California Community Care Coordination Collaborative - April 9, 2013 Webinar
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California Community Care Coordination Collaborative - April 9, 2013 Webinar



The California Community Care Coordination Collaborative launched its work with an introductory webinar on April 9. The goal of the Collaborative, funded by the Lucile Packard Foundation for ...

The California Community Care Coordination Collaborative launched its work with an introductory webinar on April 9. The goal of the Collaborative, funded by the Lucile Packard Foundation for Children's Health, is to improve the quality of care coordination for children with special health care needs by providing a structured opportunity for leaders to learn from one another, identify areas of shared need, discuss emerging challenges and connect with others engaged in this work. Each of the six regional coalitions participating in the Collaborative has begun work. In June, these coalitions will come together at the Lucile Packard Foundation for Children’s Health, which is funding the project, for their first all-day meeting. As the work of the Collaborative develops, we will post resources and information about care coordination.



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California Community Care Coordination Collaborative - April 9, 2013 Webinar California Community Care Coordination Collaborative - April 9, 2013 Webinar Presentation Transcript

  • California Community CareCoordination CollaborativeIntroductory CallApril 9, 2013
  • • Introduction and Welcome– Holly Henry, PhD, Research Program Officer– Ed Schor, MD, Senior Vice President of Programs and Partnerships– Janis Connallon, Manager of CAAdvocacy Network for Children with Special Health Care Needs• Project Descriptions and Introductions– Contra Costa California Community Care Coordination Collaborative– Orange County Care Coordination Collaborative for Kids– Rural Children’s Special Health Coalition– San Mateo County Care Coordination Learning Community– Central California Care Coordination Project– Medically Vulnerable Care Coordination Project• Preparation for In-Person Meeting• QuestionsAGENDA
  • Contra Costa California Community CareCoordination CollaborativeBarbara Sheehy, MSAdministratorCalifornia Childrens Services Contra Costa County
  • SEVEN C’S 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 Oakland and Research Center• 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
  • SEVEN C’S PROJECT GOALS1. To determine the specific needs of CSHCN, birth to 5years of age, and their families, for the Seven C’sProject.2. To align the organizational structure to implement theSeven C’s Project for CSHCN, birth to 5 years of age,and their families, providers and communities.3. To conduct a 3 month pilot program of the Seven C’sinitiative to work through and validate procedures,tools, costs and processes before full implementation.4. To create and implement a financial sustainability planto secure Care Coordination staff and other resourcesto fully implement the Seven C’s P for CSHCN, birth – 5years of age, their families, providers and communities.
  • SEVEN C’S MAIN ACTIVITIES• Convene monthly Seven C’s Partner meetings to develop,pilot, and support a county-wide CSHCN care coordinationsystem.• Learn about the Kern County, MVCCP model, history, AcuityForm and tools.• Compile and analyze Contra Costa CSHCN data to developprojected population to be served by care coordinationinitiative.• Develop a county specific resource list of pediatric specialneeds services for families and providers.• Develop and implement a county wide outreach andeducation plan for families and providers.• Create, implement, and monitor role of Care Coordinator tosupport county-wide CSHCN care coordination system.
  • SEVEN C’S ANTICIPATED CHALLENGES• Some Partners have no experience workingtogether collaboratively• Assuring family centered care is institutionalized incare coordination system
  • Orange County Care Coordination Collaborative for KidsRebecca Hernandez, MSEdProgram ManagerHelp Me Grow Orange County
  • Key Coalition Partners:• American Academy of Pediatrics, CA Chapter 4• Children and Families Commission of Orange County• CHOC Childrens Foundation• Help Me Grow Orange County• Orangewood Children’s Foundation/Bridges NetworkCollaborative 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 CAOrange County Care CoordinationCollaborative for Kids
  • OC C3 For Kids GoalsOverarching goal: To improve overall care for children and families withspecial health care needs by creating a collaborative care coordinationsystem in Orange County.1. To identify the specific needs of the Orange County care coordinationcollaborative starting with children birth to 5 years of age who have specialhealth care needs (CSHCN) and their families.2. To determine the organizational structure of the Orange County carecoordination system for children birth to five years with special health careneeds (CSHCN) and their families.3. To conduct a pilot of the proposed Orange County Care Coordination modelto 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 toimplement a care coordination countywide system with scalability andpotential 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 collaborativeproviding CSHCN case reviews, open discussion and resolution ofchallenges• Develop a care coordination protocol to address system wide issues thataffect CSHCN and their families• Develop and promote common language via a county wide risk assessmentand referral form to enhance provider communication• Maximize staff time and resources by focusing on theefficiencies of care coordination• Create a sustainable care coordination entity in OC• Conduct final evaluation combining qualitativeand a quantitative assessments to identify strengthsand weaknesses of the project
  • 13Anticipated Orange County ChallengesAs our project was developed, the core planningteam identified several challenges that may beencountered. These include:• Time constraints of the current OC C3 forKids participants• Recruitment of additional organizations whoprovide services for CSHCN• Financial constraints as there has beentremendous cutbacks to organizationstherefore limited staff to participateThank youRebecca Hernandez, MSEdProject Director, OC C3 For
  • Rural Children’s Special Health CoalitionSiskyou, Shasta and Trinity CountiesGina GrecianProgram ManagerWendy LongwellParent Health ConsultantRowell Family Empowerment of Northern California
  • Rowell Family Empowermentof Northern CA. (RFENC)• The mission of RFENC is toempower people with diverseabilities, and their families, to liveas respected and valued membersthroughout their communities byproviding support, education andadvocacy services.• RFENC is a parent founded, parentrun agency that assists families innavigating systems, understandingthe laws and regulations thatgovern these systems, and providesparent to parent support.Rural Children’s SpecialHealth Coalition (RCSHC)• Key Coalition Members willinclude: CA. Children Services Far Northern Regional Center Community Health Centers Health and Human Services First 5 Dept. of Health and HumanServices 3-5 Family Members from Shasta,Siskiyou, and Trinity counties• RCSHC is dedicated to bringingfamilies and health professionalstogether to improve healthcoordination in Shasta, Siskiyou,and Trinity counties.
  • Rural Children’s Special HealthCoalition Goals!• Professionals are moreknowledgeable about communityservice systems and the familyperspective.• Family members are moreknowledgeable about communityservice systems and how to navigatethem.• All participants see increasedcollaboration and communicationamong agencies to solve problems.• All participants find the trainingprovided has quality, is valuable,relevant, and useful.• Problem solve any issues we findaround the transition to the newmanaged care Medi-Cal.• Improving and updating the MedicalHome Binder.• All participants believe relationshipshave 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 educateeveryone involved on improving care coordination and developing a clearerunderstanding of the transition to the new managed MediCal model• Coordinate regular convening of a broad range of stakeholders in the targeted 3counties to define issues, identify local unmet needs, explore resources, anddevelop 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 thegrant, staying true to the specific agenda• Finding professional guest speakers/trainers who are willing to travel to therural and pioneer communities to provide required educational topics that alignwith the RCSHC goals and objectives.• Keeping the training to be disseminated at a level that can be easily understoodby all. Such as keeping it at a 6th grade reading level
  • San Mateo County Care Coordination Learning CommunityCheryl OkuProgram ManagerWatch Me Grow Demonstration SiteCommunity Gatepath
  • Key Coalition Members• Community Gatepath• CBOs: IHSD Head Start/Early Head Start,Lifesteps Foundation, StarVista• First 5 San Mateo County• Golden Gate Regional Center• Legal Aid Society• Lucile Packard Children’s Hospital• San Mateo County Health System• San Mateo Co. Office of EducationSan Mateo Co. Community Care Coordination Collaborative
  • Project Goals• Strengthen the existing system of carecoordination for CSHCN through acollaborative learning community• Increase access to coordinated, effective,family-centered services for CSHCN withinthe medical home• Develop a model of care coordination forCSHCN in the medical home that is replicableand sustainableSan Mateo Co. Community Care Coordination Collaborative
  • Main Project Activities• Policy Group– County-wide care coordination resources– Referral protocol– Policy recommendations• Practitioner Group– Recommend best practices for care coordination– Care coordinator handbook or toolSan Mateo Co. Community Care Coordination Collaborative
  • Major Challenges Anticipated• Integrating care coordination models andinformation across different systems• Changing availability of community resourcesfor provision of care coordination• Colocation of community care coordinator inthe medical homeSan Mateo Co. Community Care Coordination Collaborative
  • Central California Care Coordination ProjectMarion KarianExecutive DirectorExceptional Parents Unlimited Children’s Center
  • Central California CareCoordination ProjectEPU Children’s CenterFresno, California
  •  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 PartnerOversight Committee Members
  •  To establish an active, interdisciplinary multi-agencyteam to receive referrals and coordinate the care ofchildren with special health care needs. To provide outreach and information regarding carecoordination to hospital discharge planning/carecoordination staff, NICU discharge staff, privatepediatricians, and Federally Qualified Health Clinics.Project Goals
  •  Convening the Care Coordination Planning Team includingrepresentatives 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 coordinationMain Project Activities
  •  The complexities of the reimbursement systems The vast-ness of the medical systems The limitation of the presence of the project in the scopeof issues surrounding care coordination Focusing on an initial population that we can work with aswe are creating the care coordination team protocols Focusing on the ways in which we can have the greatestimpact. Determining how the Care Coordination Project can fit intothe existing SMART Model of CareMain Challenges Anticipated
  • Kern County Medically VulnerableCare Coordination ProjectMarc Thibault, MAProject Director
  • Kern County Medically Vulnerable Care Coordination ProjectMission Use enhanced coordination of existing case management services tomeasurably improve long term outcomes for children, birth to 5 years of age, who areat risk of costly, lifelong medical and developmental issues.Background Since 2008, the Kern County Medically Vulnerable (MV) Workgroup of40+ partner organizations has met monthly at First 5 Kern to address the needs ofCSHCN, 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; SpecialCare 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 moreconditions 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 ReviewCommittee, to develop best practices of care coordination.• Streamline access to, and maintenance of, health insurance and amedical home, to reduce unnecessary ER visits and hospitalizations.• Build strong, long-term provider partnerships to sustain asystem of care coordination that is practical, affordable, andresponsive to changing conditions.• Use longitudinal data to document results.• Conduct Cost Benefit Analyses to demonstrate savings on at-riskinfants and children to better serve all children in the county.
  • The LPFCH grant to MVCCP provides free technical assistance in2013 and 2014 to help implement care coordination in 3 counties by:• facilitating a series of face to face and webinar meetings to assistlocal care coordination collaboratives• sharing the MVCCP Acuity Scale Form to quickly help identify andrefer 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 inthese counties.
  • MVCCP Replication Process and Potential ChallengesReplication Process• MVCCP implemented a “first come, first served” approach, to engage withearly 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 occurringwith several counties through the MVCCP Advisory Committee.Challenges• Counties understand how big an undertaking it is to take on care coordinationfor CSHCN. Budgetary constraints and uncertainties due to local, state andfederal policy and funding changes can affect the level of commitment.• Must always remain aware of, and sensitive to, the political and historicaldynamics that can differentiate each county in the implementation process.• Previous or ongoing local collaboration efforts can impact the vision and thecommitment to cooperation, especially depending how competitive theatmosphere 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 inclusivedecision-making process to achieve optimum results.
  • • Preparation for In-Person Meeting– Finalizing Date in mid-May– Two Additional Slides• Challenges Faced• Progress Made•• Questions?