Caring for a child at great risk of physical and behavioral health problems—including mental health or substance use challenges—can extend far beyond the walls of a doctor’s office. The trouble is, so do the warning signs.
A new program in the Bronx is tackling the often-difficult problem of identifying these children by sharing data across the various systems where early red flags are found, including schools, child welfare agencies, housing organizations, and clinical care providers.
The Bronx Equity-InCK (BE-InCK) program, featured in a recent UHF webinar, is one of six across the nation testing Center for Medicare and Medicaid Innovation (CMS Innovation Center)’s Integrated Care for Kids (InCK) Model, which aims to both better identify children at risk for physical or behavioral health problems who are covered by Medicaid and better coordinate their care.
“This data-driven approach gives us the ability to broadly look at a population and start focusing our resources in the direction they need to go,” Brian Bandle, MPH, research scientist at the New York State Office of Quality and Patient Safety, told more than 50 webinar participants. “With that...they can start receiving timely approach and outreach.”
The BE-InCK team, led by the New York State Department of Health and Montefiore Medical Center, joined UHF’s Pediatrics for an Equitable Developmental Start (PEDS) Learning Network webinar on July 13 to share their program design, lessons learned, and next steps. UHF’s PEDS Learning Network is supported by the Mother Cabrini Health Foundation.
The BE-InCK model launched in 2022 after two years of planning and targets approximately 32,000 children and pregnant people covered by Medicaid in three North Bronx ZIP codes, each of which consist primarily of Black children and families who are at high risk for poorer health outcomes and, historically, have had limited access to adequate health care.
At its core is a partnership council comprised of 50 agencies and organizations—plus community members—who serve the Bronx population. Through BE-InCK, the council can access a hub of patient data and coordinate to make sure those most at risk are getting the services they need. Physical health, behavioral health, early intervention/special education, child welfare, maternal child health, food insecurity, housing instability, and more are all analyzed under the program’s algorithms.
Ultimately, the InCK Model aims to reduce inpatient admissions, out-of-home placements, and emergency department use among children through its prevention, early identification, and treatment efforts. Nationally, one in three children in Medicaid and CHIP have behavioral health needs, yet only one-third of those in need receive care, according to the U.S. Department of Health and Human Services.
In the Bronx, BE-InCK's data exploration has already led to a range of sub-projects, including advocating for health home services for those with sickle cell disease and using a maternal health app to screen for depression and monitor blood pressure in pregnant people.
The team told webinar participants they hope this data-sharing model can be implemented in other parts of the state and sustain well beyond the InCK seven-year federal grant.
“We certainly have our eye on what can be replicated,” said Douglas Fish, MD, medical director of the New York State Office of Health Insurance Programs.