Care Integration Implementation to Improve the Care of CYSHCN: Title V & Department of Public Health Partnership with Growth and Nutrition Program at Boston Children's Hospital

Full Description: The Growth and Nutrition Program (GNP) at Boston Children’s Hospital (BCH) is one of the largest Department of Public Health (DPH) funded clinics that provides care to children with growth delay or failure to thrive. BCHGNP uses a biopsychosocial approach and a multidisciplinary team to treat children with malnutrition. The clinic focuses on evaluation and treatment of the underlying feeding disorder, including assessment of social risk factors that influence growth outcomes and support to address identified needs. For 37 years, BCHGNP has received funding from DPH to promote our psychosocial care for patients, and strengthen our collaboration with community partners to improve care for this population.
To date, BCHGNP has lacked a standard approach to the assessment of outcomes of care coordination and integration. In collaboration with the BCH Department of Accountable Care and Clinical Integration (DACCI), BCHGNP fielded the Pediatric Integrated Care Survey (Ziniel et al 2016) in January 2021 to solicit family experiences of care integration. Based on the results, our team identified opportunities for improvement, and then developed and implemented new systematic care coordination tools, processes, and measurement approaches to better support our goal of providing equitable, high value, family-centered care. Interventions included: 1. Piloting a population health manager to track patient care transitions across BCH and the community and proactively work with families to coordinate inter-visit care. 2. Establishing a system to define our clinic’s roles and responsibilities to a patient’s care plan 3. Developing a patient registry to assist in this effort 4. Creating a singular administrative support role to streamline and unify the prior authorization process 5. Developing a learning community to advance interprofessional education in care integration using elements of the MCHB-funded Pediatric Care Coordination Curriculum & National Center for Care Coordination Technical Assistance (NCCCTA) 6. Expanding our support for families’ application to federal and state funded programs (e.g. SNAP/WIC), implementing a food insecurity assessment, and providing recommended foods and supplies to families by using resources available in our Medicaid Accountable Care Organization (ACO) model.
In this interactive session, we will share how we are improving care for CYSHCN with these initiatives and highlight the importance of collaboration with MA Title V and DPH colleagues, Medicaid, and the care delivery system. We will emphasize our use of tools available via the MCHB NCCCTA, resources that are freely available across the US. Attendees will learn how our model has evolved into a value-based, accountable care payment arrangement, enabling us to transform our service offerings to meet patients’ needs. Participants will learn how Title V and Medicaid can and must work collaboratively to achieve equitable, high value, integrated care outcomes.

Abbreviated Description: In this interactive session, we will share how we are improving care for CYSHCN with several care integration initiatives and highlight the importance of collaboration with MA Title V and DPH colleagues, Medicaid, and the care delivery system. We will emphasize our use of tools available via the MCHB National Center for Care Coordination Technical Assistance. Attendees will learn how our model has evolved into a value-based, accountable care payment arrangement, enabling us to transform our service offerings to meet patients’ needs. Participants will learn how Title V and Medicaid can offer complementary resources to achieve equitable, high value, integrated care outcomes.