Target Population and Eligibility: Care Management services are provided for all Medicaid children birth to 5 years of age who are determined to be high-risk and qualify for services. All patients identified as having priority risk factors will be assessed by a CC4C care managers. Proposed priority risk factors include children: with special health care needs, having or at increased risk for chronic physical, behavioral or emotional conditions and also requiring health and related services of a type and amount beyond that required by children generally; or exposed to toxic stress in early childhood including, but not limited to extreme poverty in conjunction with continuous family chaos, recurrent physical and emotional abuse, chronic neglect, severe and enduring maternal depression, persistent parental substance abuse, or repeated exposure to violence in the community or within the family; or who are in a foster care system; or who are a high cost/high user or services. All primary care providers will be encouraged to complete a referral form to identify these and other risk factors. Community providers will also be able to refer children for CC4C services.
Services: CC4C services will be provided based on the patient-need and according to risk stratification guideline. CC4C services will continue until the identified need(s) is met, or until the progress in meeting the need is no longer being made.
CC4C Outcome Measures: The overall model seeks to improve health outcomes for enrolled children, which will be measured by: the length of time from NICU discharge to first medical home visit; hospital admissions, readmissions, and ED use; and the number of children with special health care needs and/or children in foster care who have a medical home.
No one will be denied services based on inability to pay and discounts are available based on family size and income.