The document provides an overview of Kaiser Permanente Northwest's (KPNW) Pediatric Care Together program, which aims to better support children with health complexity. Figure 1 [hyperlinked in document] provides a high-level overview of how KPNW identifies children for the program and the components of the Pediatric Care Together services. The program uses a team-based approach to provide supplemental supports beyond a traditional medical home. Key elements discussed include methods for identifying children, engaging families, program supports, and developing long-term plans of care in the electronic medical record. Speakers from KPNW and the Oregon Pediatric Improvement Partnership were available to answer questions about the program.

1. Identifying and Serving Children with Health Complexity:
Spotlight on Pediatric Care Together TM
March 14, 2019

2. Meet Today’s Speakers
Colleen Reuland, MS
Director, Oregon Pediatric Improvement Partnership at
Doernbecher Children’s Hospital, Oregon Health & Sciences University

3. Kaiser Permanente Northwest Pediatric Care TogetherTM Team
Kim Luft, MD
Mt. Scott Physician Lead, Pediatric Care
TogetherTM and Pediatrician
Charlene Weaving, RN, MSN
Department Administrator for Pediatric
Specialty and Pediatric Care Together
LeadTM
Stephanie Vazquez
Community Health Navigator,
Pediatrics
Kannon Elizabeth, LCSW, LICSW
Pediatric Social Worker
Vicki Wolff, LCSW, LASW
Social Work Supervisor
Joyce Liu, MD
Medicaid Medical Director, Kaiser
Permanente Northwest and
Pediatrician

4. Ask Questions!
We look forward to a lively discussion with our audience.
Enter questions in the GoToWebinar question box.

5. Today’s Agenda
• Overview and Background in Oregon and Kaiser
Permanente Northwest (KPNW)
• Key design framework and elements of KPNW
Pediatric Care TogetherTM
• Question and Answer: KPNW Pediatric Care
TogetherTM team

6. Oregon Pediatric Improvement Partnership
The Oregon Pediatric Improvement Partnership (OPIP) supports a meaningful, long-term
collaboration of stakeholders invested in child health care quality, with the common
purpose of improving the health of the children and youth of Oregon.
OPIP is primarily contract and grant funded. We are based out of Oregon Health & Science
University, Pediatrics Department.
Learn more: oregon-pip.org

7. Building Health and Improving Outcomes for Children and Youth
OPIP uses a population based approach—starting with child/family. Our staff and projects
focus on:
1. Collaborating in quality measurement and improvement activities;
2. Supporting evidence-guided quality activities;
3. Incorporating the patient and family voice into quality efforts; and
4. Informing policies that support optimal health and development

8. Problem...or Opportunity in Oregon!
Despite wonderful gains in patient centered primary care homes, coordinated care
organizations, and other efforts there is a need to better support children with health
complexity.
– To impact children’s future health & preventable chronic conditions, need to
address predictive social determinants of health and build resilience
– In order to address children with health complexity a population and community-
based approach and cross-sector engagement is required.

9. Problem...or Opportunity in Oregon!
Requires a system-level focus.
1. What is measured is what is focused on & resources. Need for:
• Methods that are valid, reliable and meaningful for children
• Standardized and feasible using data available at the system-level
• Include data that takes into account:
2. Best match care coordination and complex health management models for children are
different than for adults. Need for models that can be used by health systems.
Medical Complexity AND
+ Social Complexity
Health Complexity

10. Grant from the Lucile Packard Foundation for Children's Health to OPIP
Title
System-Level Approaches to Identify Children with Health Complexity and Develop Models for
Complex Care Management
Goal
Inform health systems on novel and generalizable approaches to identify children with health
complexity, use of this inform to design better support systems for children and their families
Key Partners
– Oregon Health Authority (OHA)*
– Coordinated Care Organizations (CCOs)*
– Kaiser Permanente Northwest – Publicly & Privately insured
* April 2nd webinar spotlights work with OHA and CCO Partners.
Learn more: oregon-pip.org/projects/Packard.html

11. OPIP and KPNW
Collaboration
• Over last five years, OPIP received two grants
supporting consultation and support to KPNW in their
efforts to build, pilot, and evaluate a complex health
management program focused on children with
health complexity – call Pediatric Care TogetherTM.
• OPIP provided technical assistance by supplying
references, conceptualizing the health complexity
methods to apply, and creating tools for KPNW
consideration.

12. Key Design Elements of KPNW Pediatric Care Together TM
• Use health complexity information to identify patients who may benefit from
supplemental supports often not provided by a conventional medical home team
or by an exceptional needs care coordination team.
• Pediatric Care TogetherTM identifies the right team members to provide best match
supports.
KPNW piloted the model in one site, located at the Mt Scott pediatric clinic, and has
subsequently spread the model to one other site.

13. Summary and description of key elements and
learnings as of March 2019.
• Structure Anchored to Figure 1 and Hyperlinks to Specific
Sections
• Figure 1 provides a high-level overview of the key
components of the system-level and primary care-level
methods used to identify children for PCT ©, and also the
specific components of the PCT © program itself.
• Within this visual are hyperlinks to the specific sections of
this summary that provide more detail.
Identifying and Serving Children with Health Complexity:
Spotlight of Efforts to Develop and Pilot the Kaiser Permanente Northwest Pediatric Care Together©

14. Figure 1. Overview of System-Level
and Primary Care-Level Methods
Within KPNW to Identify Children
with Health Complexity and Assign
Pediatric Care Together (PCT)
Complex Health Management and
PCT Services

15. Questions for the Pediatric Care TogetherTM Team
Stephanie Vazquez, BS • Joyce Liu, MD • Charlene Weaving, RN, MSN
Kannon Elizabeth, LCSW, LICSW • Kim Luft, MD • Vicki Wolff, LCSW, LASW
(Not pictured: Vicki Wolff, LCSW, LASW)

16. Questions for the Pediatric Care TogetherTM Team
Stephanie Vazquez, BS • Joyce Liu, MD • Charlene Weaving, RN, MSN
Kannon Elizabeth, LCSW, LICSW • Kim Luft, MD • Vicki Wolff, LCSW, LASW
GETTING BUY IN
What were the keys to getting leadership buy in, support and
investments in the financial resources needed to pilot the PCT TM
program?

17. 17

18. Questions for the Pediatric Care Together© Team
Stephanie Vazquez, BS • Joyce Liu, MD • Charlene Weaving, RN, MSN
Kannon Elizabeth, LCSW, LICSW • Kim Luft, MD • Vicki Wolff, LCSW, LASW
ENGAGING CHILDREN AND FAMILIES
• What were keys to your success in engaging with children and their
families?
• What were the biggest barriers you encountered and how did you
address them?

19. 19

20. Questions for the Pediatric Care Together© Team
Stephanie Vazquez, BS • Joyce Liu, MD • Charlene Weaving, RN, MSN
Kannon Elizabeth, LCSW, LICSW • Kim Luft, MD • Vicki Wolff, LCSW, LASW
PROGRAM SUPPORTS
• What are the key elements of your program and what supports that
have been most meaningful to families?
• Why do you think this team, with various people with various skill
sets, is needed to serve children with health complexity?
• Why was it important for the team to be able to meet and support
the child/family outside of the clinic?

21. 21

22. Questions for the Pediatric Care Together© Team
Stephanie Vazquez, BS • Joyce Liu, MD • Charlene Weaving, RN, MSN
Kannon Elizabeth, LCSW, LICSW • Kim Luft, MD • Vicki Wolff, LCSW, LASW
LONG-TERM PLAN OF CARE (LPOC) IN EPIC
• What were are the key elements to the LPOC for your team?
• How did you select the wording for the sections and why is that
important?

23. Submit your questions in the questions box
Kim Luft, MD
Mt. Scott Physician Lead, Pediatric Care
TogetherTM and Pediatrician
Charlene Weaving, RN, MSN
Department Administrator for Pediatric
Specialty and Pediatric Care Together TM
Lead
Stephanie Vazquez
Community Health Navigator, Pediatrics
Kannon Elizabeth, LCSW, LICSW
Pediatric Social Worker
Colleen Reuland, MS
Director, Oregon Pediatric Improvement
Partnership
Joyce Liu, MD
Medicaid Medical Director, KPNW and
Pediatrician
Vicki Wolff, LCSW, LASW
Social Work Supervisor

24. Upcoming
Webinar
Maximizing System-Level Data to Address Health and
Social Complexity in Children: Spotlight on Oregon
April 2 at 11 am PST
An innovative methodology using system-level data to identify children with health
complexity, that is based on medical and social complexity, is transforming how
they consider improving quality of care in Oregon. Learn about this new
standardized approach and how it has helped inform priority areas, potential policy
improvements, investments and partnerships in support of children with health
complexity.
Register: lpfch.org/CSHCN