Existing law establishes various programs and services for the promotion of child health, administered by the State Department of Public Health or the State Department of Health Care Services. Existing law provides for the regulation of health facilities by the State Department of Public Health.

This bill would require specified health practice settings to offer child life specialist services, as defined, and to meet certain conditions relating to the availability of child life specialists in those settings.

Existing law establishes the California Childrens Services Program (CCS Program), which is a statewide program, administered by the State Department of Health Care Services and by counties, as specified, that provides medically necessary services for physically handicapped children whose parents are unable to pay for those services. Existing law establishes the Medi-Cal program, which is administered by the department and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.

Existing law authorizes the State Department of Health Care Services to establish, no sooner than July 1, 2017, a Whole Child Model program, under which managed care plans served by a county organized health system or Regional Health Authority in designated counties provide CCS Program services to Medi-Cal-eligible CCS children and youth.

This bill would require the CCS Program to offer child life specialist services, and would require a child life specialist to comply with the provider paneling requirements of the program in order to participate as a program provider. This bill would require the transition of those child life specialist services into the Medi-Cal managed care health plan contract in Whole Child Model counties, as specified, and would require the department to obtain any necessary federal approvals to implement that transition.

By creating new duties for counties in implementing child life specialist services under the CCS Program, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law provides that it is unlawful for any person to use any special effects fireworks unless that person possesses a pyrotechnic operator license.

This bill would make nonsubstantive changes to this law.

Date of Hearing: May 16, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 3175

Author:(Rubio) – As Amended Ver:April 19, 2018

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill requires "child life specialist" services to be offered by specified inpatient and outpatient care settings on both weekends and weekdays, as specified, and requires the California Children's Services (CCS) program to offer child life services.

FISCAL EFFECT:

1. Unknown, significant cost pressure potentially in the millions of dollars on CCS rates paid to hospitals, which will be required to fund the cost of child life services (GF, or GF/federal if federal financial participation is available). Depending how this bill was implemented, costs for services within the CCS program would be reimbursed directly or, more likely, the mandate for child life services would be added to minimum requirements providers must meet to participate in the program.

Counties currently pay a share of costs for CCS-eligible children who are not enrolled in Medi-Cal. To the extent this requirement increased counties' costs for the service by requiring a local program to provide a higher level of care, costs would be state-reimbursable.

1. Minor administrative costs to Department of Health Care Services to add providers to the panel of qualified CCS providers and to oversee facility compliance with the requirements (GF).

COMMENTS:

1. Purpose. According to the author, child life services have been shown to reduce sedation-related costs, use of pain medication, and length of hospitalizations, and increase patient and family customer satisfaction with healthcare services. The sponsor, Azusa Pacific University, notes the American Academy of Pediatric (AAP) recommends these services.
2. Child life services. According to the AAP, child life services programs have become standard in large pediatric settings to address the psychosocial concerns that accompany hospitalization and other health care experiences. According to the Association of Child Life Professionals, child life specialists help children and families cope with the stress and uncertainty of illness, injury, trauma, disability, loss and bereavement. They provide evidence-based, developmentally, and psychologically appropriate interventions including therapeutic play, preparation for procedures, and education to reduce anxiety and pain. Most inpatient and some outpatient settings that serve ill children provide child life services in some units, but it is not widespread across all children's hospital settings.
3. CCS. The CCS program serves children with significant health care needs who meet residential and financial eligibility requirements The program provides diagnostic and treatment services, medical case management, and physical and occupational therapy services to children with CCS-eligible conditions, including congenital heart disease, cystic fibrosis, cancer, traumatic injuries, and other conditions. This bill requires CCS to offer child life services through contracted hospitals, but does not necessarily require the program reimburse hospitals directly or indirectly for the services.
4. Support. Azusa Pacific University, a comprehensive evangelical Christian university that trains child life specialists, states in support that certified child life specialists help families navigate challenging and life-altering healthcare crises, and should be required in all pediatric and adolescent hospital units, outpatient clinics, palliative care services, and hospice settings.
5. Opposition. The California Children’s Hospital Association (CCHA) states in opposition that while currently all eight CCHA hospitals currently provide child life services in some settings, child life services are not reimbursed by the Medi-Cal or CCS programs, or by commercial insurers. CCHA argues this bill would create an unfunded mandate for children’s hospitals and other pediatric providers and limit their ability to decide how best to allocate scarce resources to provide for the healthcare needs of their patients.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 17, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 3175

Author:(Rubio) – As Amended Ver:March 23, 2018

SUBJECT: Child life specialist services.

SUMMARY: Requires the California Children's Services (CCS) Program to offer child life specialist services, as defined. Specifically, this bill:

1. Requires the CCS Program to offer child life specialist services, in all variations of the CCS Program including children in counties being transitioned into Medi-Cal managed care (MCMC) health plan contracts in Whole Child Model (WCM) counties, children who are enrolled in the MCMC health plan, and all other children enrolled in the state CCS Program.
2. Requires a child life specialist participating in the WCM Program to contribute toward improved care coordination of primary, specialty, and behavioral health services for CSS and non-CCS conditions.
3. Requires the Department of Health Care Services (DHCS) to obtain any necessary federal approvals to implement the requirements of this bill.
4. Requires a child life specialist to comply with the provider paneling requirements of the CCS Program to participate as a CCS Program provider.
5. Defines “child life specialist” as a person, certified by the Association of Child Life Professionals, who, in the scope of their practice, helps infants, children, youth, and families to cope with the stress and uncertainty of acute and chronic illness, injury, trauma, disability, loss, and bereavement, and provides evidence-based, developmentally, and psychologically appropriate interventions, including therapeutic play, preparation for procedures, and education to reduce fear, anxiety, and pain.
6. Specifies that the provisions above apply to all pediatric and adolescent hospital units, neonatal intensive care units, hospice and palliative care facilities, and outpatient specialty clinics, including, but not limited to, clinics providing diabetes treatment, cystic fibrosis treatment, hematology, oncology, and surgery, whose primary purpose is to serve ill, injured, and dying children and youth, and families with children or youth who are receiving medical services to offer child life specialist services. Requires these practice settings to meet all of the following conditions:
   1. Offer child life specialist services, on both weekdays and weekends;
   2. Meet a child life specialist-to-patient ratio of 1-to-15 to 1-to-20, inclusive, for appropriate levels of services, consistent with recommendations by the American Academy of Pediatrics (AAP); and,
   3. Ensure that child life specialist services are part of the core interdisciplinary teams of, and the end-of-life care of, the practice setting.

EXISTING LAW:

1. Requires DHCS to establish and administer the CCS Program for physically defective or handicapped persons under the age of 21 years, in cooperation with the federal government through its appropriate agency or instrumentality, for the purpose of developing, extending and improving the services. Requires DHCS to receive all funds made available by the federal government, the state, its political subdivisions, or from other sources. Authorizes DHCS to supervise those services included in the state plan that are not directly administered by the state. Requires DHCS to cooperate with medical, health, nursing and welfare groups and organizations concerned with the program, and any agency of the state charged with the administration of laws providing for vocational rehabilitation of physically handicapped children.
2. Specifies that CCS covered services means any or all of the following, regardless of the funding sources:
   1. Expert diagnosis;
   2. Medical treatment;
   3. Surgical treatment;
   4. Hospital care;
   5. Physical therapy;
   6. Occupational therapy;
   7. Special treatment;
   8. Materials;
   9. Appliances and their upkeep, maintenance, care and transportation; and,
   10. Maintenance, transportation, or care incidental to any other form of “services.”
3. Requires financial eligibility for treatment services to be limited to persons in families with an adjusted gross income of $40,000 or less in the most recent tax year, as calculated for California state income tax purposes. Permits the financial documentation required to enroll in Medi-Cal to be used instead of the person’s California state income tax return. Permits the DHCS Director to authorize treatment services for persons in families with higher incomes if the estimated cost of care to the family in one year is expected to exceed 20% of the family’s adjusted gross income.
4. Defines a “CCS provider” as any of the following:
   1. A medical provider that is paneled by the CCS program to treat a CCS-eligible condition;
   2. A licensed acute care hospital approved by the CCS program to treat a CCS-eligible condition; and,
   3. A special care center approved by the CCS program to treat a CCS-eligible condition;
5. Permits, after July 1, 2017, DHCS to establish a WCM program for Medi-Cal eligible CCS Program children and youth enrolled in a managed care plan served by a county organized health system or Regional Health Authority in the following counties: Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Merced, Modoc, Monterey, Napa, Orange, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Shasta, Siskiyou, Solano, Sonoma, Trinity, and Yolo.
6. Requires the goals for the WCM program for children and youth under 21 years of age who meet eligibility requirements and are enrolled in a managed care plan under a county organized health system or Regional Health Authority to include all of the following:
   1. Improve the coordination of primary and preventive services with specialty care services, medical therapy units, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), long-term services and supports (LTSS), regional center services, and home- and community-based services using a child and youth and family-centered approach;
   2. Maintain or exceed CCS Program standards and specialty care access, including access to appropriate subspecialties;
   3. Provide for the continuity of child and youth access to expert, CCS dedicated case management and care coordination, provider referrals, and service authorizations;
   4. Improve the transition of youth from CCS to adult Medi-Cal managed systems of care through better coordination of medical and nonmedical services and supports and improved access to appropriate adult providers for youth who age out of CCS; and,
   5. Identify, track, and evaluate the transition of children and youth from CCS to the WCM program to inform future CCS program improvements.
7. Requires each MCMC plan participating in the WCM program to provide a mechanism for a CCS-eligible child’s and youth’s parent or caregiver to request a specialist or clinic as a primary care provider.
8. Permits a CCS specialist or clinic to serve as a primary care provider if the specialist or clinic agrees to serve in a primary care provider role and is qualified to treat the required range of CCS-eligible conditions of the CCS child or youth.
9. Requires managed care contractors serving CCS-eligible children to maintain and follow standards of care established by the program, including the use of paneled providers and CCS-approved special care centers and to follow treatment plans approved by the program, including specified services and providers of services.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill requires Child Life Specialist services and expands services in areas lacking support for children and families, and mitigates unnecessary pain and suffering of children and families enduring difficult medical and life altering or threatening circumstances. Child Life services have been shown to reduce sedation related costs, use of pain medication, and length of hospitalizations, and increase patient and family customer satisfaction with healthcare services. Healthcare industry standards endorse the value of Child Life Services, but have fallen short of consistently mandating their availability to children and families. California, as a standard bearer for the health and welfare of its constituencies, can lead the nation in improving the social, emotional, developmental and family well-being of children suffering from serious medical conditions
2. BACKGROUND. Originally established in 1927, the CCS program provides diagnostic and treatment services, medical case management, and physical and occupational therapy services to children under age 21 with CCS-eligible medical conditions. Some examples of CCS-eligible conditions include chronic medical conditions such as cystic fibrosis, hemophilia, cerebral palsy, heart disease, cancer, traumatic injuries, and certain infectious diseases. CCS also provides medical therapy services that are delivered at public schools.
   

CCS is a statewide program. In counties with populations greater than 200,000 (independent counties), county staff perform all case management activities for eligible children residing within their county. This includes determining all phases of program eligibility, evaluating needs for specific services, determining the appropriate provider(s), and authorizing for medically necessary care. For counties with populations under 200,000 (dependent counties), the Children's Medical Services Branch of DHCS provides medical case management and eligibility and benefits determination through its regional offices located in Sacramento, San Francisco, and Los Angeles. CCS authorizes and pays for specific medical services and equipment provided by CCS-approved specialists. According to 2016 figures, the CCS Program currently serves approximately 184,000 children annually, 93% of whom are also eligible for Medi-Cal.

• 1. MCMC. MCMC contracts for health care services through established networks of organized systems of care, which emphasize primary and preventive care. Managed care plans are intended to be a cost-effective use of health care resources that improve health care access and assure quality of care. According to DHCS, approximately 10.3 million Medi-Cal beneficiaries in all 58 California counties receive their health care through six main models of managed care: Two-Plan, County Organized Health System (COHS), Geographic Managed Care, Regional Model, Imperial, and San Benito. Medi-Cal providers who wish to provide services to managed care enrollees must participate in the managed care plan’s provider network.
  2. COHS. Beginning July 1, 2017, DHCS was authorized to establish a WCM program for Medi-Cal eligible CCS children enrolled in a managed care plan under a COHS, one of the six models of managed care, as discussed above. Each COHS is created by a county board of supervisors and governed by an independent commission. In COHS counties, a single plan serves all Medi-Cal beneficiaries who are enrolled in managed care.

MCMC plans are generally subject to: i) consumer protections provided by the California Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene) and overseen by the Department of Managed Health Care (DMHC); ii) federal and state rules and regulations for Medi-Cal; and, iii) terms set forth and agreed upon in contracts between the plans and DHCS.

However, unlike other MCMC plans, COHS plans are not required to obtain Knox Keene licensure for their Medi-Cal lines of business, and unless they choose to obtain a Knox-Keene license, they are not directly regulated by the DMHC. Rather than operating under specific statutory mandates, the county is bound by the rules, terms, and conditions negotiated by in their contracts with DHCS. Despite the exemption, one COHS, the Health Plan of San Mateo, voluntarily obtained a Knox-Keene license. Additionally, all other COHS, except for Gold Coast Health Plan, have obtained a Knox-Keene license for other, non-Medi-Cal lines of business.

• 1. Child Life Specialists. According to the Association of Child Life Professionals, infants, children and youth confront a wide variety of stressful and potentially traumatic events that can impact their ability to cope. These experiences related to healthcare can lead to feelings of fear, confusion, loss of control and isolation that can inhibit their development and have negative effects on their physical and emotional health and well-being. In both healthcare and community settings, Certified Child Life Specialists help infants, children, youth and families cope with the stress and uncertainty of acute and chronic illness, injury, trauma, disability, loss and bereavement. They provide evidence-based, developmentally and psychologically appropriate interventions including therapeutic play, preparation for procedures, and education to reduce fear, anxiety, and pain. While certification is not required to become a child life specialist, it is typically an employment requirement by hospitals and other health care settings. Beginning on January, 2019, the requirements for child life specialist certification will be as follows:
     1. A bachelor's degree, in any field of study;
     2. Ten college courses in the following content areas:
        1. Child life course taught by a certified child life specialist;
        2. Child development course;
        3. Family systems course
        4. Play course;
        5. Loss/bereavement or death and dying course;
        6. Research course; and,
        7. Three additional courses, and,
     3. Six hundred hours of a child life clinical internship under the direct supervision of a certified child life specialist.

1. SUPPORT. The Azusa Pacific University (APU) states in support that certified child life specialists, who help ill, injured, dying children and youth, and their families navigate challenging and life-altering healthcare crisis, and should be required in all pediatric, adolescent hospital units; outpatient clinics; palliative care services; and hospice settings. APU notes that healthcare industry standards endorse the value of child life services but have fallen short of consistently ensuring their availability to children and families. APU, a community of scholars with diverse backgrounds and expertise in understanding child-family psychology, equips and prepares graduates for this helping profession toward national child life certification and is one of four California universities offering graduate programs in the child life profession.
2. OPPOSITION. The California Children’s Hospital Association (CCHA) states in opposition that while currently all eight CCHA hospitals currently provide child life services in some settings, child life services are not reimbursed by the Medi-Cal or CCS programs, or by commercial insurers. CCHA argues that this bill would create an unfunded mandate for children’s hospitals and other pediatric providers, and limit their ability to decide how best to allocate scarce resources to provide for the healthcare needs of their patients. CCHA states that child life specialists are a vital part of the care team at our children hospitals. This is why many hospitals employ more child life specialists than they are required to by the CCS program, and why they offer child life services in settings where they are not required to do so. However, these decisions consider the limited budget of each hospital and the relative importance of these services compared to all the other critically important care their patients need. By legislatively mandating a staffing ratio for child life services, this bill would force children’s hospitals to prioritize these services over other health care services that may be even more critical to the health and well-being of patient.
3. CONCERNS. The California Hospital Association (CHA) has concerns with the bill, noting that the bill would require a 1:15 or 1:20 ratio of child life specialists to patients for all pediatric and adolescent hospital units, neonatal intensive care units, and hospice and palliative care facilities. This bill’s requirements would also apply to outpatient specialty clinics, including clinics that provide diabetes or cystic fibrosis treatment; hematology, oncology or surgical services; or whose primary purpose is to serve ill, injured or dying children and youth and their families. CHA argues that while the bill refers to ratios recommended by the AAP, it fails to recognize an important caveat included in that recommendation — that the patient's age, mobility, and type and acuity of illness and the nature of the population on the unit should influence actual practice.
4. PREVIOUS LEGISLATION. SB 586 (Ed Hernandez), Chapter 625, Statutes of 2016, permits DHCS to establish a WCM program for children enrolled in both Medi-Cal and CCS Program in 21 counties served by four county organized health systems, instead of the existing arrangement in most counties where CCS services are “carved out” from the Medi-Cal managed care plan. Continues the CCS carve-out in the remaining 37 counties until January 1, 2022.
5. POLICY COMMENT. According to the AAP, services provided by child life specialist include therapeutic play, expressive modalities and age appropriate psychological preparation. Many of these services are within the scope of practice of occupational therapists and behavioral health therapists that are currently practicing at these facilities. Additionally, it is unclear if there should be supervision of child life specialists in order to ensure patient safety. If supervision is necessary, it is also unclear who would perform those supervisorial duties.
6. SUGGESTED AMENDMENTS. The author may wish to consider removing the staff-to-patient ratios, allowing for hospitals to determine an appropriate need and placement of this newly required provider type to meet the needs of their pediatric population.

REGISTERED SUPPORT / OPPOSITION:

Support

Azusa Pacific University

Opposition

California Children’s Hospital Association

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097