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Providing High-Quality Services to Children with Special Health Care Needs (CSHCN) Under Managed Care

Providing Selected Services Outside Managed Care

Presenters:

Julian R. Taplin, Ph.D., Director, Division of Child Mental Health Services, Delaware Department of Services for Children, Youth and Their Families, Delaware Youth and Family Center, Wilmington, DE.

Ron Caldarone, L.I.C.S.W., Chief, Office of Children with Special Health Care Needs, Rhode Island Department of Health, Providence, RI.


In contrast to the managed care systems described in previous sessions, several States have chosen to provide primary care services to CSHCN through mainstream managed care plans, while providing some of the specialty services they need through outside systems.

Julian Taplin, Division of Child Mental Health Services (DCMHS) for the State of Delaware, explained how the State provides medical services through contracted health plans, but provides mental health through the DCMHS, because they felt that commercial health plans were not providing the continuous, specialized, coordinated and family-centered mental health care that some children required.

In order to share risk with providers, the DCMHS has used a bundled rate payment structure. To assure the quality of care, the State developed a care assurance model, which focuses on the integration of clinical services, youth support systems and treatment resources. In order to assess performance, DCMHS constructed performance measures and goals to measure effectiveness, efficiency, appropriateness, accessibility, and capacity.

Ron Calderone, Chief of the Office of Children with Special Health Care Needs for the State of Rhode Island, discussed how and why his State decided to take some Part H Early Intervention services out of the standard managed care plans' responsibilities. While the managed care plans under contract with the State provide the first $3000 of early intervention services, any services needed above that limit are financed by the State Department of Health and provided by community-based early intervention providers under contract with the plans. The State developed this arrangement due to concerns over the cultural gaps between the family-centered, consumer-oriented Part H program, and the cost-driven nature of managed care.

Although the State has encountered some barriers, such as data and capacity issues, Mr. Calderone emphasized the value of frequent communication among the State plans, and the providers, to address these and other issues.

References

Taplin JR, Ray RS, Widdoes NS, Soles CW. The Care Assurance Model in Public Managed Behavioral Health Care for Children. Division of Child Mental Health Services. Department of Services for Children, Youth and Their Families. State of Delaware.

"Monthly Numbers—Appendix A." Division of Child Mental Health Services. Department of Services for Children, Youth and Their Families. State of Delaware.

State of Rhode Island. Department of Health. Early Intervention Program. RIte Care Family Survey 1997. Ann M. Bisson.

State of Rhode Island. Department of Health. Early Intervention Program. How Do RIte Care Members Access and Use the Early Intervention Program?


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