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.

1. California Community Care
Coordination Collaborative
September 2014
9/23/2014

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. 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. 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. 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. 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. Monterey County
Vulnerable Infant Care Coordination Collaborative
(VICCC)
9/23/2014

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. 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. 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. 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. 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. 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. 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. 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. 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. 9/23/2014

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. Improving Care Coordination
 Invite local counseling/behaviorist agencies
 What changes can we, as a community, make to
improve service access?
9/23/2014

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. 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. 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. 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. 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. San Mateo Learning Collaborative
September 23, 2014
LPFCH 5Cs Statewide Meeting
9/23/2014

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. 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. 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. 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. Central California Care
Coordination Project
September 23, 2014
9/23/2014

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. 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. 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. 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. Kern County Medically Vulnerable
Care Coordination Project
Marc Thibault, MA
Project Director
UPDATE
9/23/2014

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. 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. 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. 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. 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