have the information and resources needed to optimize the patient's care.
CYSHCN Cares 2, a care coordination learning collaborative, was initiated by the Mississippi State Department of Health, Office of Child and Adolescent Health, Children and Youth with Special Health Care Needs Program. In September 2018, the Program convened subject matter experts and established the CYSHCN Leadership Team. Through this invaluable collaboration, the CYSHCN Cares 2 Request for Application and curriculum were developed to recruit primary care organizations.
CYSHCN Cares 2 offers training in electronic health record utilization/analysis, quality improvement, and family engagement by focusing on communication and coordination across systems of care. Its structure is based on the Care Coordination Model, Care Model for Child Health, and Model for Improvement and aims to re-design and advance their office practices. The goal of the Care Coordination Model is to assure that all involved providers, institutions and patients have the information and resources needed to optimize the patient’s care. The Care Model for Child Health integrates the medical home concept with the chronic care model, developed by Ed Wagner. The Care Model provides a description of an ideal system of healthcare for chronic conditions. Consisting of six essential components, the model can also be applied to preventive health. The Model for Improvement is a strategy for testing, implementing, and spreading practice innovations and includes the use of Plan-Do-Study-Act (PDSA) cycles or rapid cycle improvement.
The fundamental change is from a provider-oriented system to a patient-family-community-oriented system of care utilizing a team-based approach. Awarded Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHC), and Private practices organize a team, test and measure practice innovations, then share their experiences in an effort to accelerate learning and widespread implementation of successful change concepts and ideas.