Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
California Community Care 
Coordination Collaborative 
September 2014 
9/23/2014
Orange County Care Coordination 
Collaborative for Kids 
(OC C3 For Kids) 
Rebecca Hernandez, MSEd 
Program Manager 
Help ...
Progress on Goals of OCC3 for Kids 
1. To identify the specific needs of the OC care coordination collaborative: 
• Conduc...
Products Developed 
• Goal Chart created as wallboard for use at each OC C3 for Kids 
• HIPAA Chart created as wallboard f...
Key Components For Replication 
Lessons Learned from Pilot and Focus Groups 
• All who participated in the focus groups th...
Next Steps 
• Continue to work on systems issues through the monthly gathering of the countywide 
collaborative providing ...
Monterey County 
Vulnerable Infant Care Coordination Collaborative 
(VICCC) 
9/23/2014
Progress Towards Goals 
GOAL 
• Develop comprehensive 
integrated system to serve 
children and families of 
children with...
GOAL 
• Strengthen and link local 
community resources in 
efforts to increase team’s 
knowledge base and 
identify gaps i...
GOAL 
• Formulate a plan to address 
identified service gaps. 
PROGRESS 
• In process. 
• We have identified some 
barrier...
GOAL 
• Develop duty statement and 
identify funding for MVI 
PHN Case Manager/Care 
Coordinator. 
PROGRESS 
• In Process....
Products Developed 
• We have modeled our case review template 
after Kern County’s and are currently using it 
for case r...
Key Components That Can Be 
Replicated 
• Meeting format 
• Announcements, Agency Presentations, Case Reviews, 
Action Ste...
Next Steps 
• Identify and establish short and long-term 
funding source to sustain VICCC. 
• Identify and engage key stak...
UPDATE 
Rural Children’s Special Health Coalition 
Siskiyou, Shasta and Trinity Counties 
Wendy Longwell 
Parent Health Co...
Progress Towards Project 
Goals 
 Navigating Mental Health Services 
 Access to Primary Care Physicians 
 Access to app...
9/23/2014
Coalition Collaboration 
 Round table 
 Inviting key stakeholders from various agencies 
 Guest speakers on what they d...
Improving Care Coordination 
 Invite local counseling/behaviorist agencies 
 What changes can we, as a community, make t...
UPDATE 
Contra Costa California Community Care 
Coordination Collaborative (7Cs) 
Barbara Sheehy, MS 
Administrator 
Calif...
Progress Toward Original Goals 
 Through the activities of the grant, and input from our partners, the 
needs of children...
Products Developed During Project 
 Consent form for Roundtable Meetings 
 Sign-in sheet for Roundtable that is also a 
...
Key Components That Could Be 
Replicated 
 Our 7 Cs monthly coalition meeting. It has been important to 
bring agency per...
Next Steps for 7 Cs 
 Leadership Team created to share responsibilities 
across more partners, support re-launched 
Round...
San Mateo Learning Collaborative 
September 23, 2014 
LPFCH 5Cs Statewide Meeting 
9/23/2014
Progress on Project Goals 
• Strengthened the existing system of care 
coordination through a collaborative learning 
comm...
Products 
• Policy Group 
• Map of care coordination resources 
• Assessment & Referral protocol in pediatric clinic 
• Po...
Key Components 
• Cross-training and sharing information on 
resources and processes to support more 
coordinated care 
• ...
Next Steps 
• Planning for sustainability of systems change and 
care coordination services 
• Re-engaging medical provide...
Central California Care 
Coordination Project 
September 23, 2014 
9/23/2014
Care Coordination Products 
• Referral form - agencies can now refer electronically 
through our website 
• Acuity form – ...
Long term goals and objectives 
• The long term outcome of this project is to enhance the 
existing SMART Model of Care by...
What we might share 
Lessons learned 
• What we have learned from our county’s successful 
community wide model known as t...
Next Steps 
• Continue monthly Care Coordination meetings 
• Invite new member participation (recent addition 
of IHSS) 
•...
Kern County Medically Vulnerable 
Care Coordination Project 
Marc Thibault, MA 
Project Director 
UPDATE 
9/23/2014
Slide 1 – Kern County MVCCP Replication Progress – 
Challenges and Solutions 
MVCCP Replication Process among Three Califo...
Slide 2 - MVCCP Products Developed 
MVCCP Replication Products 
1. Outreach Process with Introductory Letter 
2. Kickoff m...
Slide 3 – MVCCP Replication Models and Best Practices 
A. MVCCP Replication Products in Slide 2 
B. Lessons Learned 
1. Sy...
Slide 4 MVCCP - Next Steps 
A. Participation in 5Cs 
B. Continue Blue Ribbon Project with Targeted Case Management 
C. Ext...
In Memoriam 
Gail Davidson, APHN-BC, MSN, RN 
• Gail Davidson was MVCCP’s first Care Coordinator. 
• Gail was an RN for 34...
Upcoming SlideShare
Loading in …5
×

California Community Care Coordination Collaborative - September 2014

1,486 views

Published on

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.

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

California Community Care Coordination Collaborative - September 2014

  1. 1. California Community Care Coordination Collaborative September 2014 9/23/2014
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. Monterey County Vulnerable Infant Care Coordination Collaborative (VICCC) 9/23/2014
  8. 8. Progress Towards Goals GOAL • 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. UPDATE Rural Children’s Special Health Coalition Siskiyou, Shasta and Trinity Counties Wendy Longwell Parent Health Consultant Rowell Family Empowerment of Northern California 9/23/2014
  16. 16. 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
  17. 17. 9/23/2014
  18. 18. Coalition Collaboration  Round table  Inviting key stakeholders from various agencies  Guest speakers on what they do  Having parents as active participants in the process 9/23/2014
  19. 19. Improving Care Coordination  Invite local counseling/behaviorist agencies  What changes can we, as a community, make to improve service access? 9/23/2014
  20. 20. UPDATE Contra Costa California Community Care Coordination Collaborative (7Cs) Barbara Sheehy, MS Administrator California Children's Services Contra Costa County 9/23/2014
  21. 21. 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.
  22. 22. 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.
  23. 23. 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.
  24. 24. 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!
  25. 25. San Mateo Learning Collaborative September 23, 2014 LPFCH 5Cs Statewide Meeting 9/23/2014
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Central California Care Coordination Project September 23, 2014 9/23/2014
  31. 31. 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
  32. 32. 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
  33. 33. What we might share Lessons 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
  34. 34. 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
  35. 35. Kern County Medically Vulnerable Care Coordination Project Marc Thibault, MA Project Director UPDATE 9/23/2014
  36. 36. 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
  37. 37. Slide 2 - MVCCP Products Developed MVCCP Replication Products 1. Outreach Process with Introductory Letter 2. Kickoff meeting agenda and PowerPoint presentation 3. Sample outcomes and indicators for evaluation purposes 4. Methodology for facilitating face to face meetings and conference calls to assist local care coordination collaboratives 5. 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/process 7. Role descriptions and responsibilities for staff positions: facilitator, care coordinator, evaluator 8. Federal Financial Participation - matching funding 9. Lessons Learned and promising practices 9/23/2014
  38. 38. Slide 3 – MVCCP Replication Models and Best Practices A. MVCCP Replication Products in Slide 2 B. Lessons Learned 1. 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 9/23/2014 outreach to new partners; and maintain clear vision.
  39. 39. Slide 4 MVCCP - Next Steps A. Participation in 5Cs B. Continue Blue Ribbon Project with Targeted Case Management C. Extend County Regional Care Coordination Outreach through Public Health District Offices and Community Collaboratives D. Reduce Missed Appointments by extending collaboration with Local providers, safety net agencies, insurers, and Special Care Centers E. Continue RSV Task Force MVCCP invites you to its 4th Annual Conference Thursday, November 6, 2014 in Bakersfield The theme is: Overcoming the Challenges for CSHCN of Emergency Management, Missed Appointments, and Transportation Barriers 9/23/2014
  40. 40. In Memoriam Gail 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

×