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Advancing Systems of Services for Children and Youth with Special Health Care Needs

Grants to USA Public and Private Agencies to Improve Care
for Youth and Children with Special Health Care Needs

Agency Type:


Funding Source:

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U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), Division of Services for Children with Special Health Needs

Conf. Date:


LOI Date:


Deadline Date:

01/16/18 11:59 PM ET


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Grants to USA public and private agencies to enhance the health and well-being of youth and children with special health care needs and their families. Applicants are advised that the required registrations may take up to one month to complete. Proposals may address youth transitioning to the adult healthcare system, health care financing, and access to patient or family-centered medical homes.

This program will establish a national collaborative network of resource centers supporting state Title V programs, families of CYSHCN, child health professionals, and other stakeholders through the provision of technical assistance, training, education, partnership building, policy analysis, and research.

The overall goal of this program is to strengthen the system of services for CYSHCN and their families by awarding three separate and distinct cooperative agreements. Cooperative agreements will be awarded to three recipients, who will collaborate to establish a national network of resource centers, with one center awarded for each of the following three focus areas:

(1) Patient/family-centered medical home;
(2) Transition of youth into the adult health care system; and
(3) Health care financing models that improve care and outcomes while achieving cost savings.

The three recipients will coordinate efforts to achieve quality care, decrease health care costs, and improve experience of care for CYSHCN and their families. An applicant can apply and be awarded only one focus area.

Focus Area 1: Medical Home

The Patient/Family-Centered Medical Home has evolved from a visionary concept in pediatrics to the standard of care—acute, preventive, and chronic—for all children and adults in the United States. An important element of the medical home articulated by the American Academy of Pediatrics (AAP) is the “interaction with early intervention programs, schools, early childhood education and child care programs, and other public and private community agencies to be certain that the special needs of the child and family are addressed.” State Title V programs, health professionals, families, and other community members continue to partner in developing creative approaches to reach the full potential of the medical home model, and improve overall health and development of children, youth and families, including those with complex needs. One key component of the medical home model is care coordination. Care coordination is transforming health care delivery across systems by optimizing quality and reducing cost, and most importantly, centering care around the family. Additionally, care coordination offers an integrated approach to service delivery, built on the concept of a “collaborative care agreement” that effectively links primary care with community-based services and medical subspecialists, often referred to as a medical neighborhood. Currently, it is estimated that less than half (43 percent) of CYSHCN nationwide have a medical home, and 47.6 percent report needing care coordination services. Significant efforts are needed to address difficulties in identifying patient and family needs, connecting patients and families to state health, community-based, condition- specific resources, and collaborating with community-based service providers. The medical home focus area in the Advancing Systems of Services for CYSHCN program is designed to support state Title V programs and partners to improve access to the patient/family-centered medical home, while exploring innovative methods and evidence-based/–informed practices to improve this model of care for CYSHCN.

Healthy Tomorrows Partnership for Children:
Recognizing the need to support community-based programs, HRSA initiated the Healthy Tomorrows Partnership for Children Program (HTPCP) with the American Academy of Pediatrics (AAP). The HTPCP strives to promote access to health care for infants, children, and youth, including those with special health care needs, and their families, and to employ preventive health strategies through innovative, community- based programs. To ensure implementation of the community-based efforts, HRSA also funded a national resource center, Healthy Tomorrows (HT) Resource Center, to support the activities of the HTPCP. As part of this program, the recipient addressing the medical home focus area will provide expertise to the HT Resource Center to increase the capacity and efficiency of HTPCP grant recipients to advance pediatric medical home implementation in vulnerable and underserved communities.

Focus Area 2: Health Care Transition

For youth with special health care needs (YSHCN), the transition from pediatric to adult oriented health care is particularly critical to assure age and developmentally appropriate care, healthy lifestyles, and inclusive community living. Health care transition (HCT) should be a standard part of providing care for all youth and young adults to optimize their functioning. Every patient should have support to transition from pediatric to adult health care, regardless of his or her condition.

Eighty-four percent of YSHCN (-17 years) do not receive the services necessary to make the appropriate transition to adult health care, work, and independence. Studies identify multiple challenges and barriers to achieve successful transition. The actual transfer of care, as well as the discussions in anticipation of the transfer, may incite feelings of abandonment, loss, and distress for the youth and their families. Another challenge is the readiness of the adult health care system to receive YSHCN. Adult health care providers have expressed concerns, including their inexperience caring for YSHCN, the psychosocial needs of the youth and young adults and their families, the transition process itself, and the inadequacy of the health care system to support transition efforts. Although many challenges exist in engaging adult providers in HCT, their collaboration and support is critical to achieve continuity of care for YSHCN.

As articulated in the 20 Clinical Report, Supporting the Health Care Transition (HCT) from Adolescence to Adulthood in the Medical Home, published by the AAP, the American Academy of Family Physicians, and the American College of Physicians, youth health care transition should include four specific activities: discussing the medical home transition policy, initiating a transition plan, reviewing/updating the transition plan, and implementing an adult care model. Current quality improvement and implementation efforts demonstrate that while HCT planning is important, engaging families and YSHCN is an essential element to achieve successful HCT.17 Additionally, HCT connects with many areas touching the life of a youth/young adult, including behavioral/mental health systems, education, employment, and other services.

Advancing Systems of Services for CYSHCN is designed to bring together stakeholders to promote the implementation of HCT best practices; educate youth and young adults, particularly YSHCN, families, health professionals, payers, and policy makers on the importance of successful health care transition; disseminate cost-effective strategies that aid pediatric and adult clinicians in the implementation of HCT and ultimately, create a health care system that supports the HCT process.

Focus Area 3: Health Care Financing

Promoting evidence-based/–informed strategies to achieve high quality, cost effective care is a key component to achieve a comprehensive, integrated, accessible system of services for CYSHCN. This is an essential element for health systems serving CYSHCN, as this population often requires more health care services, including long term and complex care, which can financially burden families. These services consume a disproportionately larger share of health care dollars compared to those without special health care needs. This focus area will address several components related to health care financing, with particular attention given to increasing access to adequate insurance coverage for CYSHCN, and building capacity to promote cost effective health care delivery models serving CYSHCN.

To ensure access to needed services, state Title V programs dedicate resources and collaborate with partners to increase availability of adequate insurance coverage for CYSHCN. State Title V programs measure this outcome by analyzing the percent of CYSHCN who have adequate insurance. Disparities in insurance coverage for CYSHCN still exist, including functional and socioeconomic status, geographic location, and race. Currently, thirty-four percent of CYSHCN and their families report inadequate health insurance coverage.

This third focus area within the Advancing Systems of Services for CYSHCN network is designed to ensure innovative payment strategies, models, policies, and other such efforts will continue to make progress; help states reach this core outcome; and achieve cost savings across health care delivery systems.

GrantWatch ID#:

GrantWatch ID#: 182470

Estimated Total Program Funding:


Number of Grants:

It is estimated there will be up to three cooperative agreements, one award for each focus area.

Estimated Size of Grant:

-Medical Home Focus: Up to $820,000 per year.
-Health Care Transition Focus: Up to $500,000 per year.
-Health Care Financing Focus: Up to $500,000 per year.

Term of Contract:

The period of performance is July 1, 2018 through June 30, 2023 (5 years).

Additional Eligibility Criteria:

Eligible applicants include any public or private entities.

Faith-based and community-based organizations, tribes, and tribal organizations are eligible to apply.

Foreign entities are not eligible for HRSA awards, unless the authorizing legislation specifically authorizes awards to foreign entities or the award is for research. This exception does not extend to research training awards or construction of research facilities.

Applicants must be national in scope and have expertise in working with state Title V programs, including providing TA/T and education on a national scale in the identified focus area.

Additionally, applicants must have past and ongoing partnerships with national organizations supporting CYSHCN and their families.

Pre-proposal Conference:

The following technical assistance webinar has been scheduled for Thursday, December 7, 2017 Time: 1:00 - 2:00 PM ET.

To access the archived webinar recording, please visit the HRSA MCHB Funding
Opportunities Webpage:

Pre-Application Information:

Ensure your and registrations and passwords are current immediately. Deadline extensions are not granted for lack of registration. Registration in all systems, including and, may take up to 1 month to complete.

Although letters of intent to apply are encouraged, they are not required. You are eligible to apply even if you do not submit a letter of intent.

The letter should identify your organization and its intent to apply, and briefly describe the proposal. HRSA will not acknowledge receipt of Letters of Intent. This letter should be sent via email by December 18, 2017

The due date for applications under this NOFO is January 16, 2018 at 11:59 PM Eastern Time.

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Contact Information:

Before starting your grant application, please review the funding source's website listed below for updates/changes/addendums/conferences/LOIs.

To attend the December 7 webinar:
Call-In Number: 1-888-324-8527
Participant Code: 3517106

To submit a Letter of Intent, use HRSA opportunity number as email subject (HRSA-18-069) and send to:

Sarah Beth McLellan, MPH, Public Health Analyst
Division of Services with Special Health Needs
P: (301) 443-3272
F: (301) 594-0878

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Geographic Focus:

USA: Alabama;   Alaska;   Arizona;   Arkansas;   California;   Colorado;   Connecticut;   Delaware;   Florida;   Georgia;   Hawaii;   Idaho;   Illinois;   Indiana;   Iowa;   Kansas;   Kentucky;   Louisiana;   Maine;   Maryland;   Massachusetts;   Michigan;   Minnesota;   Mississippi;   Missouri;   Montana;   Nebraska;   Nevada;   New Hampshire;   New Jersey;   New Mexico;   New York City;   New York;   North Carolina;   North Dakota;   Ohio;   Oklahoma;   Oregon;   Pennsylvania;   Rhode Island;   South Carolina;   South Dakota;   Tennessee;   Texas;   Utah;   Vermont;   Virginia;   Washington, DC;   Washington;   West Virginia;   Wisconsin;   Wyoming