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AMCHP 2015: Care Coordination for CYSHCN
1. Lessons Learned Improving
Care Coordination for CYSHCN:
Supporting Interagency Collaboration
in California Communities
Presented by:
Marc Thibault, MA, Kern County Medically Vulnerable Care Coordination Project
Rebecca Hernandez, MSEd, Orange County Care Coordination Collaborative for Kids
2. Outline
• Describe the California Community Care
Coordination Collaborative
• Definitions
• Describe Inter-agency Collaboration
– Lessons from Orange County about how inter-
agency collaboration works
– Lessons from Kern County about how to evaluate
and pay for inter-agency collaboration
• Next Steps
4. 5Cs Initiative
• Started in April of 2013
• Funded by the Lucile Packard Foundation for
Children’s Health
• Learning collaborative of 6 county-level coalitions
which included in-person meetings, webinars and
site visits
• Focus on improving local systems of care
coordination for CYSHCN
• Second phase of funding beginning January 2015
5. Children and Youth with Special Health
Care Needs (CYSHCN)
• CYSHCN have, or are at risk for, a physical,
developmental, behavioral or emotional
condition that requires health or related
services of a type or amount beyond that
required by children generally.1
6. Case Management vs. Pediatric Care
Coordination2
Case management addresses the health needs of
patients. It tends to be focused on a limited set
of predetermined diseases and is guided by
potential health care cost savings. The process
can include assessment, planning,
implementation of services, monitoring, and
subsequent reassessment.
7. Pediatric Care Coordination
Pediatric care coordination addresses interrelated
medical, social, developmental, behavioral,
educational, and financial needs of patients and
their families to achieve optimal health and
wellness outcomes. It is a patient- and family-
centered, assessment-driven, team-based activity
designed to meet the needs of children and youth
while enhancing the care giving capabilities of
families.2
9. Community
Coalitions
Diverse Service
Providers
9
Systemic Roles in Care Coordination
• Communicate among
agencies and service
providers
• Share information,
approaches and resources
• Collaborate to improve the
system of care coordination
• Provide individualized care
coordination services
according to a shared care
plan
• Provide case management
10. Importance of Developing Interagency
Collaboration
• Provide a forum for relationship building,
information sharing, and identification of
service system gaps and hurdles
• Develop new or adapt existing groups focused
on improving care for children
• Include family representatives to participate in
all components of the work
• Develop a leadership body to guide and
problem-solve complex systems issues
11. Lessons Learned: Orange County Care
Coordination Collaborative for Kids
• Public/private partnership including hospitals,
insurers, community-based organizations and
county safety net agencies
• Meet on a monthly basis with a consistent
meeting date, time and location
• Leadership meeting immediately follows
coalition meeting
• Leadership debriefs on the most recent
meeting, assigns action items and sets the
agenda for the following month
12. Case Review Process
• Implemented as a strategy to identify systems-
level challenges encountered in accessing care
• One presentation per meeting
• Presenter contacts other organizations involved
in the case in advance
• Use of case review template
– Includes de-identified basic information on child,
case milestones, current status, summary of
challenges/issues/barriers/strengths and system
level implications
13. Confidentiality for Case Reviews
• Statement of confidentiality included on sign-
in sheet
• Case reviews do not include any of the 18
identifiers protected under HIPAA
• 18 identifiers posted as a visual reminder
• Some organizations presenting the
anonymous case reviews do ask parents to
sign consent in advance of the meeting so
that they are aware of the intent to share de-
identified information
14. Funding Interagency Collaboration:
Lessons from Kern County
• Since 2008, local collaborative has focused on
premature infants and CSHCN aged 0 to 5, their
families and providers
• Contracted with project staff to manage
meeting logistics and communications
• Since 2011, leveraged public and private funds
to sustain Public Health Nurse as System-Level
Care Coordinator to receive and track referrals
in a central database
• Secured local foundation funds to match
Federal Financial Participation dollars
15. Evaluation and Replication of Kern
County Work
• Conduct annual cost benefit analysis to
demonstrate the value of care coordination in
reducing preventable ER visits and
hospitalizations
• Consider conducting patient and family
satisfaction surveys about care coordination
experiences
• Conduct annual regional conference to
broaden participation and share lessons
learned
16. Next Steps for the 5Cs
• County-level evaluations of each coalition
• Determine a common outcome and measure
progress towards it across the six coalitions
• Replicate best practices in additional counties
• Convene a state-wide Interagency Coalition
• Host a state-wide conference on care coordination
for CYSHCN in California
17. References
1. McPherson M, Arango P, Fox H, Lauver C, McManus M, Newacheck P, Perrin J, Shonkoff J,
Strickland B. A new definition of children with special health care needs. Pediatrics. 1998;
102(1):137–140.
2. Antonelli R, McAllister J, Popp J. Developing Care Coordination as a Critical Component of a
High Performance Pediatric Health Care System: Forging a Multidisciplinary Framework for
Pediatric Care Coordination. Washington, DC: The Commonwealth Fund; 2009.
3. American Academy of Pediatrics, Council on Children With Disabilities, Medical Home
Implementation Project Advisory Committee. Patient- and family-centered care
coordination: a framework for integrating care for children and youth across multiple
systems. Pediatrics. 2014;133(5):e1451–60.
Editor's Notes
California’s system of care for CSHCN is complex, fragmented and challenging to navigate. Interagency coordination of care is generally inadequate. Developmental Services provided through one entity, medical needs covered by another
California Children’s Services - statewide program, administered at the county level, assuring children with serious or chronic physically handicapping medical conditions receive appropriate specialty care, including community based occupational and physical therapy.
Geographic Details
Population Sizes – Counties (individual variation) and State as a Whole
Kern - California’s 3rd largest county in land area; diverse population of 865,000 with Bakersfield (pop 365,000) as county seat. Economy based on agriculture, petroleum extraction, aviation, space, and military installations
Orange County, CA covers 798 square miles
Population of 3,055,792 (2102 census)
OC has more residents than 20 of the country’s states
One of the most dense counties in the nation with 3,871 people per square mile
Number of resident births in 2011 was 38,100 with 6.7% being LBW births
Youth population 0-17 years is 736,659
Over the course of 10 years there has been a 22.5% increase in the number of children under the age of 18 receiving Regional Center services. In 2012 there were 8,821 children receiving services with 3,427 of those children being under the age of four years.
OC has 39 hospitals and 69 clinics
Draws together existing organizations which have an interest in CSHCN, because they are providing services and supports, and have a commitment to improve the system of care for these children and their families.
