Welcome to the California Community Care Coordination Collaborative

June 4, 2013

• Introduction and Welcome• Icebreaker• Updates and Discussion

– Contra Costa County – 7C’s– Orange County – OC C3 for Kids– Shasta, Siskiyou, Trinity Counties – Rural Children’s Special Health Coalition– San Mateo County – SMC Care Coordination Learning Community– Fresno County – Central California Care Coordination Project– Kern County – Medically Vulnerable Care Coordination Project

• Evaluation• Learning Collaborative Planning

AGENDA

Contra Costa California Community Care

Coordination Collaborative (7C’s)

Barbara Sheehy, MS

Administrator

California Children's Services Contra Costa County

UPDATE

Seven Cs ProjectCONTRA COSTA CALIFORNIA

COMMUNITY CARE COORDINATION COLLABORATIVE

Seven Cs Coalition Members California Children’s Services CARE Parent Network Regional Center of the East Bay First 5 Contra Costa Clinic Services/Public Health Nursing Contra Costa Behavioral/Mental Health Head Start/Early Head Start Children’s Hospital & Research Center Oakland Contra Costa Health Plan Early Childhood Mental Health West Contra Costa SELPA Contra Costa Regional Medical Center, Dept of Pediatrics Kern County Medically Vulnerable Care Coordination

Project Kaiser Permanente John Muir Health

Seven Cs Project Goals1. Determine the specific needs of CSHCN, birth to 5 years

of age, and their families, for the Seven Cs Project.2. Align the organizational structure to implement the

Seven Cs Project for CSHCN, birth to 5 years of age, and their families, providers and communities.

3. Conduct a 3-month pilot program of the Seven Cs initiative to work through and validate procedures, tools, costs and processes before full implementation.

4. Create and implement a financial sustainability plan to secure Care Coordination staff and other resources to fully implement the Seven Cs Project for CSHCN, birth to 5 years of age, their families, providers and communities.

Seven Cs Main Activities Convene monthly Seven Cs partner meetings to develop,

pilot and support an county-wide CSHCN care coordination system.

Learn about the Kern County, MVCCP model, history, Acuity Form and tools.

Compile and analyze Contra Costa CSHCN data to identify projected population to be served by care coordiation initiative.

Develop a county-specific resource list of pediatric special needs services for families and providers.

Develop and implement a county-wide outreach and education plan for families and providers.

Create, implement, and monitor role of Care Coordinator to support county-wide CSHCN care coordination system.

Seven Cs Anticipated Challenges Some partners have limited experience

working together collaboratively. Assuring family centered care is

institutionalized in care coordination system.

Seven Cs Progress Hired excellent Facilitator and Project

Coordinator. Honing in on our target population and

care coordination model. Added needed Project Partners.

Seven Cs Current Challenges Difficulty getting School/Special

Education Partner participation. May be difficult to develop two

additional Round Table groups to flesh out County-wide care coordination system.

Orange County Care Coordination Collaborative for Kids

(OC C3 For Kids)

Rebecca Hernandez, MSEd

Program Manager

Help Me Grow Orange County

UPDATE

Key Coalition Partners:• American Academy of Pediatrics, CA Chapter 4• Children and Families Commission of Orange County• CHOC Children's Foundation • Help Me Grow Orange County• Orangewood Children’s Foundation/Bridges Network

Collaborative Participants:• California Children Services • Cal Optima (Orange County Medi-Cal agency)• Child Health and Disability Prevention Program • Comfort Connection Family Resource Center• County of Orange, Social Services Agency • CHOC Children’s Early Developmental Assessment Center • Family Support Network • Orange County Department of Education/Center for Healthy Kids and Schools • Public Community Health Nursing • Regional Center of Orange County • The Center for Autism and Neurodevelopmental Disorders of Southern CA

Orange County Care Coordination Collaborative for Kids

OC C3 For Kids Goals

Overarching goal: To improve overall care for children and families with special health care needs by creating a collaborative care coordination system in Orange County.

1. To identify the specific needs of the Orange County care coordination collaborative starting with children birth to 5 years of age who have special health care needs (CSHCN) and their families.

2. To determine the organizational structure of the Orange County care coordination system for children birth to five years with special health care needs (CSHCN) and their families.

3. To conduct a pilot of the proposed Orange County Care Coordination model to validate the efficacy and refine team based development of procedures, tools, costs and processes before full implementation.

4. To create and implement a sustainability plan to secure resources to implement a care coordination countywide system with scalability and potential to expand to other age groups.

OC C3 For Kids Activities

• Conduct a trend analyses of CSHCN in Orange County• Implement a monthly gathering of a diverse countywide collaborative

providing CSHCN case reviews, open discussion and resolution of challenges

• Develop a care coordination protocol to address system wide issues that affect CSHCN and their families

• Develop and promote common language via a county wide risk assessment and referral form to enhance provider communication

• Maximize staff time and resources by focusing on the

efficiencies of care coordination• Create a sustainable care coordination entity in OC• Conduct final evaluation combining qualitative

and a quantitative assessments to identify strengths and weaknesses of the project

15

Anticipated Orange County Challenges

As our project was developed, the core planning team identified several challenges that may be encountered. These include:

• Time constraints of the current OC C3 for

Kids participants• Recruitment of additional organizations who

provide services for CSHCN• Financial constraints as there has been

tremendous cutbacks to organizations

therefore limited staff to participate

Thank you

Rebecca Hernandez, MSEd

Project Director, OC C3 For Kids

Rhernan2@uci.edu

Progress Made To Date

• Meaningful engagement of multiple stakeholders with commitment to a regular monthly meeting schedule

• Hired facilitator for coordination of collaborative meetings and trend analysis fulfillment

• Identified trend analysis indicators

• Initial understanding and standards in place for confidentiality

• Initiation of case reviews intended to inform system gaps and barriers– Initial structure and template in place– Begun identification of system issues– Begun identification of opportunities for additional collaborative

efforts

Challenges Being Faced

• Ensuring the right representatives from each agency are at the table

• Engaging other payers beyond CalOptima

• Missing representation from Public Health

• Understanding how the system will function as the Affordable Care Act is implemented

• Gathering the actual data from the identified agencies for the trend analysis

• Encouraging appropriate participation by parent representatives while respecting their personal experiences

Rural Children’s Special Health Coalition

Siskiyou, Shasta and Trinity Counties

Wendy Longwell

Parent Health Consultant

Rowell Family Empowerment of Northern California

UPDATE

Rowell Family Empowerment of Northern CA. (RFENC)• The mission of RFENC is to

empower people with diverse abilities, and their families, to live as respected and valued members throughout their communities by providing support, education and advocacy services.

• RFENC is a parent founded, parent run agency that assists families in navigating systems, understanding the laws and regulations that govern these systems, and provides parent to parent support.

Rural Children’s Special Health Coalition (RCSHC)

• Key Coalition Members will include:

CA. Children Services Far Northern Regional Center Community Health Centers Health and Human Services First 5 Dept. of Health and Human

Services 3-5 Family Members from Shasta,

Siskiyou, and Trinity counties• RCSHC is dedicated to bringing

families and health professionals together to improve health coordination in Shasta, Siskiyou, and Trinity counties.

Rural Children’s Special Health Coalition Goals!

• Professionals are more knowledgeable about community service systems and the family perspective.

• Family members are more knowledgeable about community service systems and how to navigate them.

• All participants see increased collaboration and communication among agencies to solve problems.

• All participants finds the training provided has quality, is valuable, relevant, and useful.

• Problem solve any issues we find around the transition to the new managed care Medi-Cal.

• Improving and updating the Medical Home Binder.

• All participants believe relationships have been strengthened.

RCSHC Project Activities• Schedule 10 phone and/or face to face meetings per year

• Create Methods to track changes in the systems

• Develop a trainings needs plan and hire speakers and trainers to educate everyone involved on improving care coordination and developing a clearer understanding of the transition to the new managed MediCal model

• Coordinate regular convening of a broad range of stakeholders in the targeted 3 counties to define issues, identify local unmet needs, explore resources, and develop action plans to solve problems

• Work on plans and projects the coalition decide are areas we need to work on.

RCSHC Anticipated Challenges• To get all required coalition members to attend meetings from all three counties.

Challenges we may face include: Distance to travel in unsafe weather conditions from the pioneer communities Time commitment, with travel, for professionals who may have a tight schedule

• To keep coalition members focused on the goals and activities outlined in the grant, staying true to the specific agenda

• Finding professional guest speakers/trainers who are willing to travel to the rural and pioneer communities to provide required educational topics that align with the RCSHC goals and objectives.

• Keeping the training to be disseminated at a level that can be easily understood by all. Such as keeping it at a 6th grade reading level

Accomplishments• Meetings held

– 1 face to face meeting

– 1 conference call

– Next meeting: conference call

• Members of coalition have attended Partnership Health Meetings and State-Level managed Care meetings.

• Other meetings in the community helping spread information on the transition• Outreach

– Poster distribution

– Facebook

– Email

– Community partners- Head Start, Non-Profit Coalition, local businesses, Area 2 Board, CCS, Far Northern Regional Center, Local Schools and School Districts Hospital representatives, Community Health Representatives, Local Providers, Parents.

Future Activities• Next Face to Face meeting guest speakers:

– Partnership Health Representative

– Lucille Packard Representative

– State Department of Health and Human Services Representative

• Wendy Longwell will be joining the Partnership Health Community Representative Body

– Also will be applying to become a Partnership Health Board Member

• Additional informational materials will be distributed as they become available. – Ex: input from community of information that Partnership Health should include in

their documents

• State of California has been updated on the developments and issues that arise as we go through the transition.

MediCal Transition Anticipated Challenges

• State of CA not giving Partnership Health the MediCal recipient's name prior to transition.

• Misinformation presented by Partnership Health to the community.• Partnership Health does not have a local office or Executive Director and are

not planning to have either until August.• Partnership Health does not have information for our area on their website and

is not expected to have such information until July. • Primary Care Providers will be assigned by Partnership Health and recipients

must be informed that they must fill out a form to switch back to their original Primary Care Provider.

– Recipients must contact their PCP to submit form.

– Changes will only happen at the first of the month. Recipients who submit the form after the first of the month will not be able to see their PCP until the following month.

– Can cause recipients to wait to see the doctor and could end up in the emergency room.

• Healthy Families transition confusion. • Lack of language access.

Possible Solutions• What worked for your counties?

• What strategies did you use to combat these issues?

• Any ideas???

All input greatly appreciated!

San Mateo County Care Coordination Learning Community

Cheryl Oku

Program Manager

Watch Me Grow Demonstration Site

Community Gatepath

UPDATE

• Community Gatepath

• First 5 San Mateo County

• Golden Gate Regional Center

• Lucile Packard Children’s Hospital

• San Mateo Co. Community College District

• San Mateo County Office of Education

• San Mateo Medical System: CCS, MCH, Clinics, Family Health Services

PARTNERS

• Children Now

• Child Care Coordinating Council

• Fair Oaks Children’s Clinic

• IHSD: Head Start/Early Head Start

• Legal Aid Society

• Lifesteps Foundation

• Parca

• Ravenswood Family Health Center

• Silicon Valley Community Foundation

• StarVista

PARTICIPANTS

• Strengthen the existing system of care coordination for CSHCN through a collaborative learning community

• Increase access to coordinated, effective, family-centered services for CSHCN within the medical home

• Develop a model of care coordination for CSHCN in the medical home that is replicable and sustainable

PROJECT GOALS

• Policy Group

• Mapping care coordination resources

• Assessment and referral protocol

• Policy recommendations

• Practitioner Group

• Best practices for care coordination

• Care coordinator handbook or tool

MAIN PROJECT ACTIVITIES

• Integrating care coordination models and information across different systems

• Changing availability of community resources for provision of care coordination

• Co-location of community care coordinator in the medical home

MAJOR CHALLENGES ANTICIPATED

• Leveraged technical assistance from LPFCH to obtain additional funding to continue the work of the learning community

• Convened 2 meetings focused on developing a shared understanding of the system of care coordination and needs in San Mateo County

• Began mapping local care coordination resources and services for CSHCN

PROGRESS MADE TO DATE

• Uncovering gaps in the local system of care that need to be addressed to create a system of coordinated care

• Addressing a wide range, intensity and diversity of care coordination needs of CSHCN

• Establishing protocols for co-location of care coordination services in the medical home

CHALLENGES

Central California Care Coordination Project

Marion Karian

Executive Director

Exceptional Parents Unlimited Children’s Center

UPDATE

Central California Care Coordination Project

EPU Children’s CenterFresno, California

Level 1: Basic

Information and Outside Referral- 2-year-old child with expressive and receptive

language delays- Referral sent to the Central Valley Regional Center

Level 2: ModerateCare Coordination and Multi Agency Involvement

- 3- year old child referred for behavioral and developmental concerns-OCK staff ,with the family, creates a care plan with referrals

-Referral to ACC /CSC and Family Resources Center

Level 3: Intensive

Complex /Multi Agency -Care Coordination including Special Health Care Needs

- 3-year-old girl has cerebral palsy, a seizure disorder, and is dependent on G-tube feedings,

as well as having significant developmental and educational needs. - Complex Care plan must meet her various medical , developmental and educational

needs including referrals to specialists at community-based agencies and tertiary care settings.

Long term coordination. - Referral to the Central California Care Coordination Team/Care Coordinator

Fresno County Department of Social Services Fresno County Department of Behavioral Health Fresno County Department of Public Health—Public Health Nursing,

Children’s Medical Services Central Valley Regional Center Fresno Unified School District First 5 Fresno Children’s Hospital Central California CASA Children’s Services Network Exceptional Parents Unlimited Cal Viva Marjaree Mason Center (Domestic Violence Shelter)

SMART Model of Care Partner Oversight Committee Members

To establish an active, interdisciplinary multi-agency team to receive referrals and coordinate the care of children with special health care needs.

To provide outreach and information regarding care coordination to hospital discharge planning/care coordination staff, NICU discharge staff, private pediatricians, and Federally Qualified Health Clinics.

Project Goals

Convene the Care Coordination Planning Team including representatives from: California Children’s Services Central Valley Regional Center Children’s Hospital—specialty primary care clinic Children’s Hospital—High Risk Newborn Follow Up EPU Children’s Center Parents

Conducting Outreach to various providers Attending the SMART—MOCPOC Visiting Kern Medically Vulnerable Project Studying models of care coordination

Main Project Activities

The complexities of the reimbursement systems

The vast-ness of the medical systems The fragmentation and super-specialization

of medical care Focusing our efforts on the ways in which we

can have the greatest impact Determining how the Care Coordination

Project can fit into the existing SMART Model of Care

Challenges

Difficulties working with collaborative partners

Complexity of eligibility requirements Private insurance limitations Inter-agency consents

More Challenges

Care Coordination Team has been meeting monthly

Referral procedures are in place Case presentation format has been

established A complex case has been presented Beginning outreach presentationso Children’s Hospital “Charlie Mitchell Clinic”o CVRC Baby Clinico Children’s Hospital High Risk Infant Follow-up

Program

Progress

Kern County Medically Vulnerable

Care Coordination Project

Marc Thibault, MA

Project Director

UPDATE

Kern County Medically Vulnerable Care Coordination Project

Mission Use enhanced coordination of existing case management services to measurably improve long term outcomes for children, birth to 5 years of age, who are at risk of costly, lifelong medical and developmental issues.

Background Since 2008, the Kern County Medically Vulnerable (MV) Workgroup of 40+ partner organizations has met monthly at First 5 Kern to address the needs of CSHCN, their families, providers, and communities.

Partners California Children’s Services; Clinics; Family Resource Centers; First 5 Kern; Foundations; Hospitals; Insurers; Kern County Departments of Human Services, Mental Health, Public Health Services; Kern Regional Center; School Districts; Special Care Centers; Local Agencies, Community Organizations and Institutions.

MVCCP ObjectivesKey Components of the Care Coordination Process

• Use an accepted Acuity Form to quickly identify and treat more conditions earlier to make a measurable difference in a child’s life.

• Support local services that already exist. • Focus on individual cases, working together through a Case Review

Committee, to develop best practices of care coordination. • Streamline access to, and maintenance of, health insurance and a

medical home, to reduce unnecessary ER visits and hospitalizations. • Build strong, long-term provider partnerships to sustain a

system of care coordination that is practical, affordable, and responsive to changing conditions.

• Use longitudinal data to document results. • Conduct Cost Benefit Analyses to demonstrate savings on at-risk

infants and children to better serve all children in the county.

The LPFCH grant to MVCCP provides free technical assistance in 2013 and 2014 to help implement care coordination in 3 counties by:

• facilitating a series of face to face and webinar meetings to assist local care coordination collaboratives

• sharing the MVCCP Acuity Scale Form to quickly help identify and refer Children with Special Health Care Needs (CSHCN)

• implementing a process for jointly addressing CSHCN cases• working together, through a locally selected Care Coordinator• finding local solutions and resolving care coordination barriers• using evaluation results from the Kern County MVCCP• developing best practices, learned in all four counties, and• jointly addressing the overall system of health care for CSHCN in

these counties.

MVCCP Replication Process and Potential ChallengesReplication Process

• MVCCP implemented a “first come, first served” approach, to engage with early adopter counties.

• Two counties – Contra Costa and Orange – have been actively engaged, learning about MVCCP Replication, and building their local collaboratives.

• A third county is still in the process of being selected, with outreach occurring with several counties through the MVCCP Advisory Committee.

Challenges• Counties understand how big an undertaking it is to take on care coordination

for CSHCN. Budgetary constraints and uncertainties due to local, state and federal policy and funding changes can affect the level of commitment.

• Must always remain aware of, and sensitive to, the political and historical dynamics that can differentiate each county in the implementation process.

• Previous or ongoing local collaboration efforts can impact the vision and the commitment to cooperation, especially depending how competitive the atmosphere is among potential partner organizations.

• A local governance plan must reflect the collaborative nature of the initiative, provide accountability and transparency to its work, and result in an inclusive decision-making process to achieve optimum results.

Kern County MVCCP Developments• MVCCP’s first Care Coordinator, Gail Davidson, has retired. • In the last 27 months, she managed over 500 referrals to the project.• Gail was an RN for 34 years, (a nursing professor for 10 years); starting her career in

the NICU and finishing it helping to change the system of care in Kern County! • Another PHN will assume the duties of the Care Coordinator in June. • Also, our county Director of Public Health Nursing, Lucinda Wasson, is retiring at

the end of June, after 35 years. A strong partner and advocate for care coordination, Cindy will be missed!

• Transitions like this must be as seamless as possible to sustain our progress!

MVCCP Replication Process and Challenges

Replication Process• Two counties – Contra Costa and Orange – are up and running! • A third county is doing an internal review among its agency and provider

partners prior to hosting a full presentation and broader planning discussion.

Challenges• “I think we are doing that already.” Distinguish in early discussions between

case management (individual level) and care coordination (system level).• “ I didn’t know about that.” Scheduled presentations from a variety local

providers, addressing their eligibility criteria, funding, and staffing, help build out the level of system, and strengthen the connectedness among partners to coordinate care, especially for complex cases.

• “How are we going to keep this going?” Financial sustainability requires researching, building up, and maintaining relationships with key local foundations and grant makers.

MVCCP invites you to its Annual Conference

Thursday, November 7, 2013 in BakersfieldThe theme is:

Reducing Premature Births Through Coordinated Community Strategies

Thank you for attending and

sharing your thoughts and experiences!