Connecticut Medical Home Initiative for Children & Youth with Special Health Care Needs* Screener and Complexity Index Tool

Connecticut Medical Home Initiative for Children & Youth with Special Health Care Needs* Screener and Complexity Index Tool
Pediatric Primary Care
Provider Name
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Sex:

MFUnknownOther
Child’s Preferred Pronouns:
Child’s Race/Ethnicity:
Parent/Guardian
Parent/Guardian Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Language:
Child’s Insurance:
Primary diagnosis:
Insurance ID#:
Referrer:
Children and Youth with Special Health Care Needs (CYSHCN) Screener©FACCT
Does your child currently need or use medicine prescribed by a doctor (other than vitamins)?

YesNo
Is this because of ANY medical, behavioral or other health condition?

YesNo
Is this a condition that has lasted or is expected to last for at least 12 months?

YesNo
Does your child need or use more medical care, mental health or educational services than is usual for most children of the same age?

YesNo
Is this because of ANY medical, behavioral or other health condition?

YesNo
Is this a condition that has lasted or is expected to last for at least 12 months?

YesNo
Is your child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

YesNo
Is this because of ANY medical, behavioral or other health condition?

YesNo
Is this a condition that has lasted or is expected to last for at least 12 months?

YesNo
Does your child need or get special therapy, such as physical, occupational or speech therapy?

YesNo
Is this because of ANY medical, behavioral or other health condition?

YesNo
Is this a condition that has lasted or is expected to last for at least 12 months?

YesNo
Does your child have any kind of emotional, developmental or behavioral problem for which he or she needs or gets treatment or counseling?

YesNo
Is this a condition that has lasted or is expected to last for at least 12 months?

YesNo
Connecticut Medical HOMES CYSHCN Complexity Index

Adapted from a similar tool developed by Exeter Pediatric Associates and the Center for Medical Home Improvement

Category	Criteria (Score each Category 0, 1 or 2)
Hospitalizations, ER Usage and Specialty Visits (in last year)	0 = No service, activity or concern 1 = 1 hospitalization, ER or specialist visits for complex condition 2 = 2 or more hospitalizations, ER or specialist visits

Score

Category	Criteria (Score each Category 0, 1 or 2)
Office Visits and/or Phone Calls (in last year, over and above well-child visits)	0 = No service, activity or concern 1 = 1-2 Office Visits or MD/RN/care coordinator phone calls related to complex condition 2 = 3 or more office visits or MD phone calls

Score

Category	Criteria (Score each Category 0, 1 or 2)
Medical Condition(s): One or more diagnoses	0 = No service, activity or concern 1 = 1-2 conditions, no complications related to diagnosis 2 = 1-2 conditions with complications or 3 or more conditions

Score

Category	Criteria (Score each Category 0, 1 or 2)
Extra Care & Services at PCP office, home, school or community setting (see Services)	0 = No service, activity or concern 1 = One service from list below 2 = Two or more services from list below (Services: medications/medical technologies/therapeutic assessments/treatments/procedures and care coordination activities)

Score

Category	Criteria (Score each Category 0, 1 or 2)
Social Concerns	0 = No service, activity or concern 1 = “At risk” family/school/social circumstances 2 = Current/urgent complex circumstances

Score
Total Complexity Score
Completed By:
Date

MonthDayYear
*The Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs is a program supported by the State of Connecticut Department of Public Health. Information is available on their website at www.ct.gov/dph/medicalhome.
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Connecticut Medical Home Initiative for Children & Youth with Special Health Care Needs* Screener and Complexity Index Tool

Pediatric Primary Care

Children and Youth with Special Health Care Needs (CYSHCN) Screener©FACCT

Connecticut Medical HOMES CYSHCN Complexity Index