FloridaHATS Regional Coalition End-of-Year Reports June 12, 2015, 12 Noon ET

Attendees: Cynthia Campbell, Pat Dunn, Denise Adams, Chanda Jones, Rita Nathawad, Kristen Guskovict, Janet Hess

Attached are end-of year reports from each of the four regional coalitions. Discussion items included:

• Ms. Jones suggested that we have regularly scheduled face-to-face workshops or a statewidetransition conference for coalition members and other stakeholders to discuss their experiencesand share best practices. Dr. Nathawad offered to share her expertise in engaging adult providers.

• Ms. Dunn and Ms. Adams recommended that coalitions ask for representation from the FamilyNetwork on Disabilities (FND) programs in their area (see http://fndusa.org/contact-us/programs), as transition is a focus area in FND’s work.

• Also attached here is a draft Referral Form that CMSN/Pensacola and Escambia CommunityClinic use for exiting CMSN enrollees who are transitioned to the FQHC.

• Ms. Campbell reported that the draft MOA between CMSN and the Florida Association of Community Health Centers was sent to Andy Behrman (Executive Director, FACHC) for review, but he has not yet responded.

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South FloridaHATS CoalitionStrategic Planning 2014

Goal #1 Objectives Who will take lead Timeline Evaluation method

Increase education

to Adult Medical

Care Providers to

expand network of

providers acting

referrals and

buildup the number

of advocates

• Educate pediatricians about tools,

mechanisms, and protocols, along

with the need to move information

over to adult providers

o Outreach to local chapter of

AAP, Medical residents, Nurse

practitioners, CMS staff, FQHC

providers

o Promote Florida HATS provider

directory

• Suggest that peds providers pair up

with adult providers / develop

relationship with adult providers act

as consultants or a resource to new

adult providers)

• Talk with Federally qualified Health

Care Providers to find ways to help

them build capacity and meet their

mandate of working with youth and

young adults with special health

care needs.

• Look at ways to tie into an existing

program (nursing or other med)

• Start conversations to integrating into

programs (health care programs)

Dr. Rosa-Olivares

and Jean Sherman

were volunteered

Create talking points,

start identifying outreach

events, and volunteers by

12/15/14

Implement plan between

Jan- June 2015

*Action plan was

redrafted 09/2014 all

timelines will need to be

re-determined by

subcommittees

Group will participate in 2-

3 outreach events

between January – June

2015

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2

Goal #2 Objectives Who will take lead Timeline Evaluation method

Increase education

and access to

resources to create

more advocates

among families

and community

providers and to

empower families

• Identify appropriate materials such

as electronic resources and training

curriculums currently exist

• Identify gaps & determine if

resources need to be developed

• Look at potential collaboration

opportunities with groups such as:

FMD, SALT, CMS, etc

Schedule face to face trainings and

peer led support opportunities for

families and youth

•

o Create talking points

o Develop outreach plan

o Develop a speakers bureau

o Create subgroups (of family,

youth and young adults,

schools and community

providers to assist in the

identification of materials and

speakers)

o Create ‘champions’ customize

materials

Deborah Chin,

Isabel Garcia, Jose

Pinto Lisa Friedman-

Chavez

Create talking points and

develop survey start

identifying outreach

events, and volunteers

by 12/15/14

Implement plan between

Jan- June 2015

facilitate conversations

with stakeholders about

what resources they

currently look for by

September 30th

*Action plan was

redrafted 09/2014 all

timelines will need to be

re-determined by

subcommittees

Group will participate in 2-

3 outreach events

between January – June

2015

List / matrix assessing

availability of resource

(including resource

accessibility) by domain

(youth, provider, etc) will

be developed to identify

gaps.

List will grow by 10% in the

second, third and fourth

quarters of the year.

Year 1 of our strategic plan

An evolving process

� Taskforce meetings

�September 10

�January 8

�April 1

�June 2

� Subcommittee goals

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Lessons Learned

� Increasing Participation

�Better use of existing resources

�The taskforce gains momentum and motivation as a larger group

Next Steps

� Monthly meetings, rotating between live and online

access

� Increasing Participation

� Moving forward as a taskforce instead of as

subcommittees

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NORTHEAST FLORIDA HATS COALITION UPDATE

June 2015

VISION

To provide a continuum To provide a continuum To provide a continuum To provide a continuum of comprehensive, of comprehensive, of comprehensive, of comprehensive,

accessible, and quality healthcareaccessible, and quality healthcareaccessible, and quality healthcareaccessible, and quality healthcare

for youth and young adults with for youth and young adults with for youth and young adults with for youth and young adults with special health special health special health special health

care needs (YYASHCNs) living care needs (YYASHCNs) living care needs (YYASHCNs) living care needs (YYASHCNs) living in Northeast in Northeast in Northeast in Northeast

Florida.Florida.Florida.Florida.

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STRATEGIC ISSUES

� The The The The system of care for system of care for system of care for system of care for YYASHCNs YYASHCNs YYASHCNs YYASHCNs is fragmented is fragmented is fragmented is fragmented

and has multiple barriers to successful transition and has multiple barriers to successful transition and has multiple barriers to successful transition and has multiple barriers to successful transition

from pediatric to adultfrom pediatric to adultfrom pediatric to adultfrom pediatric to adult----oriented systems. oriented systems. oriented systems. oriented systems.

� Both pediatric Both pediatric Both pediatric Both pediatric and adult and adult and adult and adult providers providers providers providers would benefit would benefit would benefit would benefit

from additional training to address the special from additional training to address the special from additional training to address the special from additional training to address the special

health care and other needs of health care and other needs of health care and other needs of health care and other needs of this population.this population.this population.this population.

� Public Public Public Public policy should support better services for policy should support better services for policy should support better services for policy should support better services for

YYASCHNs during YYASCHNs during YYASCHNs during YYASCHNs during transition.transition.transition.transition.

SYSTEM OF CARE

� Identify community stakeholders interested in transition Identify community stakeholders interested in transition Identify community stakeholders interested in transition Identify community stakeholders interested in transition for YYASHCNs and meet quarterly to discuss coalition for YYASHCNs and meet quarterly to discuss coalition for YYASHCNs and meet quarterly to discuss coalition for YYASHCNs and meet quarterly to discuss coalition goals/actions.goals/actions.goals/actions.goals/actions.

� Resource developmentResource developmentResource developmentResource development� Update JaxHATS Website/Facebook/Marketing � Checklist/process for transition out of JAXHATS

� Assets and gapsAssets and gapsAssets and gapsAssets and gaps� Working group to assess needs of DD community � Dental - Clinic� Psych – Network/Collaborative Care Model� Education/Vocational needs� Youth council/support groups� JASMYN/PACE/Foster Care

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EDUCATION

� Medical OutreachMedical OutreachMedical OutreachMedical Outreach� Nemours� UF Health

� ER referrals

� Baptist/WCH� Community providers� Transition Rotation Curriculum

� Community OutreachCommunity OutreachCommunity OutreachCommunity Outreach� Pedscare� Events

� Interface Interface Interface Interface of education to healthcareof education to healthcareof education to healthcareof education to healthcare� ESE coordination with Duval and surrounding counties� Liaison for patients and caregivers in IEP meetings/College

Offices of Disabilities

ADVOCACY/POLICY

� CommunityCommunityCommunityCommunity�Family Council

� SystemSystemSystemSystem�Linkages between pediatric and adult subspecialties

�Reimbursement for transition services

� Increased access to care/overcoming barriers

� LegislativeLegislativeLegislativeLegislative�Medicaid

�AAP

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LESSONS LEARNED

� Navigating and networking are key features to

developing an effective system of care for

YYASHCNs.

� Many programs exist in the NEFL region and it is

imperative that we coordinate our efforts to best

use the resources the programs have to offer.

� Bridging the gap between pediatric to adult care is

not easy and requires intensive and holistic care

coordination.

OUTCOMES

� FeedbackFeedbackFeedbackFeedback�Families/Patients

�Providers

�Stakeholders

� Upcoming study to evaluate nonUpcoming study to evaluate nonUpcoming study to evaluate nonUpcoming study to evaluate non----medical needsmedical needsmedical needsmedical needs

1

HillsboroughHATSFY 2014-2015 Update

June 12, 2015

Action PlanUpdated 9-30-14

In 2014, Coalition agreed to focus on two objectives.

Both fall under Strategic Issue 1:

What is needed to ensure a successful health care

transition for Y/YA with complex health and

behavioral health needs as they transition from a

pediatric to adult system of care?

• Objective 1.1: Identify all potential health care and support

service resources related to transition and assets that serve

young adults with disabilities or health care needs as a first

priority.

• Objective 1.3 Encourage pediatricians including those

working in hospital settings to adopt health transition policies

in their practices.

2

Focus on Pediatric Providers

• Hillsborough County Pediatric Society

• Health Point Medical Group

• Pediatric Health Care Alliance

• NAPNAP (Pediatric Nurse Practitioners, Gulf Coast Chapter)

• Graduate Schools of Nursing:• University of South Florida

• South University

• University of Tampa

• Pediatric Social Workers

3

• CMSN distributes FLHATS brochure and

HillsboroughHATS postcard to their providers

• Fall 2014 Newsletter disseminated

• Updated HillsboroughHATS Presenter Tip

Sheet

Community Outreach

• NAPNAP

4

• Presented to community and school groups

• School Nurses, 9/14/15

• Hillsborough County Pediatric Society, 9/18/14

• Hillsborough County Community Alliance, 10/14/14

• Participated in school and community

resource fairs

• YES! Disability Fair, 10/4/14

• Hillsborough County Resource Exchange, 1/15/15

• School District Transition Resource Fair, 2/28/15

Community Outreach

5

Administration

• 2 Coalition Meetings

• 9-24-14

• 11-18-14

• Marybeth Palmigiano resigned in

3rd quarter (January 2015); no

replacement to-date

Form a group of advocates and providers to meet with local MMA plan administrators to discuss the needs of medically complex patients, and address the plans’ responsibility in making sure these patients receive an appropriate level of care.

Continuation Activityfor FY 2015-2016

6

Challenges

• Finding an interested, qualified coalition coordinator

• Identifying a convenient time & location for meetings

• Engaging coalition members • Budget cuts; many are taking on more responsibility

• Getting adult providers to take on Y/YA with complex needs due to low reimbursement rates

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Vision

The PanhandleHATS Regional Coalition’s vision is to assure continuity of health care in order to provide a seamless

transition from pediatric to adult life in the Florida Panhandle with a primary focus on those with disabilities or special

health care needs.

PanhandleHATS

Action Plan Review

CMS/ECC FQHC

Transitions

ECC History – Pre FQHC

Founded in 1992 after the closure of

University Hospital

501 (c) (3) entity

Supported and funded by BH, SHH and

Escambia County

Initially managed by a 6 member

board

Provided basic o/p primary care

Functioned in this capacity for

14 years

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ECC History – Post FQHC• Filed for FQHC status in May 2007

• FQHC grant funded September 2007

• Current Project Period is 2015 through 2018

• Managed by board of 13 (51% are users of facility)

• Only FQHC in the area

• Grown to nine service delivery sites

• Staffed by 159 dedicated employees

• Receives funding for Healthcare for the Homeless (330h).

• Two 38 ft GMC mobile units (Medical and Dental)

• 3 sites impacted by April 2014 flooding

ECC Service Delivery Sites• ECC Main Service Delivery Site - 14 W. Jordan Street, Pensacola, FL 32501 (850)436-4630

• ECC Urgent Care Clinic - 14 W. Jordan Street, Pensacola, FL 32501 (850) 436-4630

• Lanza Pediatrics - 2510 N. 12th Ave, Pensacola, FL 32503 (850)471-0508

• First Steps Pediatrics – 5868 Creek Station Dr. Pensacola, FL 32504 (850-478-1244)

• ECC at Lakeview –1221 W. Lakeview Ave. Pensacola, FL 32501

(850) 429-6993 Pediatrics in Children’s Service Center /(850) 469-3890 Adult clinic in Bldg. E

• ECC at Waterfront Mission – 350 W. Herman St., Pensacola, FL 32501 (850) 332-5900

• ECC Dental Clinic & Mobile Dental Unit- 1295 W. Fairfield Drive, Pensacola, FL 32501

(850)-912-8880

• Cantonment Medical Center - 748 Hwy. 29, Cantonment, FL 32533 (850) 937-4004

• Santa Rosa Community Clinic, - 5520 Stewart St, Milton, FL 32570

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Escambia Community Clinics, Inc.

14 West Jordan St.

Pensacola, FL 32501

Santa Rosa Community Clinic

5520 Stewart Street

Milton, FL 32570

Cantonment Medical Center

748 Hwy 29

Cantonment, FL 32533

ECC at Lakeview

1221 West Lakeview Ave

Pensacola, FL 32501

Lanza Pediatrics

2510 North 12th Avenue

Pensacola, FL 32503

ECC Urgent Care Walk-In Clinic

14 West Jordan Street Suite A

Pensacola, FL 32501

ECC at Waterfront Mission

380 West Herman Street

Pensacola, FL 325005

ECC Dental Clinic/Dental Van

1295 W. Fairfield Drive

Pensacola, FL 32501 First Steps Pediatrics

5868 Creek Station Dr. Bldg A

Pensacola, FL 32504

Escambia Community Clinics, Inc. Service Area Map

ECC Growth 2007-2014

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4

Barriers, Challenges and Successes for

PanhandleHATS 2014-2015

• Expectations of recruiting of new coalition members has

been unrealistic given numerous budget cuts and staff

changes/cuts in agencies. New approaches identified.

• Reorganization of CMS region offices and leadership has

impacted the identification of appropriate staff to attend

and represent CMS at PanhandleHATS meetings. Will

continue to work with managing staff.

• ECC FQHC has helped to create a transition process and

PanhandleHATS and ECC have developed client transition

referral form.

• Enhanced collaborative spirit over past year between

FQHCs and broadened communication between centers in

PanhandleHATS region.

Pg. 1 ECC/CMS Client Referral Form – Draft 5/14/15

Escambia Community Clinics, Inc. Client Referral Form 14 West Jordan Street Pensacola FL, 32501 Contact: Bobbie Huffman, BSW 850.436.4630 ext. 1403 Fax: 850.436.2095

Referral Date: _______________ Staffing Date: ____________ Discharge Date: _________

CMS Discharge Planner/Social Worker: ______________________ Phone:______________

FAX____________________ E-Mail_________________________________

_____________________________________________________________________________

Client Demographic Information:

Name: ________________________ DOB: _________ Gender: ____ SSN: _______________

Phone: ________________ Alternate Contact Person/Phone: _________________________

Address: ______________________________________________________________________

Education Level: ______________ Employment: ____________________________________

Insurance: Medicaid Medicare Uninsured Other/Private _____________

Legal guardian name/Power of Attorney: (relationship and contact information) _____________________________________________________________________ (Include legal documents supporting guardianship and Power of Attorney) _____________________________________________________________________________________________ Items below will be reviewed by ECC Provider to determine the appropriateness of the referral to establish ECC as the patient’s medical home. (Please submit attachments)

______ Current Medical Provider Information

_______ Current Diagnosis

______ Medical History

______ Current Medication List

______ Previous Hospitalization(s)

______ Specialty Care Provider Information ( e.g. Nemours, CMS Clinic, Other Specialist)

Pg. 2 ECC/CMS Client Referral Form – Draft 5/14/15

Medical Equipment/Supplies Yes No

List of Supplies: _______________________________________________________________________

Transportation Needs: Yes No

How are current transportation needs being met? __________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Discharge Plans/ Recommendations: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________