Texas Health Steps Well Child Care

1
Texas Health StepsWell Child Care

• Baylor College of Medicine
• Anoop Agrawal, M.D.

2
Texas Health by the numbers

• Texans living in poverty in 2004 16.7
• Texas children living in poverty in 2004 23.7
• Texas ranking among states on percentage of
  children in poverty in 2004 6th
• Texans without health insurance 25
• Texas ranking among states on of population
  uninsured in 04 1

3
What is Medicaid?

• A jointly funded state-federal health care
  program, established in Texas in 1967.
• It is an entitlement program, i.e., the federal,
  nor state govt, cannot limit the number of
  eligible people who can enroll.
• July 2006 in Texas, 1 in 9 relied on Medicaid for
  care, or long-term services and support.

4
Who does Medicaid serve?

• Primarily non-disabled children of low-income
  families.
• Related caretakers of dependent children
• Pregnant women
• Elderly
• People with disabilities

5
(No Transcript)
6
Medicaid Managed Care

• In the 1990s, Texas turned to managed care as a
  means of better coordinating care to improve
  overall quality and decrease costs.
• This was initiated as the State of Texas Access
  Reform (STAR) program.
• STARPLUS- managed care plan that integrates
  acute and long-term services and supports for
  aged and disabled individuals.

7
What is CHIP or SCHIP?
State Childrens Health Insurance Plan

• A federal program through which states receive
  funding to provide health insurance to
  low-income, uninsured children in families with
  incomes too high to qualify for Medicaid.
• Jointly funded by federal govt and states.
• Unlike Medicaid, the total federal funds alloted
  each year is capped.

8
(No Transcript)
9
Current Events

• Congress has proposed a major expansion of SCHIP
  to cover more children by 50 billion over the
  next 5 years.
• President Bush wants to limit the increase to 5
  billion over the same time frame.
• Conservatives are worried such a major expansion
  will be the beginning of socialized medicine.

10
Texas Health Steps

• Medicaid mandated medical checkup services for
  clients younger than 21 y.o.
• The visit is a comprehensive medical checkup and
  must include all assessments, screenings,
  immunizations and lab tests as indicated on the
  periodicity schedule.

11
THSteps Periodicity Schedule
12
THSteps Visit

• Providers should treat each THSteps visit as the
  only opportunity for a clients comprehensive
  assessment.
• Requirements are based on AAP recs. Texas has
  modified few items to meet local needs.
• Sports examinations are not a Medicaid covered
  service. If an adolescent is due for a THSteps,
  then this may be completed and will be reimbursed.

13
THSteps Visit Requirements

• Comprehensive health history, including
  developmental and nutritional assessment.
• Comprehensive unclothed physical exam, including
  graphic record of head circumference.
• Immunizations
• Age-appropriate lab tests for anemia, lead
  poisoning, and newborn screening.

14
THSteps Requirements cont...

• Health education, including anticipatory
  guidance, is required.
• Age-appropriate vision and hearing screening.
• Direct referral to dental checkups beginning at
  12 months of age.

15
History component

• Initial history must include
• Family medical history
• Neonatal history (can be excluded if child over 5
  y.o.)
• Physical and mental health history
• Developmental history
• History of feeding or nutrition problems
• A complete review of body systems

16
History cont...

• Subsequent histories may be specific for the
  childs or adolescents age and health history.
• TB screening - questionnaire must be completed
  annually. In areas of high prevalence, PPD must
  be placed at 12 month visit, once between 4-6
  yrs, then again once between 11-17 yrs of age.

17
History at each visit continued...

• Nutrition assessment
• Developmental assessment- a standardized screen
  (either observational or parent questionnaire)
  for a child between 9-12 months, 18-24 months,
  and every other year thereafter or until 6 years
  of age.
• At all other visits- review of milestones
• Mental Health screening

18
Physical

• A complete physical exam, preferably with the
  child unclothed and gowned.
• May be completed by MD, an NP, an RN, a PA or a
  CNS.
• an RN may only perform under a physicians
  supervision

19
Physical - Measurements

• Height, weight - at each visit.
• Head circumference up till 24 months of age
• BMI ages 2-20 - if gt85, must document counseling
  on diet and exercise
• BP - 3 yrs of age and up - if gt95 on SBP or DBP,
  then again must document counseled on diet and
  exercise
• Vision and hearing - age appropriate

20
Required Lab Tests

• Newborn screen- before hospital d/c and 1-2 weeks
  of life
• Hgb or Hct - required at 6 months, 12 months, 24
  months, 6 years, 12 years, and 16 years. At MLK,
  we perform CBC - not reimbursed by Medicaid.
• Lead screening- lab testing required at 12 months
  and 24 months at every visit until 6yrs of age,
  a lead questionnaire must be done.

21
Other lab testing

• Glucose - fasting sample for those at risk of
  type 2 diabetes.
• Hyperlipidemia - screening based on risk
  assessment have deferred to AAP recommendations.
• STD and cervical cancer screening as indicated
  (first Pap at 21 yr or 3 years from the onset of
  sexual activity or at any other age based on
  provider discretion).

22
Dental Care

• Dental referrals are required for all patients
  beginning at 1 year of age.
• Patients are eligible for preventive dental
  checkups every six months thereafter, as well as
  emergency dental services.
• Assistance in coordinating the referral can be
  done via Dental hotline [phone].
• Gold card patients are given s for city clinics.

23
Gold card or self-pay

• Gold card and self-pay patients are given the
  same care and treatment as Medicaid patients.

24
When to do THSteps?

• Every child may have a THSteps at the designated
  times on the periodicity schedule.
• For school-age and adolescents may be performed
  at any time of the year if THSteps has not been
  done since last birthday.

25
Common Scenario

• In August, a 4 yo comes in for a WCC appointment
  according to the mother. The patients chart
  shows you performed a WCC in April at the time of
  the childs 4 year birthday. She has a form from
  Head Start for a physical that needs to be
  completed. Do you repeat the WCC exam?
• Yes, it is a mandated service to perform a full
  physical for Head Start- it will be reimbursed.

26
Second Scenario

• An 8 yo new to your practice is brought in for a
  physical. Mom changed PCPs, but cannot recall if
  the child had a WCC in the last 12 months. Can
  you do a WCC and will you be reimbursed?
• Yes, if you have a new patient and the mother
  cannot provide history or records of last WCC,
  then it may be done and will be reimbursed.

27
Reimbursement

• Physician receives 70 for the complete medical
  checkup and costs related to lab specimen
  collection, shipping, testing, and receiving test
  results from the State lab.