california community care coordination collaborative - september 2014

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California Community Care Coordination Collaborative September 2014 9/23/2014

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The California Community Care Coordination Collaborative (5Cs) is a learning collaborative made up of six regional coalitions serving children with special health care needs (CSHCN) launched in April of 2013. The first phase ended in September 2014, but the coalitions continue to meet. A second phase will begin in January 2015. View this slideshow to learn about the progress, products and recommendations from each coalition.

TRANSCRIPT

Page 1: California Community Care Coordination Collaborative - September 2014

California Community Care Coordination Collaborative

September 2014

9/23/2014

Page 2: California Community Care Coordination Collaborative - September 2014

Orange County Care Coordination Collaborative for Kids

(OC C3 For Kids)

Rebecca Hernandez, MSEd

Program Manager

Help Me Grow Orange County

UPDATE

9/23/2014

Page 3: California Community Care Coordination Collaborative - September 2014

Progress on Goals of OCC3 for Kids

1. To identify the specific needs of the OC care coordination collaborative:• Conducted two stakeholder surveys• Discussed cases shared by a variety of OCC3 for Kids participants• Coordinated agency presentations to the OC C3 group to educate about their

eligibility, referral processes and misperceptions

2. To determine the organizational structure of the OC care coordination system:• Established a broad base of participants• Convened ad-hoc committees• Developed proposal for system-level Care Coordinator and job duty statement

3. To conduct a pilot of the proposed OC Care Coordination model:• Recruited and implemented tool at 5 pilot sites• Received more than 170 completed tools• Conducted focus groups for feedback on pilot and tool

4. To create and implement a sustainability plan:• Obtained funding from one additional Foundation• Plan includes public funding, private funding and integration of efforts 9/23/2014

Page 4: California Community Care Coordination Collaborative - September 2014

Products Developed

• Goal Chart created as wallboard for use at each OC C3 for Kids

• HIPAA Chart created as wallboard for reference during case reviews

• Case Review Template

• OC C3 for Kids Trend Report

• Screening Tool for use in Pilot

• Protocol for Case Review Process

• Vison , Mission and Value Statements

9/23/2014

Page 5: California Community Care Coordination Collaborative - September 2014

Key Components For Replication

Lessons Learned from Pilot and Focus Groups

• All who participated in the focus groups thought the tool was beneficial

• Parts of the tool need refinement

• When and where the screening is administered is important, and may be different for various organizations

• Certain risks were mentioned more frequently as impactful by the interviewers

• Family reaction to the tool ranged widely

9/23/2014

Page 6: California Community Care Coordination Collaborative - September 2014

Next Steps

• Continue to work on systems issues through the monthly gathering of the countywide collaborative providing CSHCN case reviews, open discussion and resolution of care coordination challenges for CSHCN, their families, providers and communities

• Develop a mechanism to improve inter-agency coordination for specific cases where CSHCN need a higher level of care coordination

• Publicize the CSHCN screening and referral protocol for providers and other stakeholders to more quickly identify, access and coordinate needed services

• Maximize staff time and resources by focusing on the efficiencies of care coordination in the face of complex health and social services for CSHCN and their families

• Demonstrate the benefits of care coordination by greatly reducing unnecessary and costly emergency room visits, hospitalizations, and re-hospitalizations

• Create a sustainable care coordination entity in OC that combines public and private interests and merge with ongoing efforts

9/23/2014

Page 7: California Community Care Coordination Collaborative - September 2014

Monterey County

Vulnerable Infant Care Coordination Collaborative(VICCC)

9/23/2014

Page 8: California Community Care Coordination Collaborative - September 2014

Progress Towards GoalsGOAL

• Develop comprehensive integrated system to serve children and families of children with special health care needs.

PROGRESS

• In process.• We have established monthly

meetings that are well-attended.• We have representation from

SARC, CCS, CHDP, WIC, DSS, local clinics and NICU’s, Coastal Kids Home Care, Adoption agency, physicians and other local agencies.

• We are identifying systems issues and brainstorming to find solutions to improve service gaps for children with special health care needs.

9/23/2014

Page 9: California Community Care Coordination Collaborative - September 2014

GOAL

• Strengthen and link local community resources in efforts to increase team’s knowledge base and identify gaps in services.

PROGRESS

• We have made great strides.

• Agency presentations take place each month.

• Group participants enjoy the presentations.

• Knowledge base about local community resources has increased.

9/23/2014

Page 10: California Community Care Coordination Collaborative - September 2014

GOAL

• Formulate a plan to address identified service gaps.

PROGRESS

• In process.• We have identified some

barriers (i.e. client’s lack of transportation/finances, providers lack of knowledge about available community resources, time constraints for local providers to make and follow-up on referrals).

• The group is continuing to identify service gaps.

• The group is beginning to create action steps to address issues of concern.

9/23/2014

Page 11: California Community Care Coordination Collaborative - September 2014

GOAL

• Develop duty statement and identify funding for MVI PHN Case Manager/Care Coordinator.

PROGRESS

• In Process.• We are developing duty

statement for a PHN care coordinator position to ensure health needs of children and families of children with special health care needs are being met.

9/23/2014

Page 12: California Community Care Coordination Collaborative - September 2014

Products Developed

• We have modeled our case review template after Kern County’s and are currently using it for case reviews.

• We have reviewed and shared Kern County’s acuity rating scale in efforts to prioritize cases to be reviewed.

9/23/2014

Page 13: California Community Care Coordination Collaborative - September 2014

Key Components That Can Be Replicated

• Meeting format • Announcements, Agency Presentations, Case Reviews,

Action Steps/Follow-Up

• Receive Mentorship• Establish relationship with a successful agency to

receive guidance and expert advice.• Continually Identify Stakeholders

• Extend invitations to key community partners as they are identified.

9/23/2014

Page 14: California Community Care Coordination Collaborative - September 2014

Next Steps• Identify and establish short and long-term

funding source to sustain VICCC.• Identify and engage key stakeholders.• Develop and implement action plan.• Establish QI process and make revisions to

agendas/action plans/protocols as needed.

9/23/2014

Page 15: California Community Care Coordination Collaborative - September 2014

Rural Children’s Special Health Coalition

Siskiyou, Shasta and Trinity Counties

Wendy Longwell

Parent Health Consultant

Rowell Family Empowerment of Northern California

UPDATE

9/23/2014

Page 16: California Community Care Coordination Collaborative - September 2014

Progress Towards Project Goals

Navigating Mental Health Services

Access to Primary Care Physicians

Access to appropriate counseling services

Continuing to work on the Medical Home Binder

9/23/2014

Page 17: California Community Care Coordination Collaborative - September 2014

9/23/2014

Page 18: California Community Care Coordination Collaborative - September 2014

Coalition CollaborationRound table

Inviting key stakeholders from various agencies

Guest speakers on what they do

Having parents as active participants in the process       

9/23/2014

Page 19: California Community Care Coordination Collaborative - September 2014

Improving Care Coordination

Invite local counseling/behaviorist agencies

What changes can we, as a community, make to improve service access?

9/23/2014

Page 20: California Community Care Coordination Collaborative - September 2014

Contra Costa California Community Care

Coordination Collaborative (7Cs)

Barbara Sheehy, MS

Administrator

California Children's Services Contra Costa County

UPDATE

9/23/2014

Page 21: California Community Care Coordination Collaborative - September 2014

Progress Toward Original Goals Through the activities of the grant, and input from our partners, the

needs of children with CSHCN & their families are much clearer. Using our governance plan, which includes our Roundtable

meetings, our 7 Cs coalition meetings, and an Early Childhood Leadership Alliance, we have established and strengthened a structure that will implement major changes to our system.

While we didn’t hire a care coordinator, our pilot of re-launched Roundtable meetings has been longer than 3 months as we continue to facilitate the changes to our system.

We were able to apply for, and receive, grant funds from Kaiser to sustain our work moving forward. We will continue to identify additional sources of sustaining funds.

Page 22: California Community Care Coordination Collaborative - September 2014

Products Developed During Project

Consent form for Roundtable Meetings Sign-in sheet for Roundtable that is also a

statement of confidentiality Resource List – for both providers, agencies and

families.

Page 23: California Community Care Coordination Collaborative - September 2014

Key Components That Could Be Replicated Our 7 Cs monthly coalition meeting. It has been important to

bring agency personnel together to discuss and plan for changes to our system.

Contra Costa Roundtable meetings, where agency staff bring newer referrals and high acuity cases to review and coordinate with other agencies who also care for the child.

Our Early Childhood Leadership Alliance, where systems issues will be referred and resolved by agency decision-makers.

Page 24: California Community Care Coordination Collaborative - September 2014

Next Steps for 7 Cs Leadership Team created to share responsibilities

across more partners, support re-launched Roundtable meetings, continue partner development and track our data & evaluation efforts.

Continue monthly coalition meetings. There is value in meeting, especially without a care coordinator

Wait to hear on our application for Phase 2 funds from LPFCH!

Page 25: California Community Care Coordination Collaborative - September 2014

San Mateo Learning Collaborative

September 23, 2014LPFCH 5Cs Statewide Meeting

9/23/2014

Page 26: California Community Care Coordination Collaborative - September 2014

Progress on Project Goals

• Strengthened the existing system of care coordination through a collaborative learning community

• Increased access to coordinated, effective, family centered services in the medical home

• Developed a model of care coordination in the medical home that is replicable and sustainable

9/23/2014

Page 27: California Community Care Coordination Collaborative - September 2014

Products

• Policy Group

• Map of care coordination resources

• Assessment & Referral protocol in pediatric clinic

• Policy recommendations

• Practitioner Group– Online resource list

– Family notebook and tips for families navigating the system of care

9/23/2014

Page 28: California Community Care Coordination Collaborative - September 2014

Key Components

• Cross-training and sharing information on resources and processes to support more coordinated care

• Updated online resource list of resources for care coordinators and families of CHSCN

• Co-location of community care coordinator in public pediatric clinics to increase access and linkage to services

9/23/2014

Page 29: California Community Care Coordination Collaborative - September 2014

Next Steps

• Planning for sustainability of systems change and care coordination services

• Re-engaging medical providers and engaging new community partners

• Focus on addressing systems issues for children with more complex health care needs

9/23/2014

Page 30: California Community Care Coordination Collaborative - September 2014

Central California Care Coordination Project

September 23, 2014

9/23/2014

Page 31: California Community Care Coordination Collaborative - September 2014

Care Coordination Products• Referral form - agencies can now refer electronically through

our website• Acuity form – Our redefined Acuity form provides a more

accurate view of family and child needs• Case presentation form – Helps to keep us focused and on task• Trifold Leaflet – Is used to describe our project and purpose to

community partners• Disclosure/Consent form – Allows us to share information to

better coordinate care• Parent Survey – Gives us much needed feedback about the

experience of our families involved with the Team• Data Base – We have expanded our data collection to include

Care Coordination demographics

9/23/2014

Page 32: California Community Care Coordination Collaborative - September 2014

Long term goals and objectives

• The long term outcome of this project is to enhance the existing SMART Model of Care by adding a child specific problem solving team within the One Call for Kids/Help me Grow system to include complex care needs of children and to address complicated interagency issues that compromise the ability of children with special health care needs to receive the support and care they require.

• 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.

• To establish an active interdisciplinary, multi-agency team to receive referrals and coordinate the care of Children with Special Health Care Needs (CSHCN) at regularly scheduled monthly meetings.

9/23/2014

Page 33: California Community Care Coordination Collaborative - September 2014

What we might shareLessons learned

• What we have learned from our county’s successful community wide model known as the SMART Model of Care

• What we have learned being an integral part of EPU and benefitting from its long history of collaborative relationships around young children with a wide range of special needs and the leadership provided by the agency in creating and promoting early and comprehensive care for vulnerable children and families.

• How to integrate/implement Care Coordination into already existing services.

• The benefit of parent representation and involvement.• We are happy to share any of the supporting documents we

have developed. (no need to reinvent the wheel)

9/23/2014

Page 34: California Community Care Coordination Collaborative - September 2014

Next Steps

• Continue monthly Care Coordination meetings• Invite new member participation (recent addition of

IHSS)• Involve more parent representation and involvement• Continue to update resources and provide

educational presentations to the CC Team• Continue to grow our collaboration with partners

especially CHCC(Madera) CVRC, PHN, CCS• Continuing our efforts to reach out to rural

communities within our county• Secure additional funding to support our efforts

9/23/2014

Page 35: California Community Care Coordination Collaborative - September 2014

Kern County Medically Vulnerable

Care Coordination Project

Marc Thibault, MA

Project Director

UPDATE

9/23/2014

Page 36: California Community Care Coordination Collaborative - September 2014

Slide 1 – Kern County MVCCP Replication Progress – Challenges and Solutions

MVCCP Replication Process among Three California Counties• MVCCP implemented a “first come, first served” approach, to mitigate

possible barriers to success, by engaging with early adopter counties.• Three counties – Contra Costa, Monterey, and Orange – have been actively

engaged and building their local collaboratives.

Early Challenges and Solutions• Each county understood how big an undertaking it was to take on care

coordination for CSHCN. Budgetary constraints from local, state and federal funding sources could affect the level of commitment from their partners.

• Each county was aware of, and sensitive to, the political and historical dynamics that differentiated each county in the implementation process.

• Each county has developed a local governance plan to reflect the collaborative nature of their initiative, providing accountability and transparency to its work, and resulting in an inclusive decision-making process to achieve optimum, long term results among diverse partners.

9/23/2014

Page 37: California Community Care Coordination Collaborative - September 2014

Slide 2 - MVCCP Products Developed

MVCCP Replication Products1. Outreach Process with Introductory Letter2. Kickoff meeting agenda and PowerPoint presentation3. Sample outcomes and indicators for evaluation purposes4. Methodology for facilitating face to face meetings and

conference calls to assist local care coordination collaboratives5. MVCCP Acuity Scale Form as draft document to quickly help

identify and refer Children with Special Health Care Needs (CSHCN) to each county

6. Case review process, including confidentiality policy/process7. Role descriptions and responsibilities for staff positions:

facilitator, care coordinator, evaluator8. Federal Financial Participation - matching funding9. Lessons Learned and promising practices

9/23/2014

Page 38: California Community Care Coordination Collaborative - September 2014

Slide 3 – MVCCP Replication Models and Best PracticesA. MVCCP Replication Products in Slide 2B. Lessons Learned1. System Level - State Policies Impact Us All 2. County Level - We are much stronger working together.3. Program Level –

• Refer, refer, refer – don’t assume anything about program eligibility!• Early intervention is critical - If not clear on the whole course of

treatment, start with an interim plan and build on “baby steps”.• Partners’ relationships streamline and expedite referrals across

systems; overall functioning and understanding is enhanced of key contact persons, partner roles, eligibility criteria, referral processes, expected timeframes, and available funding/insurance.

• Staff roles are essential to sustain the Collaborative over time - Care Coordinator and Staff responsibilities complement each other to: convene regular schedule of informational and case review meetings; receive, track, and evaluate case results; leverage funds; perform outreach to new partners; and maintain clear vision.9/23/2014

Page 39: California Community Care Coordination Collaborative - September 2014

Slide 4 MVCCP - Next StepsA. Participation in 5CsB. Continue Blue Ribbon Project with Targeted Case ManagementC. Extend County Regional Care Coordination Outreach through Public

Health District Offices and Community CollaborativesD. Reduce Missed Appointments by extending collaboration with Local

providers, safety net agencies, insurers, and Special Care CentersE. Continue RSV Task Force

MVCCP invites you to its 4th Annual Conference

Thursday, November 6, 2014 in BakersfieldThe theme is:

Overcoming the Challenges for CSHCN of Emergency Management,

Missed Appointments, and Transportation Barriers

9/23/2014

Page 40: California Community Care Coordination Collaborative - September 2014

In MemoriamGail Davidson, APHN-BC, MSN, RN

• Gail Davidson was MVCCP’s first Care Coordinator. • 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 for CSHCN, not only in Kern County but in California!

9/23/2014