Lessons Learned Improving Care Coordination for CYSHCN: Supporting Interagency Collaborationin California CommunitiesPresented by: Marc Thibault, MA, Kern County Medically Vulnerable Care Coordination ProjectRebecca Hernandez, MSEd, Orange County Care Coordination Collaborative for Kids

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

California Community Care Coordination Collaborative (5Cs)

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

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

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.

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

State Government

County/Regional Government

Community Coalitions

Diverse Service Providers

8

Systemic Approach to Improving Human Services System Performance

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

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

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

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

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

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

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

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

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.