Improving Health for Eastern Ohio’s Most Vulnerable Children: The Integrated Care for Kids Project

Some of Ohio’s children face challenges that are likely to send them to the hospital more often than other kids – and potentially lead to foster care or other placements outside of the home.

These children may live in poverty; have chronic physical or mental health concerns; face housing instability or food insecurity; have family members struggling with substance abuse or other problems. Consistent care and assistance could have a lifelong, positive impact on these children and their families.  

Now, after a two-year planning process, a $14.5 million effort with nearly 50 regional partners is poised to improve the health, well-being and future outcomes of the most vulnerable children in Licking and Muskingum counties.

The project is called Integrated Care for Kids, or InCK. It’s funded by the federal Centers for Medicare and Medicaid Services, and led by Nationwide Children’s Hospital with guidance from the Ohio Department of Medicaid and community stakeholders from both counties. Ohio InCK is one of seven similar initiatives across the United States to develop a holistic model of care to help young people who are at risk.

What sets Ohio’s version of InCK apart is the way it is trying to support, link and amplify the work that so many agencies and organizations are already doing in Licking and Muskingum counties, says Stacy Kramer, director of Regional Wellness at Nationwide Children’s. A Partnership Council with those nearly 50 regional members directs InCK’s strategy and tactics.

“We have physical and mental health care providers, schools, child protective services, health departments, ADAMH (alcohol, drug addiction and mental health) boards and others who are serving these families, but often separately,” she says. “These partners are at the table with us to co-design and co-implement InCK. We all want to make sure that InCK fits these communities and is appropriate for their needs.”

Federal funding began in early 2020, and much of the planning since then has been in developing partnerships and ways to collect and share data, says David Ciccone, Nationwide Children’s project manager for InCK. One of the primary goals of the project is to learn who is the most at risk for repeated hospitalization and placement outside of the home among the approximately 35,000 children in Muskingum and Licking counties covered by Medicaid.

Data about the types of services people have accessed can help determine that, but the partners must agree on how that information is used and shared. As that is becoming clearer, InCK is moving from its two-year planning phase into a five-year implementation phase.

The Partnership Council is considering a number of promising strategies to help the greatest number of children who are at risk, including:

• Care coordination or management. Children and families with multiple needs can find it difficult to navigate the complex care system. A care coordinator organizes and facilitates a child’s overall care.
• Evidence-based home visitation services. Home visitors can support pregnant women and new mothers as they navigate pregnancy and prepare for parenthood.
• School-based services. These services offer another access point for children needing primary care health services. Also included are programs focusing on suicide prevention and teaching young people self-regulation and coping skills.

A requirement of the federal funding is also to develop an “alternative payment model,” or a system for incentivizing better care and outcomes. Nationwide Children’s has an accountable care organization,  Partners For Kids®, which is already one of the country’s pediatric leaders in alternative payment models. InCK leaders conceptualize a system that will build on the Partners For Kids structure.

This entire InCK project was not always understood by the Licking and Muskingum county partners in the beginning, says M. Kathryn Spergel, LISW-S, executive director of the Community Mental Health and Recovery Board of Licking and Knox Counties. She admits to being a skeptic herself.

“I was not sure that it was needed, because we already had a process in place,” she says. “But then I had an ‘aha’ moment. I realized that InCK was going to be a higher level of service for our complex kids and families. I understood it was not just going to embrace mental health but include all of the care these kids need. Then I thought, ‘this is a pretty cool thing.’”

Spergel is now one of the leaders of the Partnership Council. One of her fellow leaders, Carol Howdyshell, RN, MSN, Director of Family & Community Health & Wellness for the Zanesville-Muskingum County Health Department, was ready to buy in from the first time she heard about it.

“I am in public health, and I think of everyone in the community as a possible client. I knew we weren’t meeting the need,” she says. “I can think of so many ways InCK will have an impact on making care more streamlined, on making sure everyone is working together for families. I am looking forward to the way the process evolves.”

The first two years of the project was always projected to be a planning phase. Now, in the first quarter of 2022, the real implementation begins.

“It took us a fair amount of time to set up our network, to understand what everyone could do, and to make sure we can maintain a high standard for the entire project,” says Ciccone. “Now we’re ready to help these children.”         

This project is supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $14.5 million with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS, HHS or the U.S. Government.