Innovation in Care Integration for Children and Youth with Autism Spectrum Disorders and Other Developmental Disabilities Program | Apply Online

Frequently Asked Questions (FAQs)

1. What is the Innovation in Care Integration for Children and Youth with ASD/DD Program?

This opportunity (HRSA 16-048; CFDA 93.877) is a discretionary grant from HHS HRSA that supports state-level efforts to better connect and coordinate the systems serving children and youth who are at risk for, or diagnosed with, autism spectrum disorders and other developmental disabilities (ASD/DD). The focus is on improving how families move through screening, referral, diagnostic evaluation, care coordination, and ongoing services.

2. What is the main purpose of the grant?

The main purpose is system integration: improving how multiple parts of the statewide system work together so children are identified earlier, referred faster, evaluated sooner, and connected to appropriate services with stronger care coordination and a better family experience.

3. What framework guides the program's approach to care integration?

The program uses the American Academy of Pediatrics (AAP) care integration framework as the organizing approach for building and improving coordinated systems across screening through long-term services.

4. Who is the target population for funded projects?

The target population is statewide: children and youth across the state who are at risk for, or diagnosed with, ASD/DD and their families. Projects are expected to intentionally include and benefit medically underserved communities rather than focusing only on well-served regions.

5. What does the program mean by "medically underserved communities"?

The program highlights medically underserved communities as those affected by poverty, rural geography, health professional shortages, health disparities, and cultural and linguistic barriers to care. Project design must intentionally address these barriers.

6. Is there a minimum requirement for including medically underserved populations?

Yes. Projects must define a target population in which at least 20 percent are medically underserved. The announcement references criteria such as Health Professional Shortage Areas (primary care and/or mental health) and/or populations facing economic, cultural, or linguistic barriers to care.

7. What are the three core areas states are expected to implement?

Funded states are expected to implement innovative, evidence-informed models in three core areas: (1) family support and navigation, (2) shared resources that strengthen care coordination, and (3) telehealth/telemedicine (including mobile health) tools that expand access and improve cross-system communication.

8. What is a family navigator model in this program?

A family navigator model is designed to help families move through complex systems with fewer delays. It can include support for timely diagnostic assessments and service start, understanding and using insurance coverage, choosing and using providers, making treatment decisions, coordinating among multiple providers, and ensuring care is culturally and linguistically appropriate.

9. What kinds of "shared resources" does the program expect projects to use or build?

Shared resources may include community networks, community health teams, regional extension centers, Area Health Education Centers (AHECs), or organized care teams that can be leveraged across organizations to support consistent case management and stronger communication among primary care, specialists, and community services.

10. How is telehealth/telemedicine expected to be used under this grant?

Telehealth/telemedicine activities are expected to directly support ASD/DD diagnosis (such as remote observation of behavior), improve access to treatment (including behavioral therapies), expand access to medical and non-medical providers in underserved communities, and improve coordination and data sharing across systems and with families. The program indicates telehealth should go beyond general outreach.

11. What outcomes and performance targets does the program require?

The program sets measurable objectives to be achieved by August 31, 2019, expressed as improvements over each state's baseline. Targets include increases in identification and referral of at-risk children, earlier entry into services (before 37 months), improved family knowledge and self-efficacy, and increased referrals to early intervention and/or specialists for comprehensive evaluation.

12. What are the specific improvement targets mentioned in the announcement?

• Increase by 25 percent the proportion of children identified as at risk and referred for diagnostic evaluation and ASD/DD-related services.
• Increase by 10 percent the share of children with ASD/DD enrolled in services before 37 months of age.
• Increase by 10 percent the share of children from medically underserved communities who enter services before 37 months.
• Increase by 25 percent the proportion of children, youth, and families reporting improved knowledge, skills, ability, and self-efficacy related to referrals, diagnosis, and accessing services (with attention to underserved populations).
• Increase by 25 percent the number of referrals of at-risk children to early intervention programs and/or specialists for comprehensive evaluation.

13. Are these targets the same for every state?

The targets are framed as improvements over each state's baseline. This means states are expected to measure their starting point and then demonstrate the stated percentage improvements relative to that baseline.

14. What is meant by a "community of learners" model?

Grantees are expected to test and refine innovations through structured quality improvement and a shared learning approach. This includes collaborative problem-solving, sharing lessons learned (including what did not work), and using rapid-cycle improvement methods to adapt strategies and make them more replicable.

15. Is quality improvement optional in this program?

No. The announcement indicates quality improvement is not optional. Applicants are expected to use a defined methodology that includes needs assessment, small tests of change, data-driven decision-making, spreading effective changes, stakeholder engagement, and measurement tied to the stated objectives.

16. What partnerships and governance structures are required?

Applicants must establish a multidisciplinary project advisory group that includes families and ASD/DD experts and brings together major state stakeholders across relevant systems. The intent is to demonstrate a true system-level effort rather than a single program operating in isolation.

17. Which specific stakeholders are expected to be included in the advisory group?

The advisory group is expected to include, as applicable: the State Title V program, the state LEND program, IDEA Part B and Part C representatives, family leaders and family organizations (including autism support groups and Family-to-Family Health Information Centers), and relevant professional organizations such as state AAP chapters.

18. What additional partners does the announcement encourage applicants to involve?

The announcement encourages involvement of partners that influence access and sustainability, including pediatric primary care and specialty clinicians, universities, community agencies, state legislatures, Medicaid and CHIP, private payers, early childhood education and school systems, and safety-net providers such as Federally Qualified Health Centers, community health centers, and rural health clinics.

19. Are letters of support or formal agreements required?

Applicants are expected to show they can build partnerships through letters of support and formal agreements such as MOUs/MOAs, signaling cross-agency commitment and a system-level design.

20. What are the evaluation and performance monitoring requirements?

At least 20 percent of the project budget must be dedicated to performance monitoring and to creating a comprehensive evaluation plan. The evaluation plan is expected to draw on national, state, and community data, measure progress on federal objectives and the applicant's own goals, and include at least one evaluative measure showing improvement in the statewide system of care for the ASD/DD population.

21. Does the program require a sustainability plan?

Yes. Applicants must propose a sustainability plan describing how key activities will continue after federal funding ends. This reflects HRSA's emphasis on lasting system change rather than temporary service expansion.

22. Are awardees expected to coordinate with other MCHB initiatives and grants?

Yes. Awardees are expected to coordinate, where possible, with other Maternal and Child Health Bureau (MCHB) initiatives and related grants, including LEND training programs, intervention research programs, State Public Health Coordinating Centers, Family-to-Family Health Information Centers, Early Childhood Comprehensive Systems (ECCS), and Systems Integration Grants for Children and Youth with Special Health Care Needs.

23. What meeting and participation expectations are included for grantees?

Grantees must participate in the broader MCHB CARES ecosystem, including an annual CARES grantee meeting (in-person in the Washington, DC area every other year and virtual in alternating years) and an annual Autism State Program grantee meeting. Grantees must also participate virtually in innovation community activities such as calls, workshops, webinars, and skills trainings.

24. Are there budgeting expectations tied to meetings?

Yes. The announcement specifies budgeting for two staff to attend in person when the CARES grantee meeting is held in person (every other year) and also budgeting for two staff for the annual Autism State Program grantee meeting.

25. What federal evaluation collaboration is required after an award is made?

Awardees must cooperate with MCHB's evaluation contractor, which will collect quantitative and qualitative data as part of the broader Autism CARES Act Initiative evaluation.

26. When was this funding opportunity posted, and what was the application deadline?

The opportunity was posted on March 8, 2016, with a closing date of May 10, 2016.

27. How many awards were anticipated?

HRSA anticipated making about six awards.

28. What is the maximum award amount (award ceiling) for this opportunity?

The listing shows an award ceiling of 0, which typically indicates the ceiling was not specified in the summary fields and would need to be confirmed in the full funding announcement.

29. What does it mean that this is a state-level, system-integration grant rather than a direct service program?

The announcement emphasizes that grantees are not funded simply to run an isolated program. They are expected to convene partners across agencies and sectors, test and refine innovations through quality improvement, and create approaches that strengthen the statewide system for screening, diagnosis, care coordination, and ongoing services.

30. What is the role of underserved communities in project design?

Underserved communities are a major priority area. Projects must intentionally include and benefit these groups, address barriers such as poverty, rural access limitations, workforce shortages, and cultural/linguistic barriers, and track improvements for underserved populations (including a specific target to increase early entry into services for children from medically underserved communities).