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 Success Story

Addressing Health Disparities for CYSHCN in New Mexico  

By Susan Chacon, MSW, LISW
New Mexico CYSCHN Director
In New Mexico approximately 80,000 children and youth meet the MCH definition of having a special health care needs. The percent who identify their race/ethnicity other than white alone is 74 percent. Many families live in rural/frontier areas and have high rates of poverty. Many are immigrant families of mixed status with limited options for health care.

The mission of the CYSHCN program Children's Medical Services (CMS) is to ensure coordinated, compassionate, culturally competent care for CYSHCN in NM, and increase access to specialty medical care for CYSHCN in rural NM. How does CMS close the gap in health care disparities? The provision of care coordination for CYSHCN by professional licensed medical public health social workers evens the playing field by providing access to care and alleviating the fragmented care that CYSHCN may be receiving. This care coordination is provided in local public health offices in every county of the state. The CMS social workers live where they work and are based in the culture of the community.  The public health offices are trusted community resources where clients can receive health care services such as WIC, Family Planning, immunizations and can be assessed for eligibility for Medicaid and Insurance Exchange options.

Research has shown that CYSHCN are more likely to have multiple health needs and to see multiple providers who fail to provide a full range of services. A study by Antonelli et al (Pediatrics 2004) noted that "more than half of care coordination encounters with CYSHCN were attributable to issues not considered typically medical." CMS social workers assess family needs and strengths, assist families in understanding diagnosis and its implications, assist with accessing medical information and make appropriate referrals to community services, and ensure linkages exist between families, the Medical Home and specialty providers. In addition, they develop individual care plans, and empower families as decision makers and self-advocates with providers and community system. They honor cultural diversity, plan long term care for CYSHCN and their families through the life span, share legal safeguards, provide social and emotional support, and assist youth with special health care needs to make appropriate transitions to adult health care, work and self-sufficiency. The CMS social workers strengthen support networks and systems of care including assurance that the cultural and linguistic needs of the clients are addressed during medical appointments. Most importantly, they guide families through multiple health care agencies and insurances that make up a complex and fragmented medical system.

The Public Health offices also serve as an access point for multidisciplinary pediatric specialty clinics facilitated by CMS social workers and staffed by specialists from the University of New Mexico Health Sciences Center and Presbyterian Hospital. These community-based pediatric specialty outreach clinics provide multidisciplinary, coordinated diagnostic and/or ongoing medical care to children and youth with pulmonary, endocrine, cleft palate, neurological, nephrology, metabolic and genetic conditions in rural areas that experience a dearth of specialty providers. This service is available to all CYSHCN who have diagnoses addressed by these clinics.   There were 130 clinics held in 16 towns and cities throughout the state in 2013. CMS social workers ensure that recommendations and follow-up care is linked back to the Medical Home for each client seen at clinic and provide ongoing care coordination.

CMS staff are dedicated to the clients in their communities and work on many levels to promote human rights and the principles of social justice and the empowerment of families, reduce disparities in health care access due to issues of poverty, racism and inadequate health care resources, advocate for health improvement policies, and increased funding through leadership around community and public health issues.​