Clinical Services Team: Clinical Operations Unit

% of unique members with an Individualized Education Plan (IEP) connected to a primary care provider (PCP) within 30 days of referral to COU

57.1%Q3 2021

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Notes on Methodology

  • Agency of Education (AOE)
  • Vermont School Nurses
  • Vermont Chronic Care Initiative (VCCI)
  • Providers
  • Community Health Teams
Story Behind the Curve

This performance measure is important because children benefit from having a medical home and receiving annual well child visits. When primary care providers are identified, they can review a child’s Individual Education Plan (IEP). This ensures that the care children receive in school is medically necessary and medically appropriate, and that schools receive proper reimbursement for that care.

The COU receives an IEP from the AOE for children for the following reasons:

  • There is no medical home identified for the child
  • The medical home of record declines to review the IEP because they have not seen the child for an extended period
  • The medical home does not respond to outreach from the school

CY 2021 indicates an increase in the number of unique IEP referrals received compared to CY 2020. Due to the public health emergency (PHE), disruptions experienced at school, within families, and at the medical practice level this was expected in 2020. Even given this rebound, the number of referrals are down from pre-pandemic levels in 2019.  The COU continues to be able to find primary care providers for over 50% of the IEPs received. Strategies used to date include partnering with OneCare VT, VCCI and Community Health Team members for outreach, providing educational information to primary care practices, and collecting data to identify and address problem areas.

IEPs are often reviewed annually, so that families who are non-collaborative will continue to appear in the denominator year after year. The data is expected to show a downward trend in the future, reflecting the success with obtaining medical homes for willing and able families and remaining data will reflect continued difficulties in obtaining medical homes for the families who decline assistance or experience intractable barriers to accessing a medical home.

Narrative last updated:  11/18/2021

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy