By Health Team
January 18, 2024
Top image via iStock from ozgurdonmaz
Being a parent is a daily juggling act – from school/daycare pickups and drop offs, to work commutes and cleaning, to getting food on the table. If that’s not hectic enough, parents and caregivers are also forced to navigate various complex systems across health, social, education, and early childhood services just to care for their kids. Those systems are frequently not designed with their needs and realities in mind, nor do these systems seamlessly communicate or coordinate efforts. One pediatric clinic in Alameda County found that after screening their pediatric patients for health and social needs, families needed help navigating services addressing food insecurity, housing insecurity, behavioral health needs, and child developmental delays. And also – they needed a better system to make those referrals for their patients.
For families to best access necessary services, it is critical to have an effective and compassionate referral system. One that understands a family’s life challenges and circumstances, supports informed decision-making about their care, and efficiently tracks and secures referrals to ensure follow-up and completion of services. Health and social service providers play a crucial role by connecting children to services they need. These referral loops form a web of support that includes primary care, dental, behavioral health, specialty care, and community programs addressing nutrition, housing, and developmental needs. A recent survey of families with young children confirmed how important these referrals are, showing that parents and caregivers were more likely to sign up for food assistance programs if their pediatrician told them they were eligible.
However, it’s not enough for providers to just make referrals. A truly effective system requires follow-up to “close the loop” and ensure a family was able to receive needed services. Imagine the relief of sharing concerns about your child’s health or development with a provider who not only listens but takes tangible steps to ensure that the recommended support is not lost in the bureaucratic shuffle or the daily struggle. Such a system not only acknowledges the systemic barriers placed on families and caregivers by distinct, and at times contradictory or confusing, policies and institutions, but works to eliminate and reduce the challenges parents and caregivers face in accessing services so that the goal of meeting the child’s health needs is achieved.
This type of supported vision for Medi-Cal members may soon become a reality. In 2025, a follow-up will be required when children and youth get referred for crucial health care services and community resources recommended to them. Essentially, this will “close the loop” on recommended care and services to meet a child’s needs.
However, even though a “Closed Loop Referral” policy has great potential, the design of systems and standards will be critical to ensuring its eventual success.
Keep reading below to learn more on the upcoming shift towards Closed Loop Referrals in Medi-Cal and the recommendations Children Now has for a successful referral system.
What’s the change?
Change is on the horizon with the California Advancing and Innovating Medi-Cal (CalAIM) Initiative to improve the health of Medi-Cal populations by creating and closing referral loops. As part of the CalAIM Population Health Management initiative, “Closed Loop Referrals are defined as coordinating and referring the [Medi-Cal Managed Care Plan] member to available community resources and following up to ensure services were rendered.”
Specifically, beginning in 2025, Medi-Cal Managed Care Plans (MCPs) will be required to close referral loops for their members made to/from health and community resources including: Enhanced Care Management and Community Supports providers; Community Health Workers (CHWs), peer counselors, and local community organizations; dental providers; California Children’s Services (CCS); Developmental services; CalFresh; WIC providers; county social service agencies; and specialty mental health and substance use disorder services. This transformative policy aims to streamline and improve the referral process, aligning with the State’s goals to enhance care quality, address disparities in children’s and maternity care, and boost mental health services.
Why does it matter?
A timely, quality, trusted, and completed referral makes the difference in ensuring a child gets the services/supports they need. It also provides the child’s provider and care team the information they need to appropriately follow-up on the child’s care and family’s needs. In fact, one major challenge with CalAIM implementation so far is that “Medi-Cal enrollees are turning down new services because they are being offered at the wrong time or by the wrong person.” That’s why it’s so important for children and families with Medi-Cal managed care, who need to get connected to the right care when they need it, have support through every step of the referral process. A helping hand with referrals means parents are less likely to lose valuable time chasing down information and following up on services that were recommended, or become overwhelmed trying to navigate programs and providers.
Ultimately, the State can build an approach to referrals that fosters high-quality, efficient, community-based, and culturally-sensitive care that bridges gaps and ensures equitable outcomes for children in Medi-Cal managed care. However, creating a respectful and effective referral system that closes the loop on care will require intentional family-centered planning, infrastructure resources, trusted local partnerships, and clear policy direction. For lasting impact, ongoing monitoring efforts will be crucial, and holding Medi-Cal Managed Care Plans (MCPs) accountable for improved children’s outcomes will ensure the sustainability of positive changes. California joins at least two other states (Louisiana and North Carolina) at the vanguard of using referral systems that close the loop on care as a Medicaid managed care tool to improve health equity. The lessons learned will be increasingly valuable as managed care plays an ever-important role in Medicaid programs across the country.
To help California prepare for a referral system that closes the loop on care for families, Children Now conducted extensive research and engaged in a variety of stakeholder conversations to provide insights into the current and potential future referral landscape. The findings are described in this issue brief, Closing the Referral Loop: Recommendations for Medi-Cal Referral Systems to Support Children and Families. The brief offers five key recommendations to ensure the success of Closed Loop Referrals for children and families in Medi-Cal:
- Clear Definitions and Standards: Establish precise definitions and standards to guide the referral process.
- Leverage Data and Integrate Technology: Utilize data and integrate technology to enhance the efficiency of the referral system.
- Trusted Partnerships and Referral Pathways: Build and rely on trusted partnerships and established referral pathways.
- Provider Training and Supports: Implement training and support mechanisms for healthcare providers involved in the referral process.
- Resource and Monitor Referrals: Allocate resources and establish monitoring mechanisms to track and assess the success of referrals.
Because the Closed Loop Referral policy does not take effect until 2025, it will be incredibly important for the State and stakeholders to prepare and partner throughout 2024. Children Now and our partners will be advocating for California to take the opportunity to invest in Closed Loop Referral systems that prioritize the needs of children and families, strengthening connections and communication between providers and the communities they serve.
The State recently released the application for a funding opportunity (Providing Access and Transforming Health (PATH) Capacity and Infrastructure Transition, Expansion, and Development (CITED) Round 3) that can be used, among other things, to support eligible entities (such as health providers, community-based organizations, and local government agencies) in the implementation of a closed-loop referral system. Applications are due February 15, 2024.
"Kama ilivyoelezwa katika makala ya ""Siku ya Msaada"" ya Januari 18, 2020, ""Kuwa mzazi ni tendo la kila siku la juggling - kutoka shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule ya shule." Kama hiyo si ya kutosha, wazazi na watunzaji pia wanalazimika kuendesha mifumo mbalimbali tata katika huduma za afya, kijamii, elimu, na utotoni tu kutunza watoto wao. Mifumo hiyo mara nyingi haijapangwa kwa kuzingatia mahitaji na hali halisi zao, wala mifumo hii haifanyi mawasiliano bila kusonga au kuratibu juhudi. Kliniki moja ya watoto katika Kaunti ya Alameda iligundua kwamba baada ya kuchunguza wagonjwa wao wa watoto kwa mahitaji ya afya na kijamii, familia zinahitaji msaada kuendesha huduma zinazoshughulikia ukosefu wa usalama wa chakula, ukosefu wa usalama wa makazi, mahitaji ya afya ya tabia, na ucheleweshaji wa maendeleo ya watoto. Na pia <unk> walihitaji mfumo bora wa kufanya rufaa hizo kwa wagonjwa wao. Kwa familia kupata huduma muhimu bora, ni muhimu kuwa na mfumo wa kuelekeza ufanisi na huruma. Msaada wa afya unaoelewa changamoto na hali za maisha ya familia, unaunga mkono maamuzi ya habari kuhusu huduma yao, na kwa ufanisi hufuatilia na kupata marejeo ili kuhakikisha ufuatiliaji na kukamilika kwa huduma. Watoa huduma za afya na kijamii wana jukumu muhimu kwa kuunganisha watoto na huduma wanazohitaji. Vipindi hivi vya kuelekeza huunda mtandao wa msaada ambao unajumuisha huduma za msingi, meno, afya ya tabia, huduma maalum, na programu za jamii zinazoshughulikia lishe, makazi, na mahitaji ya maendeleo. Uchunguzi wa hivi karibuni wa familia zilizo na watoto wadogo ulithibitisha umuhimu wa rufaa hizi, ikionyesha kuwa wazazi na watunzaji walikuwa na uwezekano mkubwa wa kujiandikisha kwa programu za msaada wa chakula ikiwa daktari wao wa watoto aliwaambia walikuwa na haki. Hata hivyo, si ya kutosha kwa watoa kutoa tu kufanya marejeo. Mfumo mzuri kweli inahitaji kufuatilia "kufunga kitanzi" na kuhakikisha familia ilikuwa na uwezo wa kupokea huduma zinazohitajika. Fikiria jinsi inavyokuwa rahisi kushiriki wasiwasi kuhusu afya au ukuaji wa mtoto wako na mtoa huduma ambaye hawasikii tu, lakini pia huchukua hatua halisi kuhakikisha kwamba msaada uliopendekezwa haupotezi katika mzunguko wa kiutawala au mapambano ya kila siku. Mfumo kama huo haukubali tu vizuizi vya mfumo vilivyowekwa kwa familia na watunzaji na sera na taasisi tofauti, na wakati mwingine zinazopingana au zenye kuchanganyikiwa, lakini hufanya kazi kuondoa na kupunguza changamoto ambazo wazazi na watunzaji wanakabili katika kupata huduma ili lengo la kukidhi mahitaji ya afya ya mtoto lipatikane. Aina hii ya maono ya msaada kwa wanachama wa Medi-Cal inaweza kuwa ukweli hivi karibuni. Katika 2025, kufuatilia kutahitajika wakati watoto na vijana wanapelekwa kwa huduma muhimu za huduma za afya na rasilimali za jamii zilizopendekezwa kwao. Kimsingi, hii itakuwa <unk>kufunga kitanzi<unk> juu ya huduma iliyopendekezwa na huduma ili kukidhi mahitaji ya mtoto. Hata hivyo, hata ingawa sera ya "Closed Loop Referral" ina uwezo mkubwa, kubuni mifumo na viwango itakuwa muhimu ili kuhakikisha mafanikio yake ya mwisho. Kuendelea kusoma hapa chini kujifunza zaidi juu ya mabadiliko ya karibu kuelekea Uelekezo wa Mzunguko uliofungwa katika MediCal na mapendekezo ya Watoto Sasa ina kwa mfumo wa uelekezo wa mafanikio. Mabadiliko ni yapi? "Kama ilivyoelezwa hapo juu, mpango wa ""California Advancing and Innovating MediCal"" (CalAIM) una lengo la kuboresha afya ya watu wa MediCal kwa kuunda na kufunga vifungo vya rufaa." "Kama sehemu ya mpango wa ""Usimamizi wa Afya ya Idadi ya Watu"" (CalHealth), ""Usimamizi wa Afya ya Idadi ya Watu"" (Closed Loop Referral) hufafanuliwa kama kuratibu na kuelekeza mwanachama wa ""MediCal Managed Care Plan"" kwa rasilimali za jamii zinazopatikana na kufuatilia huduma zinazotolewa.Kufikia 2025, mipango ya huduma za matibabu ya MediCal (MCPs) itahitajika kufunga mizunguko ya rufaa kwa wanachama wao waliotengenezwa kwa rasilimali za afya na jamii, pamoja na: Huduma za afya ya akili na matumizi ya dawa za kulevya (CHWs), washauri wa rika, na mashirika ya jamii." Sera hii ya mabadiliko inakusudia kurahisisha na kuboresha mchakato wa rufaa, ikilingana na malengo ya Jimbo la kuboresha ubora wa huduma, kushughulikia tofauti katika utunzaji wa watoto na uzazi, na kukuza huduma za afya ya akili. Kwa nini jambo hilo ni muhimu? Uelekezo wa wakati unaofaa, wa ubora, wa kuaminika, na uliofanywa hufanya tofauti katika kuhakikisha mtoto anapata huduma au msaada wanaohitaji. Pia hutoa mtoa huduma wa mtoto na timu ya utunzaji habari wanayohitaji ili kufuatilia kwa usahihi utunzaji wa mtoto na mahitaji ya familia. "Kwa kweli, changamoto moja kubwa na utekelezaji wa CalAIM hadi sasa ni kwamba ""Wajaribi wa MediCal wanakataa huduma mpya kwa sababu zinapewa wakati usiofaa au na mtu asiyefaa.""Hiyo ndiyo sababu ni muhimu sana kwa watoto na familia na huduma ya MediCal, ambao wanahitaji kuunganishwa na huduma sahihi wakati wanahitaji, wana msaada katika kila hatua ya mchakato wa kumbukumbu." Kujiunga na kuruhusu kwa wazazi ni rahisi, kwa sababu wazazi hawawezi kupoteza muda wa thamani kufuatilia habari na kufuata huduma zilizopendekezwa, au kuwa na wasiwasi kujaribu kuendesha programu na watoa huduma. Mwishowe, Serikali inaweza kujenga mbinu ya kuelekeza ambayo inakuza huduma ya hali ya juu, ufanisi, msingi wa jamii, na utamaduni-uhisi ambao unashughulikia mapungufu na kuhakikisha matokeo ya haki kwa watoto katika huduma ya MediCal. Hata hivyo, kuunda mfumo wa kuelekeza wenye heshima na ufanisi ambao unaziba mzunguko wa huduma itahitaji mipango ya makusudi ya familia, rasilimali za miundombinu, ushirikiano wa kuaminika wa ndani, na mwelekeo wa sera wazi. Kwa athari ya kudumu, juhudi za ufuatiliaji zinazoendelea zitakuwa muhimu, na kuweka mipango ya huduma ya kudhibitiwa ya MediCal (MCPs) kuwajibika kwa matokeo bora ya watoto itahakikisha uendelevu wa mabadiliko mazuri. California inajiunga na angalau majimbo mengine mawili (Louisiana na North Carolina) katika mstari wa mbele wa kutumia mifumo ya rufaa ambayo hufunga mzunguko wa huduma kama chombo cha huduma ya Medicaid ili kuboresha usawa wa afya. Mafunzo yaliyopatikana yatakuwa na thamani zaidi kwani utunzaji uliodhibitiwa una jukumu muhimu katika programu za Medicaid kote nchini. Ili kusaidia California kuandaa mfumo wa rufaa ambao unaziba mzunguko wa huduma kwa familia, Watoto Sasa walifanya utafiti mkubwa na kushiriki katika mazungumzo mbalimbali ya wadau ili kutoa ufahamu wa mazingira ya sasa na ya baadaye ya rufaa. Matokeo yanaelezwa katika kifupi hiki cha toleo, Kufunga Mzunguko wa Uelekezo: Mapendekezo kwa Mifumo ya Uelekezo wa Medi-Cal ili Kuunga mkono Watoto na Familia. "Kufikia sasa, kuna mapendekezo matano ya msingi ya kuhakikisha mafanikio ya ""Mipango ya Mzunguko uliofungwa"" kwa watoto na familia katika MediCal: - Ufafanuzi wazi na viwango: Kuanzisha ufafanuzi sahihi na viwango kuongoza mchakato wa rufaa." - Leverage Data na Kuunganisha Teknolojia: Kutumia data na kuunganisha teknolojia ili kuongeza ufanisi wa mfumo wa rufaa. - Ushirikiano wa kuaminika na njia za rufaa: Kujenga na kutegemea ushirikiano wa kuaminika na njia za rufaa zilizowekwa. - Mtoaji Mafunzo na Msaada: Kutekeleza mafunzo na mifumo ya msaada kwa watoa huduma za afya kushiriki katika mchakato wa rufaa. - Rasilimali na Ufuatiliaji wa Uelekezo: Toa rasilimali na kuanzisha mifumo ya ufuatiliaji kufuatilia na kutathmini mafanikio ya uelekezo. Kwa sababu sera ya Uelekezo wa Mzunguko uliofungwa haitaanza kutumika hadi 2025, itakuwa muhimu sana kwa Jimbo na wadau kujiandaa na kushirikiana katika 2024. Watoto Sasa na washirika wetu watatetea kwa California kuchukua fursa ya kuwekeza katika mifumo ya Uelekezo wa Mzunguko uliofungwa ambao unatoa kipaumbele kwa mahitaji ya watoto na familia, kuimarisha uhusiano na mawasiliano kati ya watoa huduma na jamii wanazohudumia. "Mwaka huu, serikali ya Marekani imetoa maombi ya fursa ya ufadhili (Providing Access and Transforming Health (PATH) Capacity and Infrastructure Transition, Expansion, and Development (CITED) Round 3) ambayo inaweza kutumika, miongoni mwa mambo mengine, kusaidia vyombo vinavyostahili (kama vile watoa huduma za afya, mashirika ya jamii, na mashirika ya serikali za mitaa) katika utekelezaji wa mfumo wa ""kuelekeza kwa mzunguko uliofungwa.""" Maombi yanapaswa kufanywa Februari 15, 2024.