3/21/2011 1 Services for Children with Special Needs 1 March 23, 2011 Agenda • About the ADRC • Services for Children with Special Needs Services for Children with Special Needs Background – Gertrude Carter, M.D. CalOptima – Peter Scheid, M.D. California Children’s Services – Hoda Kaddis, M.D., F.A.A.P. Regional Center of Orange County – Peter Himber, M.D. OC HCA Behavioral Health Services/Children & Youth Services – Marcy Garfias, L.C.S.W. Transitions – Linda O’Neal, M.A. 2 • Case Study and Q&A
Transcript
3/21/2011
1
Services for Children with Special Needs
1
March 23, 2011
Agenda
• About the ADRC
• Services for Children with Special NeedsServices for Children with Special NeedsBackground – Gertrude Carter, M.D.CalOptima – Peter Scheid, M.D.California Children’s Services – Hoda Kaddis, M.D., F.A.A.P.Regional Center of Orange County – Peter Himber, M.D.OC HCA Behavioral Health Services/Children & Youth Services –
Marcy Garfias, L.C.S.W.Transitions – Linda O’Neal, M.A.
2
,
• Case Study and Q&A
3/21/2011
2
3
Supported by the California Health and Human Services Agency and U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services under Grant CFDA 93.779
4
3/21/2011
3
ADRC OC Program Function
Information & Resource
Referrals
Information & Resource
Referrals
OptionsCounseling Advice &
Assistance
OptionsCounseling Advice &
Assistance
Community Education &
Outreach
Community Education &
Outreach
5
Assistancewith
Transitions
Assistancewith
Transitions
Information & Resource Referrals
Call the County of Orange Office on Aging at 1-800-510-2020
Speak to an Information p& Assistance Referral Specialist
Find resources online at www.adrcoc.org
The searchable directory includes many resources to help you
6
Visit any of the 3 ADRC partner locations
Please refer to your handout for a list of locations close to you
3/21/2011
4
Services for Children with Special Needs
7
Learning Objectives
• Know the services offered by key agencies
• Determine most appropriate resourceDetermine most appropriate resource
• Understand how to prepare and assist families applying for services
• Make appropriate referrals
8
• Know transition supports for children as they reach adulthood
3/21/2011
5
Background
9
Gertrude Carter, M.D.
CalOptima, Chief Medical Officer
CalOptima’s Health Care Delivery System
10
Peter Scheid, M.D.CalOptima, Medical Operations Medical Director
3/21/2011
6
CalOptima’s Mission
To provide members with access to quality health care services delivered in a cost-effective and
compassionate manner
11
What does CalOptima cover?
• Physician services
• Hospital services
• Medical supplies
• Prescription drugs
• Lab tests and X-rays
• Prenatal care
• Immunizations
• Durable medical equipment
• Prosthetics and orthotics
• Transportation
• Hospice
• Long-Term Care
12
• Physical, speech and occupational therapy
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for Children
3/21/2011
7
What is “carved out” of CalOptima?
• CalOptima contracts with the California Department of Health Care Services for Medi-Cal health benefits
• Medi-Cal benefits “carved out” of CalOptima’s contract:Mental health services
Psychotropic medications
California Children’s Services
Personal care services
13
What is “carved out” of CalOptima?
• CalOptima contracts with Managed Risk Medical Insurance Board (MRMIB) for Healthy Families benefits
• Healthy Families benefits “carved out” of CalOptima’scontract with MRMIB:Dental & vision access through plan selected at enrollment
Mental health services for serious emotional disturbance (Covered by Children & Youth Services)
14
California Children’s Services
3/21/2011
8
How is eligibility determined?
• Medi-CalOrange County Social Services Agency
Children
Pregnant Women
CalWorks/TANF
Persons with Disabilities
Persons aged 65 and over
Social Security Administration Persons receiving Supplemental Security Income (SSI) or
State Supplemental Payment (SSP)
15
• Healthy Families ProgramMRMIB
Newly Assigned Members
• What does CalOptima know?Name
GenderGender
Address
Phone number
Aid code (reason for Medi-Cal eligibility)
• What don’t we know?Diagnoses
16
Diagnoses
Medical needs
Barriers to care
3/21/2011
9
CalOptima’s Delivery System
• 2/3 of Medi-Cal and all Healthy Families members receive care through delegated health networks (see list in hand-out)
• 1/3 of Medi-Cal members receive services through CalOptima Direct or CalOptima Care Network (CalOptima works directly with providers)Populations in CalOptima Direct Administrative
Transitioning members, Medi-Medi, Share of Cost
17
Populations receiving care through CCN Long-Term Care Aid Codes
Foster Care (~4,000)
Members with Hemophilia
Other condition-specific populations
CalOptima Delivery System
Health Plan
Identification of Children with Special Needs Health Risk Assessments Disease Management/Health Education Grievances and Appeals Customer Service Community Liaison
Health Network
Customer Service, Community Liaison Provider Forums
Identification of Children with Special Needs Case Management for moderate and high
risk members Utilization Management Initial Appeals
18
Provider
Direct patient care, identification of clinical needs Case management for low risk members Primary care coordination Initiation of referral process Interaction with HN and Plan to obtain services
3/21/2011
10
CalOptima Services
• Early Identification of children with special needsHealth Risk AssessmentsPatient SurveysUtilization DataUtilization DataCase Management referrals
• Case Management screening to determine needsDevelopment of Individual Care PlanTrained nurses and support staff help determine needs,
identify resources, and coordinate care between all providersRegional Center Liaison
19
Pediatric Specialty Case Manager
• In development: Pediatric-specific interdisciplinary care teams
CalOptima Services
• Provider Support
Continuing Medical Education
Consultation (i.e., doctor to doctor)
Resource manual for providers
Behavioral health support
• Member and Family Support
Health Education
Disease Management
Community Liaison (customer service)
20
Community Liaison (customer service)
Regional Center Liaison
• Forum with other stakeholders to improve servicesRCOC, CCS, School Nurses
3/21/2011
11
Support For CalOptima Members
• CalOptima Customer Service and Member Liaison Program for seniors, people with disabilities, chronic conditions or who are homelessconditions or who are homeless(714) 246-8500 (888) 587-8088
• www.caloptima.org
• 1120 W. La Veta Avenue
21
Orange, CA 92868
California Children’s ServicesOrange County
22
Hoda Kaddis, M.D.Medical Director
3/21/2011
12
CCS Organizational Structure
Children’s Medical Ser ices
Three State Regional Offices
Local County CCS OfficesServices
Central State Office in Sacramento
Offices Offices
Overall Program Policy Development
Monitoring counties, CCS approved facilities and
providers, and consulting
Determination of Eligibility and Benefits, Authorization
of Services, and Direct Therapy
23
CCS Eligible Medical Conditions
• Serious chronic catastrophic disabling disfiguring conditions, such as:Cancer HIV infection HIV infectionCongenital heart defectsCleft lip and palate Insulin dependent diabetesHemophiliaHearing loss Extreme prematurityKidney failure Severe burns
24
Severe burns Traumatic brain injuries.
• Medical Therapy Program provides OT/PT for: Spastic CP Other disabling conditions, such as Muscular dystrophy
• Covered conditions carved out of managed careRefer a child with a diagnosed eligible condition to CCS
for treatment
• PT /OT in the medical therapy units on public school
26
grounds
3/21/2011
14
CCS Services
• Medical treatment from approved providers and facilities only with prior authorizations Except emergency treatmentp g y
• Payment for treatment of eligible conditions only
• Services coordination with managed care, PPOs, RCOC, and school districts
27
CCS Enrollment Process
• Referral by fax, mail or in person by anyone
• Medical documentationReportsLabsX-rays
• Demographic and insurance information
• Application and services agreement for non Medi-Cal or HF li t
28
HF clients
• Eligibility determination within 5 working days
• Authorizations for treatment
3/21/2011
15
Who Pays for CCS Services?
• Commercial insurance pays first then CCS
• CCS pays for authorized for medical treatmentp yProvided by CCS approved providers To treat only the CCS conditionNot for primary care
• Submit claims to fiscal intermediary agency
29
CCS Tips and Advice
• PCP determines if treatment is for eligible condition
• Follow through with the paperwork and application process
• Only eligible conditions
• Not covered by CCS, may be covered by other agenciesPrimary care, school physicals, immunizations, colds, ear infections Mental, behavioral or psychiatric disorders, developmental delay,
learning disabilities and autismNeed coverage for other medical and health services
30
g
• For medication, take CCS authorization and prescription to pharmacy
• A denial can be appealed
3/21/2011
16
For More CCS Information
• California Children’s Services200 W. Santa Ana Blvd., Suite 100Santa Ana, CA 92701Santa Ana, CA 92701
• Phone: (714) 347-0300
• Fax : (714) 347-0301
• www.ochealthinfo.com/ccs
31
Services for Children with Special Needs
32
Peter Himber, M.D.Chief Medical Officer
3/21/2011
17
RCOC Basics
• Regional Centers established by Lanterman Act
• 21 Regional Centers in Californiag
• Serve ~ 216,000
• Non-profit organizations contracts with State of California
• Administered by Department of Developmental Services (DDS)
33
(DDS)
RCOC Basics (cont.)
• Only Regional Center in O.C.
• 3 Programs with different eligibility criteria and services g g yofferedEarly Start: 0 - 3 years old (~2800 consumers)Prevention: 0 - 3 years old (~ 300 children)Lanterman: 3 years old - adult (~14,000 consumers)
• Annual budget ~ $250 million
34
• Shared clients41% Medi-Cal 5% CCS
3/21/2011
18
RCOC Goals
• Normalization - regardless of degree of disability, each individual has right to: Live as normal as possiblepMake own choices Live as independently
• Community integration - opportunity to benefit from and participate in all daily living experiencesEducation Employment
35
Socialization
• Go to extraordinary lengths to avoid institutionalization
Funding for RCOC Services
• Entitlement, not based on financial status
• Most services are free (may change)( y g )
• Mandated payor of last resort and we are required to look for alternative resources including:CalOptimaOC Mental HealthSchoolOther government programs
36
CCSPrivate Health Insurance
3/21/2011
19
RCOC Is The Payor Of Last Resort
• Families must access other services first
• Examples:Examples:2 year old boy with speech delay
RCOC pays for evaluation and determines he needs speech therapy Pediatrician refers for speech therapy through CCS, CalOptima or other health
plan If all others deny coverage, then RCOC funds for speech therapy
5 year old girl with behavioral concerns School district pays for behavioral services related to academic performance
only
37
only RCOC funds for in-home behavioral services
RCOC Programs
• Programs:Early Start: 0 - 3 years of age Prevention: 0 - 3 years of ageLanterman: 3 years - adult
• Each has their own eligibility criteria and services offeredState determines eligibility criteriaRCOC follows legal requirementsServices based on the needs of the child
Referral can be made b an one
38
• Referral can be made by anyone
3/21/2011
20
RCOC Prevention Program
• Children 0 - 3 years old at risk for substantial developmental disability 2 or more risk factors for developmental disability such as2 or more risk factors for developmental disability such as
prematurity, seizures, birth illness or injuryParent has a developmental disability33 - 49% delay in one area, such as speech or motor skills
• Services: Assess and develop program plan within 60 daysPeriodic developmental monitoring
39
Case managementReferral to other resources, such as Hanen, Head Start,
CalOptima or CCS Parent training
RCOC Early Start Program
• Children 0-3 years old with:Condition with established risk of developmental delay, such as
Down SyndromeSignificant developmental delaySignificant developmental delay
0 - 23 months: 33% delay in 1 or more areas 24 - 36 months: 50% in 1 area or 33% in 2 or more areas
• Services: Assess and develop program plan within 45 daysCase managementTherapy (speech, occupational and physical) if not provided by
alternative resources such as CalOptima CCS or private
40
alternative resources such as CalOptima, CCS or private insurance
Behavioral ServicesRespiteReferral to other resources
3/21/2011
21
RCOC Lanterman Program
• Children over 3 years old with a permanent, significant developmental disabilityExpected to continue for a lifetimePresent before age 18 Eligible conditions
Autistic Disorder Cerebral Palsy Epilepsy Intellectual Disability Other condition functions similar to or requires same services as intellectual disability
Substantial disability in at least 3 areas of major life activity
E l d l l hi t i di d d l i
41
• Excludes solely psychiatric disorders and learning disabilities
• Eligibility criteria much stricter than Early Start (90% of Early Start kids do not qualify)
RCOC Lanterman Timeline
• 15 working days from referral to complete assessment
• 120 calendar days of assessment to determine eligibility120 calendar days of assessment to determine eligibility
• 60 days of eligibility determination to develop Individualized Program Plan (IPP)
42
3/21/2011
22
RCOC Lanterman Services
• Individualized based on needService coordination and advocacy; examples:
• Crisis assessment (714) 517-6353Medi-Cal beneficiaries Indigent youth under 18
47
CYS Regional Services
• Out-patient population 0 - 20 years old Special education studentsMedi-Cal beneficiaries Healthy Families beneficiaries with serious emotional
disturbance (SED)Wards and dependents of court (group homes) Indigent
• ServicesMental health
48
Mental health Therapeutic behavioral Evidence-based treatmentMedication monitoringCoordination with school districts
3/21/2011
25
CYS Regional Services Locations
• South: 6 sites
• North: Placentia
• West: Westminster
• East: Santa Ana
• Costa Mesa
49
• Mission Viejo: 2 sites
• Outpatient contract services: 18 sites
CYS MSHA Services
• 0 - 18 and 16 - 25 transitional age youth (TAY)Un/underserved seriously emotionally disturbed children and
familiesHomeless or at risk of being homeless, hospitalized, or
incarceratedEthnic and linguistic populations to assist children and families to
access mental health services.
• ServicesFull service partnershipsMentoring
50
Mentoring
3/21/2011
26
MSHA Contracted Services• Services for Children and AdolescentsRenew: Full Service Partnership (FSP)Focus: FSP In-Home Crisis Stabilization In Home Crisis StabilizationCrisis ResidentialOutreach and EngagementProject Together: Mentoring
• Services for TAYSTAY: FSP
FOCUS: Children & TAY FSP
51
FOCUS: Children & TAY FSP
Youthful Offender Wraparound (YOW): FSP
Crisis ResidentialSocial Rehabilitation Program
Girls Court
CYS Central Services
• 0 - 17 years oldDependents at Orangewood Children and Family Center (OCFC)Wards (Juvenile Hall and Probation Camps)Probation youthFoster youth Youth at risk for out-of-home placement and/or hospitalization
• ServicesMental health servicesEvidence-based treatmentMedication monitoring
May, a five-year old, was in a serious car accident.May, a five year old, was in a serious car accident. May received a traumatic brain injury, which resulted in severe cognitive impairment. The accident also resulted in left sided paralysis.
