Information Memorandums (IMs)—2009

Accessing Professional Medical and Dental Services
ACF–IM–HS–09–05

INFORMATION MEMORANDUM

TO: Head Start and Early Head Start Grantees and Delegate Agencies

SUBJECT: Accessing Professional Medical and Dental Services

INFORMATION:

Head Start recognizes the critical role that access to comprehensive preventive and primary health care services plays in promoting school readiness. Each child’s ability to participate in and enjoy success in early childhood education programs is supported through the provision of health, educational, nutritional, social, and other services that are determined, based on family needs assessments, to be necessary. See Section 636 of the Head Start Act.

Head Start Program Performance Standards 45 CFR 1304.40(f)(2)(i) and (ii) require Head Start and delegate agencies to assist parents in enrolling and participating “in a system of ongoing family health care” and to encourage “parents to become active partners in their children’s medical and dental health care process and to accompany their child to medical and dental examinations and appointments.” 45 CFR 1304.20(a)(1)(i) requires grantee and delegate agencies to:

“Make a determination as to whether or not each child has an ongoing source of continuous, accessible health care. If a child does not have a source of ongoing health care, grantee and delegate agencies must assist the parents in accessing a source of care.”

45 CFR 1304.20(e) describes a number of ways through which Head Start and delegate agencies must involve parents in children’s health and developmental assessments, treatment, and ongoing care.

In assisting parents, as required by the Head Start Program Performance Standards, some Head Start and delegate agencies may be uncertain about what medical and dental health care services are available to enrolled families, and how families can access such health care services.
 
Challenges to accessing medical and dental services

Grantee and delegate agencies have sometimes encountered challenges in finding providers of medical and dental services for enrolled children. Barriers to access may include:  lack of availability of pediatric medical and dental service providers in the community; reluctance of health care providers to accept some forms of health insurance such as Medicaid; limitations placed by health care providers on the number of children insured through specific programs accepted into the practice; and/or strict lateness or “no-show” policies that make it unlikely that resource-challenged families will be able to remain in the practice.

Challenges to connecting enrolled children and families with community providers of health care services may be based on the lack of health insurance or coverage.
 
Grantees and delegate agencies have also experienced challenges in finding health care providers who are aware of and responsive to all of the requirements of the Early and Periodic Screening Diagnosis and Treatment (EPSDT) schedule and of the Head Start Program Performance Standards (HSPPS).
 
Strategies for accessing medical and dental services by engaging community health care providers

The grantee’s Health Services Advisory Committee (HSAC) can be a critical resource to identify, recruit, and engage preventive and primary health care providers in the community. HSACs that include community clinical providers such as physicians, nurse-practitioners, nurses, dentists, dental hygienists, and mental health professionals within their memberships may be particularly effective at developing health care resources, policies and procedures.
 
Strategies to engage community health care providers may include:      

• Identification of  health care delivery systems in the community, including private practices, hospital-based ambulatory clinics, and publicly-funded programs such as Federally Qualified Health Centers (FQHCs),  Migrant Health Centers, Rural Health Clinics, and others;    
• Direct person-to-person contact initiated by grantee staff or members of the HSAC with community providers of health care services;         
• Invitations extended to community health care providers to attend HSAC meetings;
• Invitations extended to community health care providers to give presentations to Head Start staff and/or families;          
• Development of collaborative models between grantees and provider offices to help families keep appointments with community health care providers (to address “no-show” concerns); and     
• Development of collaborative models between grantees and provider offices to assist families in participating in the health care provider’s ongoing plan of care.

Strategies for obtaining comprehensive primary and preventive services as determined by each state’s EPSDT schedule may include:

• Clinician members of the HSAC initiating person-to-person contact with community health care professionals to make them aware of the health services requirements for Early Head Start and Head Start children, and the rationale for such services;
• Clinician members of the HSAC contacting local or state clinician organizations (such as the state chapter of the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Pediatric Dentistry) to place material in member newsletters, on-line resources, or to address clinicians directly at chapter meetings through speaking opportunities; and  
• The HSAC identifying and utilizing local child health care clinical resources, such as the State Chapter Child Care Contact through the American Academy of Pediatrics, state contacts through the American Academy of Pediatric Dentistry, and others.

Strategies for connecting children with sources of health insurance or other health care coverage

The majority of children enrolled in Head Start qualify for health care coverage through programs such as Medicaid; State Children’s Health Insurance Programs (SCHIP); health care benefits for Uniformed Services families (Note: the “Uniformed Services” includes Army, Navy, Air Force, Marine Corps, Coast Guard, National Oceanic and Atmospheric Administration, and Public Health Service); or may receive services based on eligibility through the Indian Health Service (IHS). When a child and family are identified without continuous, accessible health care due to the lack of health care coverage, it is essential that staff take action to determine the family's eligibility for health care coverage or services and assist them in applying for benefits and enrolling in a source of accessible and ongoing health care. In circumstances in which the child is not eligible for health care coverage through private insurance, Medicaid, SCHIP, Uniformed Services health care (TRICARE/CHAMPUS, CHAMPVA) or is not eligible for services through IHS, grant-supported Federally Qualified Health Centers are designed to offer a sliding fee scale on services for uninsured individuals.
 
Accessing medical and dental services through publicly-funded Health Centers

Many of the issues grantees and families face in accessing preventive and primary health care services may be addressed through the collaboration of Head Start agencies with health centers administered by the Bureau of Primary Health Care (BPHC) of the Health Resources and Services Administration (HRSA).
 
The mission of the Bureau of Primary Health Care is to improve the health of the nation's underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality, primary health care services.
 
Health centers are community-based and patient-directed organizations that serve populations with limited access to health care. These include low-income populations, the uninsured, those with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and those living in public housing.    
                                                                   
Types of Health Centers

1. Grant-Supported Federally Qualified Health Centers are public and private non-profit health care organizations that meet certain criteria under the Medicare and Medicaid Programs (respectively, Sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act) and receive funds under the Health Center Program, Section 330 of the Public Health Service (PHS) Act. They include the following:

• Community Health Centers serve a variety of underserved populations and areas.
• Migrant Health Centers serve migrant and seasonal agricultural workers.
• Healthcare for the Homeless Programs reach out to homeless individuals and families and provide primary care and substance abuse services.
• Public Housing Primary Care programs serve residents of public housing and are located in or adjacent to the communities they serve. 

2. Outpatient health programs/facilities are operated by tribal organizations (under the Indian Self-Determination and Education Assistance Act, P.L. 96-638) or urban Indian organizations (under the Indian Health Care Improvement Act, P.L. 94-437).
 
3. Federally Qualified Health Center Look-Alikes are health centers that have been identified by HRSA and certified by the Centers for Medicare and Medicaid Services as meeting the definition of “health center” under Section 330 of the PHS Act, although they do not receive grant funding under Section 330.
 
4. Rural Health Clinics (RHC) are located in areas that are designated or certified by the Secretary of the Department of Health and Human Services as Health Professional Shortage Areas (HPSA) or Medically Underserved Areas (MUA).

Additional resources for access to medical and dental services

In some circumstances, even the reduced cost of services through federally- or state-funded programs may present a barrier to the child’s access to services. In other cases, the care needed exceeds the services available through such a provider organization. The Head Start program’s HSAC and staff should be aware of resources in or near their community willing to provide volunteer services, services offered at reduced cost, or services made available under an extended payment plan. The child’s primary health care provider may be aware of such resources and may be able to assist in accessing them. The local or State Department of Health or the Department of Social Services may be aware of resources as well. Community or referral hospitals in the area, medical and dental schools, and professional membership and referral organizations may also provide resources. A partial listing of such entities appears below.
 
Resources to explore for additional help in locating and accessing medical or dental services include:
 
The State’s Medicaid/SCHIP program
The State or local Department of Health
State Offices of Rural Health
Tribal Health Resources
Funded health care service providers which include the following resources:
   Federally-Qualified Health Centers (FQHCs) 
   The Indian Health Service (IHS)
   Uniformed Services/Armed Forces Health Care: TRICARE/CHAMPUS
   Migrant Health Centers
   State-based FQHC “look-alikes”
The State Medical Society
Directory of Health Organizations - State or local groups for promoting general access to care or with a focus on specific health conditions (e.g. asthma, hearing loss, or heart disease)
Private health insurers for private insurance enrolled children
Community providers of primary and sub-specialty health care services
Community and referral hospitals
Universities with medical and dental schools
State or local charitable organizations with a health focus.                                               
 
Use of Head Start grant funds
 
Head Start Program Performance Standard 1304.20(c)(5) states that “Early Head Start and Head Start funds may be used for professional medical and dental services when no other source of funding is available. When Early Head Start or Head Start funds are used for such services, grantee and delegate agencies must have written documentation of their efforts to access other available sources of funding.”  The grantee or delegate agency’s HSAC should assist the Head Start agency in developing policies and procedures through which the program identifies resources to pay for medical and dental services; assists parents or guardians in accessing such resources; and determines the appropriateness and availability of program funds to pay for services.
 
Programs are encouraged to contact their Regional Office for additional assistance regarding the use of grant funds to pay for professional medical or dental services.

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