2. Delivering Care To Children and Youth In Need
One in 10 youth will experience mental health challenges that are severe enough to impair their ability
to function at home, at school and in the community. Of these children, 10 percent will drop out of
high school as a result of their disorder.1
Many of the children and youth who are afflicted by severe
emotional disturbances lack access to care. In fact, based on a recent NIH national survey, only half of
all children and youth in need of behavioral and emotional health care services end up receiving them.
Those who are able to access care may not receive an appropriate treatment plan due to gaps in the
child welfare system and a lack of information sharing between health care providers, family members,
and community supports who work with the child or youth.
The Case for Good Care Coordination: Better Outcomes, Reduced Costs
Coordinated care is difficult to standardize, because each child or youth requires a customized care plan.
That said, all care coordination models have two things in common: the strategies are team-based,
involving more than two participants, and family-driven. Care coordination, when implemented well, has
been shown to provide many benefits for children and youth who experience significant behavioral and
mental health challenges, and their families. Some of these benefits include:
• Improved care outcomes and overall health
• Greater satisfaction for the youth, family and providers
• Reduced costs associated with care fragmentation and over-utilization of care
Coordinated care models ultimately function to reduce gaps in the child welfare system. This helps
deliverbetteraccess to care,while offering a more effective and less expensive alternative to emergency
department visits, residential treatment and hospitalizations, or juvenile justice programs.2
Why Integrated Care is Federally Recommended
In 2013, the Center for Medicaid and Medicare Services and SAMHSA released a statement that
encouraged States to use the Medicaid program to cover a range of behavioral and mental health
services, including: care coordination, intensive home-based services, family support, respite care, and
Wraparound care.
Good care coordination has been proven to improve
outcomes for children and youth who suffer from
significant behavioral and mental health challenges.
1 National Center for Children in Poverty, Children’s Mental Health: What Every Policymaker Should Know
2 Banghart, P.; Cooper, J.L. 2010. Unclaimed Children Revisited: Focusing on Outcomes – A Case Study of the Michigan Level of Functioning Project. New York, NY: National Center for Children in
Poverty, Columbia University Mailman School of Public Health.
3. WHO IS ELIGIBLE FOR COORDINATED CARE?
Five core considerations are used to determine a child or youth’s eligibility3
1. Condition or Diagnosis
The child or youth needs to have a specific condition or diagnosis. This criteria varies based
on a wide range of factors, including state and federal requirements, clinical judgment,
payer preferences, and advocacy initiatives.
2. Medicaid Eligibility
The child or youth must be currently enrolled in Medicaid, and these programs are often
limited and varied by state.
3. Age
Some children and young adults may be excluded based on their age due to transition
issues when a child ages out of their eligibility.
4. Payer Cost Savings
Care coordination may be prioritized when the payer identifies that it provides a return
on investment by replacing “unnecessary” or “avoidable” services, such as emergency
department visits or hospitalization.
5. Risk Analysis
Will the child or youth’s care be expensive to payers? Is the individual involved in foster care
or child welfare programs? Does the individual experience complicated medical, social or
support-based challenges? Based on the organization and family’s needs, risk will be taken
into consideration when determining care coordination eligibility.
What Does High Fidelity Care Coordination Look Like?
Successful care coordination models take into consideration many aspects of each child or youth’s lives, which
includes: their community, culture and beliefs, language skills, academic background, the youth’s core competencies
and strengths, family and life at home, medical history, nutrition, community partnerships and supports, social services
and mental, behavioral, and emotional health.
Care coordination is separate from disease management or even case management. Although both case management
and care coordination produce individualized care plans, coordinated care requires a team and network of providers as
opposed to a singular agency. Studies show that outcome-based systems are able to track youth outcomes, improve
provider capacity and tailor services.2
3 Bachman, S; Comeau, M; Jankovsky, K. 2015. The Care Coordination Conundrum and Children and Youth with Special Health Care Needs.
4. Providing Care Coordination through Systems of Care
The system of care is a framework and philosophy for delivering effective care coordination. It involves coordinated
collaboration across a network of provider agencies, youths, and families. The goal is to provide children and youth
who experience seious emotional disturbances (SED) with enhanced accessibility to the treatment they need.
Systems of care also aim to improve outcomes through coordinated care that reflects each individual’s strengths,
needs, background and social supports.
Improving Outcomes through Care Coordination
A recent SAMHSA report shows that the rate of suicidal thoughts among children and youth with SED who received
system of care services dropped by 26% in six months and 43% in one year.5
Systems of care are encouraged to
abide by guiding values and principles to ensure better care coordination outcomes. In addition, accountability has
been shown to render better fidelity to the system of care practice model. In particular, 10 core factors, defined
as the Getting To Outcomes® (GTO) guidelines, should be considered when deploying a system of care strategy
to improve accountability: Needs and resources, Goals, Best Practices, Fit, Capacities, Plan, Process Evaluation,
Outcome Evaluation, Quality Insurance, and Sustainability.6
4 McKay, M. M.; Hibbert, R.; Hoagwood, K.; Rodriguez, J.; Murray, L.; Legerski, J.; et al. 2004. Integrating Evidence-based Engagement Interventions into “Real World” Child Mental Health Settings.
Brief Treatment and Crisis Intervention 4(2): 177-186. 5SAMHSA Children website. Applicable URL accessed on May 5, 2016. 6Getting to Outcomes In Systems of Care. July 2009. Icons provided by
Freepik at www.flaticon.com
The system of care should
be heavily informed by the
needs of the youth and their
family. Understanding the
youth’s needs and strengths
will help determine the
right mix of services and
supports needed.
Supports in the community
are a fundamental facet
of the system of care
philosophy. They help
contribute to youth and
family engagement. In turn,
this engagement has been
shown to improve treatment
efficacy.4
Agencies, services
and treatment programs
should reflect the cultural,
ethnic, linguistic and racial
differences of the youth and
their family. This helps deliver
better access to treatment
and helps to eliminate
disparities in care.
SYSTEM OF CARE VALUES
Culturally &
Linguistically Informed
Family Driven
& Youth Guided
Community Based
5. HOW FIDELITYEHR ALIGNS
WITH SYSTEM OF CARE GUIDING VALUES
FidelityEHR was designed to support family-driven and team-based
coordinated care models to produce better emotional health outcomes
for children and youth. These values are:
1. Family Driven
2. Youth Guided
3. Evidence Based
4. Cultural & Linguistic Competence
5. Individualized and Community Based
1.
FAMILY
DRIVEN
Families have a primary decision-making role when it comes to
the care of their children, and they should be involved in:
• Choosing supports, services and providers
• Setting goals
• Designing and implementing programs
• Monitoring outcomes
• Determining the effectiveness of all efforts
How FidelityEHR supports Family Driven care coordination:
• FidelityEHR captures family-centered interviews, insights, family
timelines, and family systems assessments that inform the treatment
plan
• Care plans embed signatures from family and youth to ensure their
consent and that their views and needs have been acknowledged
• Team meeting worksheets incorporate ongoing assessment of family
support, connections, and satisfaction
• Youth and family can log in to the health record portal to access
messages, reminders, educational resources for diagnoses and
medications, a copy of the treatment plan, and other features that
display shared data regarding goal tracking and interests
6. 2.
YOUTH
GUIDED
Youth guided systems of care engage the youth as an equal
partner in creating change to produce better outcomes.
Feedback from youth will help to inform policies and procedures at
the individual, community, state and national levels.
FidelityEHR emphasizes youth and family preferences, visions
and strengths to promote self-efficacy
• The EHR tracks both initial and ongoing assessments of needs and
strengths identified by the youth. These insights help to shape strategies
that reflect care plan’s goals and anticipated outcomes
• FidelityEHR captures youth-centered interview, insights, timelines, and
family systems assessments that inform the treatment care plan
• Care plans embed signatures from youth to ensure their consent and
that their views and needs have been acknowledged
• Team meeting worksheets incorporate ongoing assessment of youth
support, connections, and satisfaction
• The youth has access to their FidelityEHR health record portal where
theycan find messages, reminders, educationalresources fordiagnoses
and medications, a copy of the treatment plan, and other features that
display shared data regarding goal tracking and interests
• Youth can complete standardized assessments, such as the CANS,
CAFAS and WFI-EZ
3.
EVIDENCE
BASED
Evidence-based practices are important facets of an effective
coordinated care service delivery system.
Feedback from youth will help to inform policies and procedures at the
individual, community, state and national levels.
FidelityEHR is the only electronic health record provider that
continues to conduct ongoing evidence-based research to
demonstrate improved care coordination efficacy in systems of
care.
• Better fidelity is rendered to care coordination models due to its
outcome-based configuration and ongoing real-time data analysis
• Based on the team’s goals and strategies, FidelityEHR’s team meeting
worksheet includes all core assessments and case notes to track both
baseline and ongoing progress made toward the treatment plan’s goals
• Core Assessment outcomes are graphically monitored in the Youth
Record dashboard, making it easy to share outcomes with all team
members:
7. • Youth Needs Progress • Residential Outcomes
• Family Satisfaction • Youth Connections
• School Outcomes • Family Connections
• Community Outcomes
• Customizable assessments and licensed assessments, such as the
CANS or CAFAS, can be integrated to support outcome-based and
data-driven decision-making
4.
CULTURAL
& LINGUISTIC
COMPETENCE
Agencies, programs and services should reflect the cultural, racial
and ethnic diversity of the system of care’s populations.
Cultural competence evolves over time and helps stakeholders to work
effectively in cross-cultural situations.
How FidelityEHR supports cultural competence:
• The care plan and Team Meeting Worksheet emphasize the team’s
understanding of the youth and family’s values and beliefs regarding
challenges, as well as their preferences for next steps
• Gender, race, ethnicity, language, cultural and spiritual domains are
assessed and tracked in FidelityEHR
• Primary caregiver, legal guardian and multiple family members are
included and can be given access to the EHR
• Community-based outcomes are assessed continuously in FidelityEHR
5.
INDIVIDUALIZED
& COMMUNITY
BASED
Each child or youth that is provided care through a system of care
should have a customized care plan that is developed by the
family team.
Community-based services have been shown to be enhanced through
building partnerships with service systems and resources throughout the
childoryouth’scommunity.Managementanddecision-makingresponsibility
are also provided to community stakeholders, such as teachers, mentors,
coaches, community group leaders and more.
Quickly update the Treatment Plan information and collaborate
with family team and community team members in FidelityEHR.
• Youth and family vision building for both home and community
integration into the treatment plan is a critical piece in the puzzle.
• FidelityEHR offers ongoing assessment in these domains.
• Service and billing options are customizable and highly flexible to
reflect any care coordination practice environment.
• Team meeting reminders, invites and messaging between meetings
are delivered through FidelityEHR
8. FidelityEHR is designed to make every day more efficient
Instead of forcing users to fit their unique practice into a rigid health record, FidelityEHR generates data that
directly applies to the way each user prefers to manage their cases and track outcomes. Since the beginning,
FidelityEHR software development has involved significant field testing and purposeful development to make it
user-friendly, practical and, most importantly, helpful to care managers.
What can FidelityEHR do?
FidelityEHR's blueprint reflects evidence-based practice models from: System of Care, Wraparound, Integrated
Behavioral Healthcare and Person-Centered Planning.
How it was designed:
FidelityEHR received financial support from the National Institutes for Health to develop and field test the
software through a partnership with Eric J. Bruns, Ph.D. at the University of Washington. Over 70 behavioral health
organizations are currently active field test members, and the EHR combines feedback and user testing insights
from over 100 different organizations. By conducting continuous user field-testing research, FidelityEHR stays
current and directly reflects what users want most out of their results-based health record software.
Customized to align with a wide range of coordinated care models, FidelityEHR uses cutting-edge technical
features to provide a flexible repository of information. The important aspects of the EHR are that it:
1. SUPPORTS TEAM-BASED COLLABORATION:
The platform facilities easy and secure communication and information sharing between team members.
2. PROVIDES A HOLISTIC VIEW:
FidelityEHR integrates with medical electronic health records, to provide a holistic depiction of the
youth’s overall mental, behavioral and physical well-being.
3. RECORDS RESULTS:
It aids supervision by helping track staff performance evaluation, while analyzing services,
implementation, and costs associated with meaningful outcomes.
STREAMLINED DATA ENTRY,
BETTER OUTCOMES.
Let one of our solutions architects show you how FidelityEHR
has helped system of care organizations cut costs, maintain
fidelity to their care model and improve outcomes.
www.fidelityehr.com/demo
1.888.978.8305 | 2100 Calle de la Vuelta, C-202, Santa Fe, NM 87505 | www.fidelityehr.com
