Curriculum for Promotores(as)/
Community Health Workers in
Texas Health Steps Outreach
and Informing Activities to
Enrolled Texas Health Steps
Recipients
1
Table of Contents
Program Overview…………………………………………………………page 1
Intake and Assessment…....................................................................page 9
Medical Home……………………………………………….……………page 14
Non-medical Home………………………………………………………page 23
Other Needs to Facilitiate Access to Care…………………………….page 32
Follow Up………………………………………………………………….page 41
Resources…………………………………………………………………page 46
Notes………………………………………………………...…………….page 48
Appendices
Appendix A: Intake Dosage Form……….…………………….………page 51
Appendix B: Follow up Dosage Form………………………………...page 55
Appendix C: Tracking Form……………………………………………page 58
1
Glossary
Children with Special Health Care Needs (CSHCN) – Children with special health
care needs are those children who have or are at increased risk for a chronic physical,
development, behavioral, or emotional condition and who also require health and
related services of a type or amount beyond that required by children generally.
Client –A child who is identified as eligible to receive promotor(a)/community health
worker services in the emergency department.
Data Specialist- Person responsible for serving as the data manager for a
Promotores(as)/CHWs pilot program site. Responsibilities include performing data
entry, and collecting follow-up information to be used in the evaluation of the program.
Dental Home – A partnership between a child, the child’s family, and the place where
the child gets primary dental care services. At a dental home, the child’s family and
dental care experts are a team. They work together to find and get all the services the
child and family need.
Department of State Health Services (DSHS) – DSHS is responsible for the oversight
of health services in Texas and provides direct administration of some programs.
Dosage Form - An evaluation tool that captures client encounters. It captures the
number, type, and duration of services received.
Health and Human Service Commission (HHSC) –HHSC oversees the operations of
the health and human services system, provides administrative oversight of Texas
health and human services programs, and provides direct administration of some
programs.
Medical home A partnership between a child, the child’s family, and the place where
the child gets primary health care services. At a medical home, the child’s family and
health care experts are a team. They work together to find and get all the services the
child and family need, even if they are not medical services.
Non-Acute Condition – A non-life threatening condition that will not result in serious
harm without immediate medical attention.
Preventive Care –measures to prevent illness or injury.
Promotores(as)/Community Health Worker (P/CHW)- Lay members of communities
who work either for pay or as volunteers in association with the local health care system
in both urban and rural environments and usually share ethnicity, language,
socioeconomic status, and life experiences with the community members they serve.
2
Recipient – A child who receives Texas Health Steps benefits.
Texas Health Steps –A service under Medicaid that provides medical and dental
checkups, care, and case management services to children from birth through age 20
who are enrolled in Medicaid. DSHS and HHSC work together to administer Texas
Health Steps.
3
Promotores(as)/Community
Health Workers in Texas Health
Steps Outreach and Informing
Activities to Enrolled Texas
Health Steps Recipients
Program Overview
4
PROMOTORES(AS)/COMMUNITY HEALTH WORKERS IN TEXAS HEALTH STEPS
OUTREACH AND INFORMING ACTIVITIES TO ENROLLED TEXAS HEALTH STEPS
RECIPIENTS
Background
In response to the high rate of emergency department utilization by Texas Health Steps
recipients for non-acute care, the Texas Health and Human Service Commission in
collaboration with the Texas Department of State Health Services has developed the
Promotores(as)/Community Health Workers in Texas Health Steps Outreach and
Informing Activities to Enrolled Texas Health Steps Recipients (pilot program).
The pilot program places Promotores(as)/Community Health Workers (P/CHWs) in
emergency departments with high rates of Texas Health Steps recipients who present
with non-acute conditions. During the non-acute visit to the emergency department, the
P/CHWs will provide outreach and informing on Texas Health Steps benefits and
services, assist in identifying a medical and/or dental home for the Texas Health Steps
recipient, link the Texas Health Steps recipient with providers, and follow-up to
encourage utilization of preventive care.
The P/CHWs in each participating hospital will be paired with a Data Specialist to
ensure effective follow-up, accurate data collection and entry, and to facilitate the
evaluation of the pilot.
Goals
The primary goals of the pilot program are to achieve the following objectives:



Enhance targeted outreach and informing efforts toward Texas Health Steps
recipients and/or caretakers who are accessing services for a non-acute
condition in an acute care setting.
Promote the medical and dental home concept and utilization of preventive
health services to Texas Health Steps recipients utilizing the emergency
department for non-acute care.
Identify a medical and/or dental home for each presenting Texas Health Steps
recipient and increase Texas Health Steps medical and dental checkup
participation rates.
5
CLIENT ELIGIBILITY
Client eligibility shall be limited to children birth through age twenty (20) enrolled in
Medicaid who present in the emergency department for non-acute care. Identification of
potential clients for intervention by P/CHWs is based on the following criteria: client is
enrolled in Medicaid, is aged from birth though twenty (20), is in the emergency
department and has a non-acute condition. A non-acute care visit to the emergency
department is generally considered a visit that is unnecessary or avoidable and involves
a health problem that can be treated by a primary care physician or could have waited
longer than 12 hours to treat. Each emergency department will determine which clients
meet these eligibility criteria for referral to the P/CHW.
SCOPE OF WORK
The pilot program will utilize P/CHWs to address non-acute care visits to emergency
departments by Texas Health Steps recipients. P/CHWs will focus on providing
additional outreach and informing on Texas Health Steps benefits and services,
identifying a medical and/or dental home for a Texas Health Steps recipient, linking the
Texas Health Steps recipient with providers, and following up to encourage utilization of
preventive care in a medical and dental home among Texas Health Steps recipients
utilizing the emergency department for non-acute care.
Data will be gathered through the intake and follow-up processes to ensure the
effectiveness of the pilot through a systematic evaluation.
Upon receiving a referral to see a Texas Health Steps recipient, the P/CHW will begin
the intake process and will complete an intake dosage form that will gather basic
information about the client and the visit to the emergency department.
Promotores(as)/CHW Responsibilities
The P/CHWs placed in the emergency department will be responsible for the following:

Coordinating with emergency department staff to identify Texas Health Steps
recipients accessing the emergency department for non-acute care.

Facilitating the completion of the intake dosage form by the Texas Health Steps
recipient and/or caretaker.

Assessing for barriers that contribute to the client’s use of the emergency
department for non-acute care. Providing information and resources to address
6
barriers to accessing the medical or dental home to assist client in limiting or
avoiding the use of the emergency department for non-acute needs in the future.

Assisting in identifying a medical and/or dental home for Texas Health Steps
recipient (if not currently established).

Linking the Texas Health Steps recipient and/or caretaker with a provider.
Data Specialist Responsibilities
The designated Data Specialist will be responsible for the following:

Providing training to the P/CHWs on intake process.

Serving as the data manager responsible for regular and timely entry of data
from data collection tools (i.e., tracking forms and dosage forms), quality
assurance of data, and monthly data submission to DSHS.

Following up by telephone with each Texas Health Steps recipient to check on
perception and utilization of preventive care.

Collecting and documenting follow-up information on the follow-up dosage form.
TRAINING AND EVALUATION
Training
DSHS will be responsible for the initial training of P/CHWs on the pilot program
curriculum. If P/CHW staff turnover occurs, additional training will be the responsibility of
contracted hospitals. It is expected that hired P/CHWs will already be certified through
the DSHS Promotores(as) or Community Health Worker Training and Certification
Program and will have the competencies necessary for providing services. At a
minimum, the P/CHWs will have completed the following four Texas Health Steps online
provider education modules available at www.txhealthsteps.com prior to P/CHW
curriculum training:

Overview,

Introduction to the Medical Home,

Cultural Competence, and

Case Management Services in Texas.
7
Curriculum
DSHS has developed a curriculum that will provide the necessary information P/CHWs
will need to facilitate the pilot program. For P/CHWs, the curriculum includes scripts and
prompts to be used with the Texas Health Steps recipient and/or caretaker. The
curriculum will train P/CHWs to provide information tailored to meet each Texas Health
Steps recipient’s individual needs to include, but is not limited to, information to help
address transportation needs, identify provider resources, and educate about other
Medicaid services.
Evaluation and Data Collection
Each hospital will be responsible for overseeing data management/entry/quality
assurance, and data submission to DSHS. DSHS will be responsible for the overall
evaluation of all pilot programs. Hospital activities necessary to support the program
evaluation include intake and follow-up data collection from Texas Health Steps
recipients including but not limited to:












documenting demographic information of client (i.e., gender, race, ethnicity,
etc.),
documenting reason for non-acute emergency department visit,
documenting information on primary care provider/dentist and medical/dental
home (i.e., does the client have a PCP/dentist and/or medical/dental home),
self-reported perceived importance of keeping regularly scheduled preventive
care appointments (medical/dental),
documenting duration of encounter,
documenting education given on role of medical/dental home, role of
medical/dental provider for non-acute conditions, and Texas Health Steps and
preventive health care,
documenting number and type of referrals (given by certified P/CHWs),
documenting information on primary care provider/dentist and medical
home/dental (i.e., does the client have a PCP/dentist and/or medical/dental
home),
at follow-up, documenting whether appointment with PCP and dentist was
made/kept,
at follow-up, assess client satisfaction with services,
at follow-up assess client confidence in using a PCP/dentist for non-acute
conditions, and
at follow-up, assess self-reported perceived importance of keeping regularly
scheduled preventive care appointments (medical/dental)
Data collection completeness, accurate and regular entry, and timely submission
of data to DSHS are all key elements of the pilot program evaluation.
8
Promotores(as)/Community
Health Workers in Texas Health
Steps
and
Informing
Texas Outreach
Emergency
Department
Activities
Enrolled Texas
Diversion to
Program:
Health Steps Recipients
Intake
Intake and Assessment
9
Intake and Assessment
INTAKE PROCESS
Upon receiving a referral to see a Texas Health Steps recipient, the P/CHW will
complete an intake dosage form that will gather basic information about the client and
the visit to the emergency department. Information that will be gathered includes:
1)
2)
3)
4)
5)
6)
7)
8)
Medicaid ID
Client gender and date of birth,
Race,
Ethnicity,
Reason for visit to the emergency department,
Primary care provider/dentist name (if known),
Barriers to accessing care, and
Perceived importance of keeping regularly scheduled preventive care
appointments (medical/dental).
This information is the foundation to the outreach and informing interaction and is a
gateway to talking to the client and/or caretaker about Texas Health Steps and the
benefits of preventive care.
Utilizing information gathered from the intake dosage form will help determine which
pathway to take with the family. For example, if the family said that they do not have a
primary care provider or dentist, then the pathway for “Non-Medical/Dental home”
should be followed.
This form will also allow the P/CHW to document the duration of the contact, and any
resources and/or referrals that were made during the brief visit. Referrals may include:



Contacting Texas Health Steps to connect the family with a primary care
provider,
Providing information about the Medical Transportation Program, or
Offering local community resources if needed.
A comprehensive tracking form must also be completed during the visit. It will be used
to contact the client and/or caretaker for follow-up one week later. The tracking form
may be filled out by the client and/or caretaker, but the P/CHW is responsible for its
completion.
10
Intake and Assessment
CLIENT IDENTIFICATION AND REFERRAL PROCESS
The following process chart provides the P/CHW with the steps for identifying clients
who would be appropriate for the pilot program. Each pilot program may vary in how
the referral process is implemented; however, the clients who are eligible to be referred
will remain the same across all sites.
11
Intake and Assessment
ASSESSMENT PROCESS AND BARRIER IDENTIFICATION
Once the P/CHW receives a referral to consult with an eligible client, a formal intake
process is conducted using a standardized dosage form (Appendix A). A
comprehensive tracking form (Appendix C) will be completed during the intake process
for use at follow-up to contact the client one week after initial contact in the emergency
department. The information collected during the intake process will be entered in to a
database to assist in the evaluation of the program.
During the intake process, the P/CHW will engage the client and/or caretaker to gain a
better understanding of any barriers that may exist for the client/caretaker in accessing
their medical or dental home. Barriers to accessing care will be addressed through
three primary areas: 1) accessing the medical or dental home, 2) the client/caretaker
does not have a medical or dental home; or 3) other barriers that may limit the client or
caretaker’s access to care.
The chart below describes the intake and assessment process to help the P/CHW
determine which pathway of intervention he/she will take with each client or caretaker.
12
Intake and Assessment
RESOURCE LINKING BASED ON NEED
The following figure provides the P/CHW with an overview of resources that can be
provided or steps that may be taken with the client/caretaker based on the individual’s
needs. For example, if a client/caretaker is pleased with his/her provider, but has
problems accessing care due to transportation problems, one of the options is to
provide the client/caretaker with information about the Medical Transportation Program.
The P/CHW may also find that linking the client/family to services such as case
management or local community resources may be appropriate as well.
13
Promotores(as)/Community
Health Worker in Texas Health
Steps Outreach and Informing
Activities to Enrolled Texas
Health Steps Recipients
Medical Home
14
Medical Home Process
IDENTIFYING MEDICAL/DENTAL HOME NEEDS
The following process chart provides the P/CHW with the steps for identifying and
addressing medical/dental home needs. The amount of time spent on each of these
steps will depend on the client/caretaker’s individual needs.
15
Medical Home Process
Assess for barriers to Medical/Dental Home
Easy access to a medical/dental home is a necessary part of preventive health care.
Many families have an established medical/dental home; however, they have difficulty
accessing the doctor/dentist due to certain barriers. Barriers may include lack of
transportation, school attendance issues, employment issues, doctor’s/dentist’s office
hours and/or location of office, and many more. As part of the visit with the
client/caretaker, it is the responsibility of the P/CHW to complete the intake dosage form
referenced in the Intake and Assessment Section of this manual and included as
Appendix A. This section will provide some guiding questions for the P/CHW to assist
them in identifying barriers and completing the intake dosage form.
Guiding Questions/Discussion Prompts*
*These questions are only meant to be conversation starters and do not fully capture
the extent of the conversation.









Tell me about what brought you here today.
I understand that you see (Insert Primary Care Provider name). Is (Insert
Primary Care Provider name) aware that you are here today?
Did your doctor or the office staff tell you to come to the emergency department?
Did you consider calling your doctor before coming to the ER? If no, is there a
particular reason?
Tell me, is there anything that kept you from seeing your doctor for “today’s
reason”.
Are you able to get an appointment with your doctor/dentist easily when you
need to?
Is (Insert Primary Care Provider/dentist name) meeting your needs?
What might make it easier for you to see your doctor/dentist when you need to?
When was the last time you visited (Insert Primary Care Provider/dentist name)?
ADDRESS BARRIERS LIMITING ACCESS TO THE MEDICAL/DENTAL HOME
Addressing the barriers to accessing the medical/dental home may make the difference
between a Texas Health Steps recipient regularly using their primary care provider and
unnecessarily utilizing the emergency department for non-acute conditions. Each
client/caretaker will have his/her unique needs addressed. Below you will find the steps
to address the barriers to accessing a medical/dental home. Certain steps may refer
the P/CHW to later sections of this manual.
16
Medical Home Process
1) Determine if client/caretaker is interested in changing providers to better meet
individual needs.
If the client or caretaker is NOT interested in changing providers,
refer to “Other Needs” section of this manual for guidance.
2) Identify new provider options
a. Determine what the client/caretaker is looking for in a medical/dental
home
i. Examples include: extended office hours, closer to home or bus
line, language spoken by physician/staff, etc.
ii. Example prompts may include:
“Would a doctor’s office on a bus line be easier for you to get to?
“Is it easier for you to visit the doctor in the evening?”
b. Review the Online Provider Look-up (OPL) and work with client/caretaker
to select up to 3 potential providers.
3) Contact Texas Health Steps at 1-877-847-8377 and assist client/caretaker in
selecting a provider and setting up a follow-up appointment.
4) If client/caretaker has other barriers that may prevent them from accessing their
medical/dental home, refer to “Other Needs” section of this manual for
guidance.
5) Determine if client/caretaker is familiar with benefits of regular checkups and
preventive health care, immunization schedule, periodicity chart, etc. If not
familiar with Texas Health Steps Checkups, see Educate about the role and
expectations of Medical/Dental Home in this section of the manual.
EDUCATE ABOUT THE ROLE AND EXPECTATIONS OF MEDICAL/DENTAL HOME
A medical/dental home is designed to be the primary relationship dedicated to a child’s
health care. A medical/dental home is a partnership between a child, the child’s family,
and the place where the child gets primary health or dental care. At a medical/dental
home, the child’s family and health care experts are a team. They work together to find
and get all the services the child and family need.
Below are some points the P/CHW can share with the client/caretaker about the role
and expectations of the medical/dental home.
17
Medical Home Process
Role of Medical/Dental home
1) A medical/dental home strives to improve an individual’s health and quality of life.
2) Provides continuous care – the same doctor sees the individual over time.
a. Familiar with the specific individual’s needs.
b. Familiar with the specific health history.
c. Can help the individual make better informed decisions about health care.
What can be expected from a medical/dental home
You and/or your family can expect that the medical/dental home staff will:
1) Know and remember you and/or your child,
2) See you and your family as the expert in your/your child’s care,
3) Respect your and/or your family’s ideas, customs, and beliefs,
4) Help you and/or your family coordinate care and information among
multiple professionals and services, and
5) Provide community-based health care at times that best serve the
community and the family.
EDUCATE ABOUT TEXAS HEALTH STEPS BENEFIT PACKAGE AND
PREVENTIVE HEALTH CARE
Families receive orientation information about Texas Health Steps upon their initial
enrollment in Medicaid, and this can be an ideal time to reinforce their knowledge and
understanding of the benefits of Texas Health Steps. The following will provide the
P/CHW with some basic talking points to share with the client/caretaker about Texas
Health Steps benefits.
As a reminder, if the client is an adolescent or young adult, age 11 through 20,
speak to the client in addition to the parent/caretaker as appropriate. Instead of
referring to “your child” below, speak directly to the adolescent/young adult and
say “you.” When speaking to both the adolescent/young adult and the
parent/caretaker, make sure they understand you are talking about
benefits/services for the adolescent/youth.
The P/CHW might say:
Texas Health Steps will:

Help you find a doctor and dentist for your child.

Help you set an appointment for your child to see a doctor and dentist.
18
Medical Home Process

Help you get a ride or money for gas to get to health care appointments.

Answer questions you may have about the services your child can receive.
You can always call 1-877-847-8377 with any questions.
(Note to P/CHW: Provide Texas Health Steps wallet card)
Your child can receive:
-
Medical and dental checkups and treatment at no cost to you.
Vision and hearing screenings.
Lab tests and shots, if needed, at no cost to you.
Case management for children who have a health condition/risk and need
assistance in getting related services.
New eye glasses and repair or replacement if glasses are lost or broken.
Hearing aids and repair or replacement through the Hearing Services for
Children Program.
Prescriptions to help your child stay well or get well when sick.
Checkup information
Why are checkups important?
1) Checkups find health problems when they are small even when your child
feels okay.
2) Checkups prevent health problems that make it hard for your child to grow
and learn.
3) Dental checkups can help your child have a healthy smile. Dental checkups
are needed every 6 months to catch problems early.
4) Shots that may be given during medical checkups help to keep children of all
ages safe from harmful diseases.
Provide the client/caretaker age specific reasons for checkups: use appropriate
age grouping for the child presenting in the ER. For youth 11 thru 20, you are
encouraged to speak directly to the child to provide this information.
The following are some points the P/CHW can share with the client/caretaker
about what the provider may look for during a regular checkup.
19
Medical Home Process
(Provide: Texas Health Steps Checkups by Your Child’s Age Handout)
Birth to 1 year old:

Babies should be seen at 3-5 days old, 2 weeks old, 2, 4, 6, and 9
months old.

Make sure your baby is eating enough and gaining weight as
he/she should.

During checkups, babies have their physical development, hearing,
vision, and behavior checked to make sure they are developing as
they should.

Dental home visits should begin at 6 months old.
1 to 4 years old:

Toddlers should be seen by the doctor at 12, 15 and 18 months, 2,
3, and 4 years old.

Make sure toddlers are eating healthy foods and developing
healthy sleeping habits.

Doctors check toddlers to see if they are beginning to crawl and
walk, are learning to speak words, and are beginning to play with
others.

Dental checkups begin at 6 months old and continue every six
months, and dentists will check to make sure your baby’s mouth
and teeth are healthy.
5 to 10 years old:

Your school-aged child will have his/her hearing and vision screened
during medical checkups so he/she will be able to hear their teacher
and can see to read and write.

Your child’s height and weight are measured to make sure they are
growing as they should.

Dentists will put special coatings called sealants on children’s teeth
that help prevent cavities.
20
Medical Home Process

Children should be seen by their doctor each year and should receive
a dental checkup every 6 months.
11 to 21 years old: (Try to talk to both the Teen/young adult AND the
parent. Use “your” or “your child” as appropriate, but make sure they
understand you are talking about benefits/services for the teen.)

You need a medical checkup every year.

Your doctor will talk to you about eating habits, physical activity, how to
keep safe, and how to have a healthy lifestyle.

Even as a teenager or young adult, you should still see the doctor
every year whether you’re sick or not. Teens and young adults should
see a dentist for a dental checkup every 6 months.
Clients/caretakers may ask, “How do I know when it is time for a checkup?”
The P/CHWs may share the following information with the client/caretaker.
1) Check the Medicaid Identification form for a message by your child’s name
that shows a medical and/or dental checkup is due.
2) If no message appears by your child’s name, then a checkup is not due.
3) If your child is sick or hurting but not due for a checkup, you should take your
child to see the doctor or dentist.
21
Medical Home Process
FOLLOW-UP WITH CLIENT AND/OR CARETAKER
Following the interaction with the client, and once resources and/or referrals have been
provided, let the client/caretaker know that a representative from the hospital (i.e., the
data specialist) will be giving them a call in one week to verify that they were able to
make/keep their appointment with the doctor/dentist. They will also be asked about the
experience working with the P/CHW in the emergency department. See Follow-up
Section in this manual for further follow-up process details.
22
Promotores(as)/Community
Health Workers in Texas Health
Steps Outreach and Informing
Activities to Enrolled Texas
Health Steps Recipients
Non-Medical Home
23
Non-Medical Home Process
IDENTIFYING MEDICAL/DENTAL HOME NEEDS
The following process chart provides the P/CHW with the steps for identifying and
addressing medical/dental home needs when there is no medical/dental home
established. The amount of time spent on each of these steps will depend on the
client/caretaker’s individual needs.
24
Non-Medical Home Process
EDUCATE ABOUT THE ROLE AND EXPECTATIONS OF MEDICAL/DENTAL HOME
Having an established medical/dental home is an important part of preventive care. Not
every Texas Health Steps recipient will have an established medical/dental home and/or
may not understand the importance of establishing one. A medical/dental home is
designed to be the primary relationship dedicated to a child’s health care. A
medical/dental home is a partnership between a child, the child’s family, and the place
where the child gets primary health care. At a medical/dental home, the child’s family
and health care experts are a team. They work together to find and get all the services
the child and family need.
Below are some points the P/CHW can share with the client/caretaker about the role
and expectations of the medical/dental home.
Role of medical/dental home
1) A medical/dental home strives to improve a client’s health and quality of
life
2) Provides continuous care – the same doctor (or group of doctors) sees the
client over time.
a. Familiar with the client’s specific needs.
b. Familiar with the specific health history.
c. Can help you make better informed decisions about health care.
What can be expected from a medical/dental home
You and/or your family can expect that the medical/dental home staff will:
1) Know and remember you and/or your child,
2) See you and your family as the expert in your/your child’s care,
3) Respect your and/or your family’s ideas, customs, and beliefs,
4) Help you and/or your family coordinate care and information among
multiple professionals and services, and
5) Provide community-based health care at times that best serve the
community and the family.
25
Non-Medical Home Process
EDUCATE ABOUT TEXAS HEALTH STEPS BENEFIT PACKAGE AND
PREVENTIVE HEALTH CARE
Families receive orientation information about Texas Health Steps upon their initial
enrollment in Medicaid, and this can be an ideal time to reinforce the benefits of Texas
Health Steps and preventive health care, and assist clients in establishing a
medical/dental home. The following will provide the P/CHW with some basic talking
points to share with the client/caretaker about Texas Health Steps benefits.
As a reminder, if the client is an adolescent or young adult, age 11 through 20,
speak to the client in addition to the parent/caretaker as appropriate. Instead of
referring to “your child” below, speak directly to the adolescent/young adult and
parent/caretaker, make sure they understand you are talking about
benefits/services for the adolescent/youth. Consider teen privacy and consent
issues and possibly speak only to the teen.
The P/CHW might say:
Texas Health Steps will:

Help you find a doctor and dentist for your child.

Help you set an appointment for your child to see a doctor and dentist.

Help you get a ride or money for gas to get to health care appointments.

Answer questions you have about the services your child can receive.
You can always call 1-877-847-8377 with any questions (Note to P/CHW: Provide
Texas Health Steps wallet card)
Your child can receive:







Medical and dental checkups and treatment at no cost to you.
Medical checkups include vision and hearing screenings.
Lab tests and shots, if needed, at no cost to you.
Case management for children who have a health condition/health risk and need
assistance in getting related services.
New eye glasses and repair or replacement if lost or broken.
Hearing aids and repair or replacement through the Hearing Services for
Children Program.
Prescriptions to help you or your child stay well or get well when they are sick.
Checkup information
26
Non-Medical Home Process
Medical and dental checkups are offered to you or your child at no cost.
Why are checkups important?
1) Checkups find health problems when they are small even when your child
feels okay.
2) Checkups help to prevent health problems that make it hard for your child
to grow and learn.
3) Checkups help your child have a healthy smile.
4) Shots that may be given during medical checkups keep children of all
ages safe from harmful diseases.
5) Dental checkups are needed every 6 months to catch problems early.
Provide the client/caretaker age specific reasons for checkups: use appropriate
age grouping for the child presenting in the ER. For youth 11 thru 20, you are
encouraged to speak directly to the child to provide this information.
The following are some points the P/CHW can share with the client/caretaker
about what the provider may look for during a regular checkup.
(Provide: Texas Health Steps Checkups By Your Child’s Age Handout)
Birth to 1 year old:

Babies should be seen at 3-5 days old, 2 weeks old, 2, 4, 6, and 9
months old.

Make sure your baby is eating enough, gaining weight, and growing
as they should.

During checkups, babies have their physical development, hearing,
vision, and behavior checked to make sure they are developing as
they should (give examples).

Dental home visits should begin at 6 months old.
1 to 4 years old:

Toddlers should be seen by the doctor at 12, 15 and 18 months, 2,
3, and 4 years old.
27
Non-Medical Home Process

Make sure toddlers are eating healthy foods and developing
healthy sleeping habits.

Doctors check toddlers to see if they are beginning to crawl and
walk, are learning to speak words, and are beginning to play with
others.

Dental checkups begin at 6 months old and continue every six
months, and dentists will check to make sure your baby’s mouth
and teeth are healthy.
5 to 10 years old:

Your school-aged child will have his/her hearing and vision screened
during medical checkups so he/she will be able to hear their teacher
and can see to read and write.

Your child’s height and weight are measured to make sure they are
growing as they should.

Dentists will put special coatings called sealants on children’s teeth
that help prevent cavities.

Children should be seen by their doctor each year and should receive
a dental checkup every 6 months.
11 to 21 years old: (Talk to the Teen/young adult AND the parent. Use “your” or
“your child” as appropriate, but make sure they understand you are talking about
benefits/services for the teen.) Consider teen privacy and consent issues and
possibly speak only to the teen.
You need a medical checkup every year.

Your doctor will talk to you about eating habits, physical activity, how to
keep themselves safe, and how to have a healthy lifestyle.

Even as a teenager or young adult, you should still see the doctor
every year whether you’re sick or not. Teens and young adults should
see a dentist for a dental checkup every 6 months.
Clients/caretakers may ask, “How do I know when it is time for a checkup?”
The P/CHWs may share the following information with the client/caretaker.
28
Non-Medical Home Process
4) Check your Medicaid Identification form for a message by your child’s name
that shows a medical or dental checkup is due.
5) If no message appears by your child’s name, then a checkup is not due.
6) If your child is sick or are hurting but not due for a checkup, you should take
your child to see the doctor or dentist.
ASSESS FOR MEDICAL/DENTAL HOME NEEDS AND ADDITIONAL BARRIERS
Easy access to a medical/dental home is a necessary part of preventive health care.
Some Texas Health Steps recipients do not have an established medical/dental home
and have difficulty accessing the doctor /dentist due to certain barriers. Barriers may
include lack of transportation, school attendance issues, employment issues,
doctor’s/dentist’s office hours and/or location of office, and many more. As part of the
visit with the client/caretaker, it is the responsibility of the P/CHW to complete the intake
dosage form referenced in the Intake and Assessment Section of this manual and
included as Appendix A. This section will provide some guiding questions for the
P/CHW to assist them in identifying barriers and completing the intake dosage form.
Guiding Questions/Discussion Prompts*
*These questions are only meant to be conversation starters and do not fully capture
the extent of the conversation.







Tell me about what brought you here today?
Who do you usually see for care when your child isn’t feeling well? (answers from
client may include: the hospital, local clinic, no one, etc.)
In the past did your child regularly see a primary care provider for care?
Can you tell me some of the reasons you stopped seeing (Insert Primary Care
Provider name)?
When was the last time your child went to the primary care provider for a
checkup? (i.e. preventive care, well-child checkup)
What might make it easier for you to see a primary care provider/dentist when
you need to?
How would you describe your child’s ideal primary care provider/dentist?
29
Non-Medical Home Process
ADDRESS MEDICAL/DENTAL HOME NEEDS AND ADDITIONAL BARRIERS
Addressing reasons why a Texas Health Steps recipient may not access a
medical/dental home may make the difference between a recipient regularly using their
primary care provider and unnecessarily utilizing the emergency department for nonacute conditions. Each client/caretaker will have his/her unique needs addressed.
Below you will find the steps to help a Texas Health Steps recipient establish a
medical/dental home. Certain steps may refer the P/CHW to later sections of this
manual.
1) Determine if client/caretaker has a medical/dental home.
If family is NOT interested in establishing a new medical/dental
home, refer to the “Resources” section of this manual to address
other needs.
2) Identify new provider options
a. Determine what the family is looking for in a medical/dental home
i. Examples include: extended office hours, closer to home or
bus line, language spoken by physician/staff, etc.
ii. Example prompts may include:
“Would a doctor’s office on a bus line be easier for you to get
to?
“Is it easier for you to visit the doctor in the evening?”
b. Review the Online Provider Look-up (OPL) and work with
client/caretaker to select up to 3 potential providers.
3) Contact Texas Health Steps at 1-877-847-8377 and assist
client/caretaker in selecting a provider and setting up a follow-up
appointment.
4) If client/caretaker has other barriers that may prevent access to a
medical/dental home, refer to “Other Needs” section of this manual for
guidance.
30
Non-Medical Home Process
FOLLOW-UP WITH CLIENT AND/OR CARETAKER
Following the interaction with the client, and once resources and/or referrals have been
provided, let the client/caretaker know that a representative from the hospital (i.e., the
data specialist) will be giving them a call in one week to verify that they were able to
make/keep the follow-up appointment with the doctor/dentist. They will also be asked
about the experience working with the P/CHW in the emergency department. See
Follow-up Section in this manual for further follow-up process details.
31
Promotores(as)/Community
Health Workers in Texas Health
Steps Outreach and Informing
Activities to Enrolled Texas
Health Steps Recipients
Other Needs to Facilitate
Access to Care
32
Other Needs to Facilitate Access
Other needs that the P/CHWs may need to address with the client/caretaker may fall
into three categories: transportation needs, the need for case management, and the
need for additional community support services and education. Clients may need only
one or multiple of these areas to be addressed. Once the P/CHWs have addressed the
identified need(s), the P/CHWs will follow-up with the client/caretaker as discussed in
previous sections of this manual.
33
Other Needs to Facilitate Access
TRANSPORTATION
Lack of transportation can often be a barrier to accessing health care. Even if
transportation is available some of the time (e.g. family shares one car), coordinating
transportation during the day, when most clinics are open, may prove to be challenging
for clients and their families.
Medical Transportation Program (MTP)
Medical transportation services are available for Medicaid recipients that have no other
means of transportation to get to a scheduled healthcare appointment.
Texas Health Steps recipients are eligible for medical transportation services through
the Medical Transportation Program (MTP). Below is some information about the
program that can be shared with the client/caretaker. Provide the MTP brochure to
client.
MTP offers a free ride to and from appointments for healthcare services covered by
Medicaid if clients have no other way to get there. Covered Medicaid services include
but are not limited to dental and well child checkups, immunizations, pharmacies, and
medical or dental treatment.
Before calling for a free ride, the client/caretaker must have already scheduled an
appointment to see a healthcare provider. MTP requires at least two workdays
advance notice for most appointments. MTP will try to accommodate urgent
requests as much as possible. For example, if the child has a new onset of illness,
and transportation is an issue, the family may call MTP to see if MTP can get them a
ride. The family should be sure to call the doctor/dentist to schedule the appointment
first.
MTP arranges transportation services through the most cost effective type of
transportation that fits the client’s needs. For example, services may be provided by
fixed route bus service, where available, if the client is going to a medical or dental
checkup.
Services are available on weekdays from 8:00 a.m. to 5:00 p.m., including during the
noon hour.
MTP may provide other transportation services such as mileage reimbursement, mass
transit tickets, and out-of-area transportation.
See MTP brochure for additional information
34
Other Needs to Facilitate Access
The following are some strategies to help families address transportation needs:
1) Does the family have a vehicle? Strategize how competing transportation needs
can be coordinated to allow the family to access medical/dental home. If the
family has a vehicle, but cannot afford to purchase gas, they may be able to be
reimbursed for gas and mileage used to take the child to the appointment. The
intake worker at MTP can advise them if and how they can become eligible for
this service.
2) Can the client/caretaker enlist the help of family and friends? If so, then
transportation services can be provided by this individual who will be reimbursed
for gas and mileage if they become an Individual Transportation Provider (ITP).
See Mileage reimbursement information from MTP
3) Can the client/caretaker access public transportation? —Help client/caretaker
map out a bus route to medical/dental home. See Mass Transit Tickets
information from MTP
4) Are there other local services available? (e.g. cab vouchers)
**Special note for 15 through 17 year olds
P/CHWs are encouraged to speak directly to older teens to provide this
information. Consider teen privacy and consent issues if speaking only to the
teen without the caretaker present.
A teen may travel without an adult if the caretaker has filled out a consent form before a
trip is scheduled.
** Special note about Mileage Reimbursement that the P/CHW should share with
the client/caretaker about what Medicaid/MTP requires:

Medicaid will provide mileage reimbursement to someone else to drive you to
your health care appointment or to the drug store. The driver must fill out the
Individual Transportation Provider Form, each trip must be approved before the
person drives you, and MTP must receive verification that the appointment was
kept before the ITP will be paid. ITPs are individuals who drive a client to a
Medicaid health care appointment. An ITP may be a family member, relative,
friend, or a neighbor. ITPs are reimbursed for the mileage they incur while
transporting a client. The reimbursement rate is the same rate as for state
employees. ITPs must have a current driver’s license, vehicle registration, and
automobile liability insurance. They must also sign the ITP agreement with MTP.
35
Other Needs to Facilitate Access
Requesting MTP Services:
Eligible clients, or their parent/caretaker can request transportation services by calling
the MTP toll-free telephone at 1-877-633-8747.
Please call:

8 a.m. to 5 p.m. Monday through Friday

2 business days or more before the ride is needed

5 business days or more before the ride is needed for out-of-town or long
distance appointments.

MTP staff will try to accommodate urgent same or next day service requests but
cannot guarantee a ride.
When calling MTP, the following information must be provided to the MTP intake staff:

Medicaid number of the person needing the ride.

Address where you want to be picked up and a telephone number, if available,
where you can be reached.

Name, address and telephone number of the health care provider where the ride
is needed.

Date and time of the appointment and any special services needed, for example,
a wheelchair.

Statement that no other means of transportation are available.
If the child’s appointment has been changed or canceled after transportation
arrangements have been made with MTP the parent/caretaker must notify MTP staff as
soon as possible but no later than one business day in advance of the scheduled ride or
service.
36
Other Needs to Facilitate Access
CASE MANAGEMENT
Complicated or chronic health conditions can often be a barrier to accessing health
care. Even if conditions are managed well, families can benefit from additional support.
Case Management for Children and Pregnant Women is a Medicaid benefit offered in
Texas.
The following are eligibility requirements to receive case management services.
Infants, children, teens and young adults (birth through age 20)
1) Medicaid Eligible;
2) Have or are at-risk for having a health problem that keeps them from doing
things that other kids their age do;
3) Need help getting services to keep health problems from getting worse;
4) Have to want case management services.
Pregnant Women (including pregnant adolescents)
1)
2)
3)
4)
Medicaid Eligible;
Have a high-risk pregnancy;
Need services to prevent problems with pregnancy;
Have to want case management services.
Case Management through Texas Health Steps
Texas Health Steps recipients are eligible for case management if the criteria listed
above are met. Below is some information about the program that can be shared with
the client/caretaker. Provide Case Management brochure to client.
Case Management can assist Texas Health Steps recipients with the following:
1)
2)
3)
4)
5)
6)
Access to needed health care services,
Family problems,
Education/school issues,
Financial concerns,
Finding help near where they live, and
Equipment and supplies.
Case managers help by:
1) Finding out what the client needs,
2) Making plans to meet those needs,
3) Helping clients find the services they need where they live,
37
Other Needs to Facilitate Access
4) Referring children, women who are pregnant, and their families to community
resources and other services,
5) Teaching individuals and families how to find and get services they need, and
6) Following-up to make sure needs have been met.
To link families who might be appropriate for Case Management Services, call 1877-847-8377 or provide the client/caretaker with the Case Management Brochure.
38
Other Needs to Facilitate Access
COMMUNITY SUPPORT SERVICES AND EDUCATION
In the course of meeting with the client/caretaker, the P/CHW may identify other needs
that may impact the family’s health and access to a medical/dental home. As a trained
P/CHW, the P/CHW has specialized knowledge of the community and its resources. If
other basic needs are identified through the intervention in the emergency department,
make referrals to the appropriate local agencies as needed and as time allows.
Some examples of additional referrals include:











Women, Infants, and Children Program (WIC)
Housing assistance
Food Stamps/Food Pantry
Utility/Rental Assistance
Domestic Violence Services
Education/School Support
Employment Assistance
Child care
Legal Assistance
Early Childhood Intervention
2-1-1
39
Other Needs to Facilitate Access
FOLLOW-UP WITH CLIENT OR CARETAKER
Following the interaction with the client, and once resources and/or referrals have been
provided, let the client/caretaker know that a representative from the hospital (i.e., the
data specialist) will be giving them a call in one week to verify that they were able to
make/keep the follow-up appointment with the doctor/dentist. They will also be asked
about the experience working with the P/CHW in the emergency department. See
Follow-up Section in this manual for further follow-up process details.
40
Promotores(as)/Community
Health Workers in Texas Health
Steps Outreach and Informing
Activities to Enrolled Texas
Health Steps Recipients
Follow Up
41
Follow Up Process
The following process chart demonstrates the follow-up process which is where the
P/CHWs involvement with the family ends. The P/CHW completes the visit and
provides the data specialist with the necessary information on the intake dosage and
tracking form to conduct the follow-up calls. The follow-up process is further described
below.
Promotora/Community Health Worker completes visit with
client/caretaker
1 week following visit data specialist will contact
client/caretaker for follow-up
If client/caretaker has not been
successfully contacted after 3
attempts, data specialist will
note on follow up dosage form
and enter into database within
48 hours after final attempt
If client/caretaker is
successfully reached
within 3 attempts to
contact, follow up is
complete
Texas Health Steps will complete
the follow-up process
42
Follow Up Process
WINDOW PERIOD FOR FOLLOW-UP WITH CLIENT OR CARETAKER
The data specialist will use the tracking form to follow-up with the client/caretaker.
The data specialist will be responsible for contacting the client/caretaker for follow-up
beginning one week after the initial visit and for up to three weeks after the initial visit.
The window period for attempted follow-up enhances the opportunity for successful
contact. Three attempts to contact the client/caretaker must be made before the followup dosage form can be marked “lost to follow up.” An attempt is defined as: a call that
rings 10 or more times without an answer, a one call to a number that is revealed as
disconnected, a busy signal, or a message left. Attempts should be made on multiple
days within varying time periods (i.e., morning and evening, weekends) to account for
client/caretaker availability. Clients/caretakers and other contacts identified on the
tracking form will be called no more than two times a week with no more than two
messages left on each phone number listed.
Note to data specialist: Participation in the follow-up evaluation is completely
voluntary. For those who participate, the client/caretaker has the right to refuse to
answer any or all questions on the follow-up dosage form. If the client/caretaker
refuses to participate in the follow-up evaluation, that must be noted on the
follow-up dosage form
43
Follow Up Process
SUCCESSFUL ATTEMPT TO CONTACT CLIENT OR CARETAKER
Once the data specialist has successfully reached the client/caretaker and completed
the follow-up dosage form, the information from the follow-up dosage form should be
entered into the database on a daily basis. If information cannot be entered the same
day, it must be entered as soon as possible. In no event should data be entered more
than 72 hours after its collection.
To minimize training necessary for data management, the data will be entered into a
password protected database created by DSHS and provided to each of the data
specialists at their respective sites. Separate databases will be made for the dosage
(intake and follow-up) and tracking forms. DSHS will conduct initial training on data
management and entry and provide technical assistance as needed throughout the pilot
program. Copies of the databases will be sent to DSHS monthly to ensure quality
assurance and for ongoing evaluation of the program.
44
Follow Up Process
UNSUCCESSFUL ATTEMPT TO CONTACT CLIENT OR CARETAKER
After 3 unsuccessful attempts to contact the client/caretaker during the follow-up
window period, the data specialist will be responsible for noting on the follow up dosage
form that the case was lost to follow-up. This form is to be completed immediately after
the last attempt and entered into the database, but in no event more than 72 hours later.
45
Promotores(as)/Community
Health Workers in Texas Health
Steps Outreach and Informing
Activities to Enrolled Texas
Health Steps Recipients
Resources
46
Resource brochures that should be provided to client/caretaker as needed:
Medical Transportation Program
-
TXDOT MTP brochure (white)
-
TXDOT Need a ride to get to medical or dental care? (yellow)
Case Management
-
Case Management for Children and Pregnant Women
Medical Home
-
What is a Medical Home?
Dental
-
Take time for teeth
Checkups
-
Checkups and a whole lot more brochure
-
Checkups and a whole lot more (designed for teens/young adults)**
-
Visits to the Doctor and Dentist
-
Visits to the Doctor and Dentist (designed for teens/young adults)**
-
Texas Health Steps Checkups Wallet card
-
Texas Health Steps Checkups by your Child’s Age handout
Local Community Resources
-
P/CHWs should locate and have available brochures on local community
resources specific to their region to provide to client/caretaker as appropriate.
47
Promotores(as)/Community
Health Workers in Texas Health
Steps Outreach and Informing
Activities to Enrolled Texas
Health Steps Recipients
Notes
48
This will be a section for the P/CHWs to keep notes.
49
Promotores(as)/Community
Health Workers in Texas Health
Steps Outreach and Informing
Activities to Enrolled Texas
Health Steps Recipients______
Appendices
50
Appendix A: Intake Dosage Form
Promotor(as)/Community Health Workers Program—Intake Dosage
Form
Please print numbers clearly: 1 2 3 4 5 6 7 8 9 0
Staff ID
Intake Date
/ / 

Medicaid Number
Date of Birth of child 0 to 20 years old:
//

MM
/DD
/YYYY
Demographics of child 0 to 20 years old
Ethnicity:
Race:
 White
 Black  Other  Hispanic
Gender:
 Not Hispanic
 Male
 Female
Reason for Non-Acute Emergency Department Visit:





Unexplained or high fever
Ear Infection
Asthma
Dental
Other ___________________________________
Information on Primary Care Provider/Dentist and Accessing Care:
Does client (18 to 20 yrs) or caretaker of client (if client < 18 yrs) know the name of her/his or
his/her child’s PCP?
 Yes  No
If Yes, name of PCP_______________________
Does client (18 to 20 yrs) or caretaker of client (if client < 18 yrs) know the name of her/his or
his/her child’s dentist?
 Yes  No
If Yes, name of dentist_______________________ Barriers to accessing care?
 Does not have medical/dental home
 Has medical/dental home but has trouble accessing it
 Other needs _________________________________________________________________
Perceived importance of keeping regularly scheduled preventive care appointments
(medical/dental): On a scale of 1 to 3 where 1 is “Important” and 3 is “Not at all important,” how important
is it for you/your child to make and keep regularly scheduled well-child and dental appointments?
Important
 Somewhat Important
 Not at all Important
 I don’t know
51
Services Rendered

Duration (in minutes):
Performed:

Not Performed:

Education on the role of Primary Care Provider/Dentist for non-acute
conditions
Performed:

Not Performed:

Education on Texas Health Steps and preventive health care
Performed:

Not Performed:

Education on the role and expectations of a Medical/Dental Home
Referrals:
Texas Health Steps: Primary care physician/ Dentist (choosing new provider
or reinforcing use of existing provider)
Medical Transportation program




Case Management for Children and Pregnant Women


Community Support Services and Education: WIC, housing assistance,

food stamps/food pantry, utility/rental assistance, domestic violence
services, education/school support, employment assistance, child care, etc.

Referral Made:
Referral not Made
Referral Made:
Referral not Made
Referral Made:
Referral not Made
Referral Made
Referral not Made
Additional Notes:
52
Appendix A: Intake Dosage Form Instructions
Promotor(as)/Community Health Workers Program—Intake Dosage Form
Instructions
Client
Defined as child 18 to less than 21 years old.
Caretaker of Client
Defined as parent or caretaker of child less than 18 year old.
Staff ID
3 digit ID of staff administering services
Intake Date
Date intake dosage form was completed. This only needs to be filled
out on the initial contact with each client or caretaker.
Reason for Non-Acute
Emergency Department Visit:
Check reason for non-acute ED visit by child age 0 to less than 21 year
old. If “other,” indicate the reason may (i.e., couldn’t get into my MD’s
office, couldn’t make MD appt, etc).
Does client (18 to 20 yrs) or
caretaker of client (if client <
18 yrs) know the name of
her/his or his/her child’s PCP?
Ask “Do you know the name of your/your child’s Primary Care
Physician?”
Ask the question of the client, if the client is 18 years or older ,and ask
the caretaker, if the client is less than 18 years old.
Check “yes” or “no” regarding knowledge of PCP’s name. Fill in the
PCP’s name if “yes.”
The Primary Care Physician (PCP) can be an MD, PA, OB-GYN, Nurse
Practitioner or Certified Nurse Midwife.
Does client (18 to 20 yrs) or
caretaker of client (if client <
18 yrs) know the name of
her/his or his/her child’s
dentist?
Ask “Do you know the name of your/your child’s dentist?”
Ask the question of the client, if the client is 18 years or older, and ask
the caretaker, if the client is less than 18 years old.
Check “yes” or “no” regarding knowledge of dentist’s name. Fill in the
53
dentist’s name if “yes.”
Barriers accessing care
Focus is on care for the individual 0 to less than 21 years old.
Responses indicate that either client (age 18 to less than 21 years old)
cites the barriers or that caretaker of client less than 18 years old has
barriers accessing care for the child.
Perceived importance of
Ask “On a scale of 1 to 3 where 1 is “Important” and 3 is “Not at all
keeping regularly scheduled
important,” how important is it for you/your child to make and keep
preventive care appointments regularly scheduled well-child and dental appointments?”
(medical/dental):
Ask the question of the client, if the client is 18 years or older, and ask
the caretaker, if the client is less than 18 years old.
Duration
Amount of time spent providing services in minutes.
Education on medical/dental
home, use of PCP/dentist for
non acute conditions, and
THSteps
Focus is on care for the individual 0 to 20 years old. Check box if
education on topics were provided to client (if 18 to 20 year old) or to
caretaker of client (if less than 18 years old). If education was not
performed, use “additional comments” space to indicate reasons why.
Referral and Other Services
Check box if making referral to client or caretaker of client for each
type of service.
Additional Comments
Any additional comments about services rendered may be added to
this section. If no education or referrals are made, please indicate
reason why.
54
Appendix B: Follow up Dosage Form
Promotor(as)/Community Health Workers Program—Follow up
Dosage Form
Please print numbers clearly: 1 2 3 4 5 6 7 8 9 0
Staff ID
Follow-up Date
/ / 

Medicaid Number

Follow up status



Completed follow up within window period
Completed follow up outside/beyond window period
Unable to complete follow up/lost to follow-up
Information on Primary Care Provider/Dentist and Accessing Care: Does client (18 to 20 yrs) or
caretaker of client (if client < 18 yrs) know the name of her/his or his/her child’s PCP?
 Yes  No
If Yes, name of PCP_______________________
Does client (18 to 20 yrs) or caretaker of client (if client < 18 yrs) know the name of her/his or his/her
child’s dentist?
 Yes  No
If Yes, name of dentist_______________________
Information on Actions Taken After Intervention:
Was an appointment with the primary care physician (PCP) made as  Yes  No  Does not
a function of what was learned during the intervention?
apply
Was a preexisting appointment with the primary care physician (PCP)  Yes  No  Does not
kept as function of what was learned during the intervention?
Was an appointment with the Dentist made as a function of what
apply
 Yes  No  Does not
was learned during the intervention?
Was a preexisting appointment with the Dentist kept as function of
apply
 Yes  No  Does not
what was learned during the intervention?
Was the client/caretaker of client satisfied with the services received during
the intervention?
apply
 Yes  No
Confidence in Using PCP/Dentist instead of Emergency Department for non-acute care: How
confident is the client/caretaker of client that she/he can go to a PCP/dentist for a non-acute condition
instead of using the emergency department in the future?
55
 Very confident
 Confident
 Somewhat confident
 Not at all confident
Perceived importance of keeping regularly scheduled preventive care appointments (medical/dental):
On a scale of 1 to 3 where 1 is “Important” and 3 is “Not at all important,” how important is it for you/your child
to make and keep regularly scheduled well-child and dental appointments?
 Important
 Somewhat Important
 Not at all Important
 I don’t know
Additional Notes:
56
Appendix B: Follow up Dosage Form Instructions
Promotor(as)/Community Health Workers Program—Follow up
Dosage Form Instructions
Staff ID
3 digit ID of staff administering services
Follow-up Date
Date the follow-up call was completed with client/caretaker. If
client/caretaker was unavailable for follow-up within the two week
window period, put “0” in each space for the date.
Follow-up Status
If client/caretaker was unable to be contacted, check that box.
Otherwise, indicate whether contact was made within or outside the
window period.
Information on Primary Care
Provider/Dentist and
Accessing Care
Focus is on the individual 0 to less than 21 years old. If client is 18 to
less than 21 years old, the client responds for his/herself. If child is less
than 18 years old, caretaker of client responds regarding the child’s
PCP/dentist+.
Does client (18 to 20 yrs) or
Ask “Do you know the name of your/your child’s Primary Care
caretaker of client (if client <
Physician?”
18 yrs) know the name of
her/his or his/her child’s PCP?
Ask the question of the client, if the client is 18 years or older, and ask
the caretaker, if the client is less than 18 years old.
Check “yes” or “no” regarding knowledge of PCP’s name. Fill in the
PCP’s name if “yes.”
The Primary Care Physician (PCP) can be an MD, PA, OB-GYN, Nurse
Practitioner or Certified Nurse Midwife.
Does client (18 to 20 yrs) or
guardian of client (if client <
18 yrs) know the name of
her/his or his/her child’s
dentist?
Ask “Do you know the name of your/your child’s dentist?”
Ask the question of the client, if the client is 18 years or older, and ask
the caretaker, if the client is less than 18 years old.
Check “yes” or “no” regarding knowledge of dentist’s name. Fill in the
57
dentist’s name if “yes.”
Information on Actions Taken
After Intervention
Focus is on the individual 0 to 20 years old. Check if appointments
were made or kept with a PCP and dentist, as applicable.
Confidence in Using
PCP/dentist instead of ED for
non acute care
Focus is on using a PCP/dentist for the individual 0 to 20 years old. If
client is 18 to 20 years old, the client responds for his/herself. If child is
less than 18 years old, caretaker of client responds regarding using a
PCP/dentist for the child.
Perceived importance of
keeping regularly scheduled
preventive care
appointments
(medical/dental):
Ask “On a scale of 1 to 3 where 1 is “Important” and 3 is “Not at all
important,” how important is it for you/your child to make and keep
regularly scheduled well-child and dental appointments?”
Additional Notes
Any additional comments about services rendered may be added to
this section. If client/caretaker responded “does not apply” for any
question, please indicate the reason why (i.e., no referrals were made).
Use “you” if the client is 18 years or older or “your child” if asking the
caretaker of a child less than 18 years old.
Appendix C: Tracking Form for Client less than 18 years old
58
Promotor(as)/Community Health Workers Program - TRACKING FORM
We are interested in keeping up with you in the near future to see how your child is doing.
But sometimes, people become hard to find.
help us to contact you.
Please help us by giving us information that will
ALL INFORMATION THAT YOU GIVE US WILL BE KEPT
CONFIDENTIAL.
First, I want to verify your full name
F ir st N a m e
M iddl e N a m e
La s t N a m e
M iddl e N a m e
La s t N a m e
Second, I want to verify your child’s name
F ir st N a m e
Now, I’d like to get some information about you and the people who usually know where you
are. We will contact these people only if we are unable to locate you. However, they will
not be told any details about your child or this program.
Your Phone Number(s)
Whose Name is the phone under?
Best Time to call:
Home Phone
Cell Phone
Work Phone
59
PEOPLE WHO KNOW HOW TO REACH YOU:
Contact Lives
Contact Person’s Telephone
Number(s)
Contact Person’s
Your Contact Person’s
with You?
Relationship to You
Name
Please Circle
Parent(s) –
Yes or No
if not listed above
Grandparent(s)
Yes or No
Sibling(s)
Yes or No
Other Relative(s)
Yes or No
Friend(s)
Yes or No
Other
Yes or No
If we are unable to reach you by phone, you may receive a letter in the mail from Texas Health
Steps giving you information on services available to your child. Please provide your complete
mailing address below:
______________________
____________________
______
Mailling address
City
State
____________
Zip Code
60
Appendix C: Tracking Form for Client Age 18 to less than 20 years old
Promotor(as)/Community Health Workers Program - TRACKING FORM
We are interested in keeping up with you in the near future to see how you are doing.
But
sometimes, people become hard to find. Please help us by giving us information that will help
us
to
contact
you.
ALL
INFORMATION
THAT
YOU
GIVE
US
WILL
BE
KEPT
CONFIDENTIAL.
First, I want to verify your full name
F ir st N a m e
M iddl e N a m e
La s t N a m e
Now, I’d like to get some information about you and the people who usually know where you
are. We will contact these people only if we are unable to locate you. However, they will
not be told any details about you or this program.
Your Phone Number(s)
Whose Name is the phone under?
Best Time to call:
Home Phone
Cell Phone
Work Phone
PEOPLE WHO KNOW HOW TO REACH YOU:
Contact Lives
Contact Person’s Telephone
Number(s)
Contact Person’s
Your Contact Person’s
with You?
Relationship to You
Name
Please Circle
Parent(s) –
Yes or No
61
if not listed above
Grandparent(s)
Yes or No
Sibling(s)
Yes or No
Other Relative(s)
Yes or No
Friend(s)
Yes or No
Other
Yes or No
If we are unable to reach you by phone, you may receive a letter in the mail from Texas Health
Steps giving you information on services available to you. Please provide your complete mailing
address below:
______________________
____________________
______
____________
Mailling address
City
State
Zip Code
62