ࡱ> TVSa ~.jbjbA]A] 1N+?+?)TL8(,TLL1.0000000,2R.5N)1)1t 41t t t 0t T60t t o/|0 /0101/|5t |5$0t LLLLChild s Name __________________________ B/D _____/______/____ Parent/Guardian ____________________________ B/D _____/______/____ Child s Place of Birth: % In Orange County-Hospital: __________ % In United States-State: _________ % In California& County: _____________ % Outside US-Country: __________ FRC Name: _________________________ PHN Name ____________________ Date Case Closed: _______/_______/_______ ProjectConnections.FRC Health Access Service Outcome Survey (SOQs) *Attach authorization form and CDOM questionnaire (if applicable) Type and Intensity of Services: SVC-1. From the list below, check all the services your program provided to this child and/or family. (Select all that apply) 1. Information and Referral % 1.1 Provided information % 1.2 Made referral(s) % 1.3 Followed up on referral(s) 2. Health Access % 2.1 Health Insurance status check % 2.2 Health Insurance enrollment assistance % 2.3 Medical Home status check % 2.4 Assistance with connecting to Medical Home 3. Care Management/Home Visitation/Prenatal Care % 3.3 Home Visits % 3.4 Home Safety Inspection 7. Parent Education % 7.1 Parent Education  Breast Feeding Assistance % 7.2 Parent Education - Child Development % 7.3 Parent Education  Childhood Injury Prevention % 7.4 Parent Education  Child Passenger Safety % 7.5 Parent Education  Health Related % 7.6 Parent Education  Oral Health % 7.7 Parent Education  Parenting Skills % 7.8 Parent Education  School Readiness % 7.9 Parent Education  Child Abuse Prevention % 7.10 Parent Education  Children with Special Needs % 7.11 Parent Education  Job skills, ESL, GED, parent literacy % 7.12Parent Education  Smoking Cessation % 7.13 Parent Education  Alcohol/Substance Abuse prevention % 7.14 Parent Education - Nutrition/Fitness % 7.16 Parent Education  Other 8. Screening % 8.1 Immunization Screening % 8.2 Dental Screening % 8.3 Developmental Screening % 8.4 Cognitive Screening % 8.5 Mental Health/Behavioral Screening % 8.6 Physical Health Screening % 8.7 Psychosocial Risk Factors Screening % 8.8 Speech, Hearing, Vision Screening % 8.9 Fitness/Physical Activity Screening SVC-2. How many times did your program interact with this child and family? (examples of an interaction  a day of preschool, a clinic visit, a home visit, parent attending a class one day, completed phone call with family) (dont confuse types of service with number of interactions: a child and family may receive several services in one interaction) a. 1 interaction b. 2-5 interactions c. 6-10 interactions d. 11-20 interactions e. 21-50 interactions f. 51-100 interactions g. More than 100 interactions OBJECTIVE: Increase the number of children who are screened and/or assessed for developmental milestones, including vision, hearing, speech and language, psychosocial issues and other special needs, and receive appropriate referrals. HC7S-1. Did the developmental screening uncover a problem that needed to be addressed through an assessment? a. Yes b. No c. No developmental screening performed < Do not answer the remaining questions> HC7S-2. In your professional judgment, how would you classify the problem(s) uncovered by the screening? Please only use Other special needs if the other categories dont come close. (select all that apply) a. Vision b. Hearing c. Speech and Language d. Psychosocial Issues e. Motor Skills f. Weight (BMI) g. Dental h. Other Health Please specify _____________________ i. Other Special Needs Please specify____________________ HC7S-3. Was the child referred for an assessment of the problem(s)? (A referral can be either within your agency or to an outside agency) a. Yes b. No referral was made but feedback was provided to the family c. No referral was made and no feedback was given to the family HC7S-4. Did the child go to a practitioner for the problem for which they were referred (either the agency you referred or an agency of their own choosing)? a. Yes b. No c. Dont know HC7S-5. Did the agency or person who assessed the child communicate the results back to you? a. Yes b. No c. Assessment was never completed HC7S-6. Did your program continue serving this child after the referral for assessment? a. Yes b. No HC7S-7. In your professional judgment with respect to the identified condition(s), what was the childs status at the end of your program? (Select all that apply) a. All conditions improved b. Some conditions improved c. Condition(s) did not improve d. Intervention is still in progress e. Caregivers are not cooperating f. Condition(s) cannot be improved g. Dont know or client lost to follow up Objective: Increase to at least 95% the proportion of children who have a health care home. Objective: Increase to 100% the number of children with health coverage HC11-1. Did this child have health insurance when they arrived at your program for services? a. Yes, public insurance (e.g. Medi-Cal, CalOptima, etc. including infant coverage under the mothers insurance) b. Yes, private insurance (through employer or self) c. No coverage d. Our program did not determine the health insurance status of this child HC11-2. At any time while serving this child, did anyone from this program complete a new application or renewal for health insurance or refer this child to another agency for an application or renewal? a. Yes, our program completed an application or renewal b. Yes, we referred the child to another agency c. No, but we helped the family complete their application or renewal d. No, the child had and maintained insurance e. No HC11-3. Is this child now enrolled? a. Yes, public insurance b. Yes, private insurance c. No d. Dont know or child lost to follow up HC12-4. Did your program provide instruction to this parent about the importance of preventive health care for children? a. Yes b. No c. Dont know or client lost to follow up HC12-5. Did this child have an accessible medical home when they arrived at your program for services? a. Yes b. No c. Our program did not determine whether this child had a medical home HC12-6. In your professional opinion, was your program instrumental in helping this parent secure a medical home or improve accessibility to a medical home for this child? a. Yes, helped child secure a medical home b. Yes, improved accessibility c. No, child had and maintained an accessible medical home d. No e. Dont know or client lost to follow up HC12-7. Does this child have an accessible medical home now? a. Yes b. No c. Dont know or child lost to follow up HC12-8. Has this child been to the medical home for a well child visit? a. Yes b. No c. Dont know or client lost to follow up OBJECTIVE: Increase age appropriate immunizations to at least 95% HC14-1. What was the status of the childs immunizations when they arrived at your program? a. Received all recommended age appropriate shots (including infants under 2 months who have received no shots) b. Received some recommended age appropriate shots c. Received no shots d. Our program did not provide immunization services or screening for this child HC14-2. How did you determine the status of the childs immunizations when they arrived at your program? a. Medical Records b. Yellow Immunization booklet review c. Immunization Registry d. Caregiver report e. Other Please specify __________________ HC14-3. What was the status of the childs immunizations when they completed your program? a. Received all recommended age appropriate shots (including infants under 2 months who have received no shots) b. 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