Special Kids Special Care Pediatric Program

The Special Kids-Special Care program was created in partnership with the Massachusetts Department of Social Services and the Division of Medical Assistance to assure that medically complex children in the custody of DSS who are living in foster homes have access to high-quality, well-coordinated, medically appropriate health care services. This pediatric program utilizes a "medical home" model of care that helps Primary Care Providers and their patients ensure that care is "accessible, family-centered, coordinated, continuous, comprehensive, compassionate and culturally effective" (American Academy of Pediatrics, 1992). Each child enrolled in the program has his/her own community-based Primary Care Provider as well as a CMA Pediatric Nurse Practitioner (PNP) who works collaboratively with the pediatrician, the foster family, the case workers and all involved providers to ensure that the child receives the best care possible. The program incorporates all of the key elements of the CMA model, including the involvement of an expert pediatric behavioral health specialist who works with the team, child and foster family to obtain the most appropriate behavioral health services The outreach element ensures that all of the PNP's encounters with the child is in the foster home, at school, at physician's offices or wherever the member may be. Home visits often substitute for emergency room visits.

Special Kids/Special Care provides for a full range of services and accelerates access to them because the primary care team authorizes all care, equipment and services. Working closely with specialty providers, the PCP and other providers, the pediatric nurse practitioner provide, co-manage, arrange, and authorize all of the child's care. The nurse practitioner also provides 24 hour/7 on-call services, ensuring access to a clinician familiar with the unique needs of the child. Although the pediatric nurse practitioners practice very similarly to the NPs in the adult programs there is one difference. The PNPs collaborate closely with the DSS caseworkers and work intensely with foster parents, adoptive parents and often the biological parents. When children are transitioned to new homes, often in different geographical areas and new care systems and with little advance notice, the PNPs coordinate the care and services, provide education to the new parents, ensure that all equipment and supply needs are met and communicate medical information to the new providers.

To qualify for this program a child must be MassHealth eligible, in DSS custody and living in a foster home. MassHealth makes the determination for eligibility. The child must require:

• Complex medical management on a regular basis over a prolonged period of time AND
  • Direct administration of skilled nursing care on a regular basis over a prolonged period of time, requiring complex nursing procedures OR
  • Skilled assessment or monitoring on a regular basis over a prolonged period of time related to an unstable medical condition