Funded Projects

Problem:

Across the state, Rhode Island families continue to face adversity at increasing rates. There are growing rates of poverty, particularly among young children; the growing immigrant populations face challenges in accessing services that are linguistically and culturally appropriate; the system of services, which includes both Pediatric Primary Care and Family Home Visiting, for young children can be complicated and difficult to navigate.

Goals and Objectives:

1) PCMH-Kids practices and FHV programs have the tools, data and work flows needed to integrate care coordination; 2) PCMH-Kids practices and FHV programs acquire knowledge, skills and relationships for integrating care coordination through participation in a year-long Learning Collaborative; 3) PCMH-Kids practices and FHV programs develop and implement strategies to support family engagement in primary care and FHV programs; and 4) Integrated Care Coordination activities will continue after the period of federal funding ends.

Methodology:

Goals will be accomplished through activities that align with the Healthy Tomorrows Partnership for Children Program funding priorities: family involvement in care coordination activities and project advisory committee meetings, enhancing medical home care coordination, linking families to evidence-based home visiting services and supports that foster early child development with a focus on underserved communities, developing integrated care coordination training tools, work flows and resources, utilizing continuous quality improvement with a strong evaluative component, and developing project outcomes reports and communications to disseminate to early childhood professionals and advocates statewide.

Coordination:

Rhode Island's existing partnerships speak to the state's readiness to successfully implement the work described in this application. If funded, RIDOH FHV and PCMH-Kids are poised to achieve the goals objectives of the work plan.

Evaluation:

RI will evaluate outcomes of the proposed series of year-long Integrated Care Coordination (ICC) Learning Collaboratives. The ongoing activities of the Learning Collaboratives as well as their overarching evaluation will contribute to continuous quality improvement. The primary domains of the evaluation will be (1) Primary Care level change, reflecting process measures at the agency level; (2) Primary Care integration with Family Home Visiting, reflecting process measures at the systems level; and (3) Referral and Engagement with Family Home Visiting, reflecting outcome measures at the family level. The evaluation team will address the specific performance measures and outcome measures described by HRSA as listed in the Notice of Funding Opportunity.