california community care coordination collaborative ii - kickoff webinar january 2015
TRANSCRIPT
California Community Care
Coordination Collaborative II
Kick-off Webinar
January 6, 2015
• Welcome
– Holly Henry, PhD, Manager of Program Research
• Project Overviews
– Contra Costa California Community Care Coordination Collaborative (7 Cs)
– Orange County Care Coordination Collaborative for Kids (OCC3 for Kids)
– San Mateo County Care Coordination Learning Community
– Alameda County CCS/Behavioral Health Services Integrated Care
Coordination Project
– San Joaquin County 5Cs Project
– Ventura County (VC-Pact)
• Discussion and Details for In-Person Meeting
AGENDA
Contra Costa California Community Care
Coordination Collaborative (7 Cs)
Barbara Sheehy, MS
Administrator
California Children's Services Contra Costa County
Contra Costa CountyContra Costa California
Community Care Coordination Collaborative
Key Coalition Members
California Children’s Services
Kaiser Permanente
Regional Center of the East Bay
Care Parent Network
First 5 Contra Costa
Special Education Local Plan Areas
Early Start/Head Start
Contra Costa Regional Medical Center
Contra Costa Mental Health
We Care Services for Children
Contra Costa Health Plan
Contra Costa Public Health Nursing
John Muir Health
Early Childhood Mental Health
Center for Early Intervention on Deafness
Contra Costa Child Care Council
Project Goals
Initial Project
Each month key county agencies discussed challenges to
providing care coordination for children with special health
care needs and suggestions for improvement.
Drafted a consent form that agencies use to refer cases to
our re-launched Roundtable meetings.
Developed job description for a Children’s Service System
Coordinator.
Secured funding from the Kaiser Community Foundation to
fund our Children’s Service System Coordinator.
Project Goals Continued
Current Grant Period
Fully implement care coordination system including a data
collection and evaluation plan.
Develop and implement a Leadership Team to share
responsibilities across coalition partners.
Develop and implement a family experience component to
keep the family at the center of care coordination efforts.
Share the 7 Cs project experience and mentor a new 5Cs
project.
Main Project Activities
Enhance Roundtable meetings by providing a leadership
presence at each meeting; continue to identify and recruit
meeting participants; begin to collect data at each meeting;
and identify systems issues to pass on to 7 Cs and possibly
Early Childhood Leadership Alliance.
Develop a family experience model, including recruiting and
training family participants, and schedule and implement
family experience meetings with 7 Cs partners.
Integrate our new Children’s Service System Coordinator into
our Roundtable and 7 Cs meetings. Work to secure continued
funding for that position.
Major Challenges Anticipated
Securing additional funds for our Children’s Service
System Coordinator position beyond December 2015.
Continue to recruit agencies to participate at our
Roundtable meetings, and to have participants refer
complex cases to discuss.
Assure the referral chain for identifying and seeking to
resolve systems issues works as planned.
Orange County Care Coordination Collaborative for Kids
(OCC3 for Kids)
Rebecca Hernandez, MSEd
Program Manager
Help Me Grow Orange County
Key Collaborative Participants:
• American Academy of Pediatrics, California Chapter IV
• California Children’s Services
• CalOptima
• Center for Autism and Neurodevelopmental Disorders
• Children and Families Commission of Orange County, including representatives of
Bridges Maternal Child Health Network and School Readiness Nurses
• CHOC Children’s Hospital
• CHOC Children’s Foundation
• Comfort Connection Family Resource Center
• Early Development Assessment Center
• Family Support Network
• Help Me Grow Orange County
• OC Department of Education, Center for Healthy Kids and Schools
• OC Health Care Agency, Children and Youth, Behavioral Health Services
• OC Health Care Agency, Public Health Nursing
• OC Social Services Agency, Children and Family Services Division
• Regional Center of Orange County
Orange County Care Coordination Collaborative for Kids (OCC3 for Kids)
OCC3 For Kids Phase II Goals
Phase I Overarching Goal:
To improve overall care for children and families with special health care
needs by creating a collaborative care coordination system in Orange
County.
Phase II Goals:
1. Strengthen communication and collaboration among agencies providing
services to CSHCN
2. Implement system-level care coordination in Orange County for CSHCN
3. Ensure the OCC3 collaborative and system-wide care coordination
continue beyond the LPFCH grant funds
Phase II Activities
• Continue to work on systems issues through the OCC3 for Kids monthly
gatherings
• 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
• Continue to create a culture and common language of collaboration and
coordination
• 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
• Create a sustainable care coordination entity in Orange County
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Anticipated OCC3 for Kids Challenges
As we move into Phase II, several potential
challenges were identified that include:
• Continuing to secure participation by insurance
plans including CalOptima
• Barriers during the rollout of the screening tool
• Ensuring adequate % of FTE for our
countywide Care Coordinator as awareness
and demand increase
Thank you
Rebecca Hernandez, MSEd
Project Director, OCC3 For Kids
San Mateo County Care Coordination Learning Community
Cheryl Oku
Program Manager
Watch Me Grow Demonstration Site
Community Gatepath
San Mateo Learning Collaborative
January 6, 2015
LPFCH 5Cs II Webinar
Key Coalition Members
• California Children’s Services
• Community Gatepath
• Family Resource Center
• First 5 San Mateo County
• Golden Gate Regional Center
• San Mateo Co. Office of Education
• San Mateo Medical System
• Stanford Children’s Health and LPCH
• Includes 28 participating agencies and families
Project Goals
• Strengthen the existing system of care coordination through a
collaborative learning community
• Increase access to coordinated, effective, family-centered services in
the medical home
• Develop a model of care coordination in the medical home that is
replicable and sustainable
• Increase communication between medical providers and community-
based services
• Increase access to information and resources for families and
providers who coordinate care for CSHCN
Project Activities
– Systems Change Group
• Cross training and information sharing
• Workgroups: care coordination tool and exploration of
central telephone access
– Community Care Coordination in Pediatric Clinics
– Medical Provider Group focused on children with
complex health care needs
Major Challenges Anticipated
• Sustaining the group momentum and focus
on care coordination as a strategy for
improving the system of care
• Sustainability for clinic care coordination
• Family participation
• Medical provider engagement
Alameda County CCS/Behavioral Health Services Integrated
Care Coordination Project
Katie Schlageter, MS-HCA
Administrator, California Children’s Services
Deputy Division Director, Family Health Services
Alameda County Public Health Department
Presented by:
Francine Crockett
PROJECT GOALS• Organize a multi-disciplinary coalition of key stakeholders to
coordinate service systems for California Children’s Services (CCS) children with both medically complex conditions and behavioral health care needs.
• Improve access for CCS-enrolled children to behavioral health services through development and use of referral protocols, pathways and forms by key service system stakeholders, particularly CCS and Behavioral Health (BH).
• Enhance care coordination among key service providers to ensure that CCS patients are receiving the right care at the right time and at the right place.
• Improve participation and training of behavioral health providers in serving CCS children through implementation of clear protocols to enhance billing and reimbursement for behavioral health services through CCS.
MAIN ACTIVITIES Hire a consultant to act as Project Coordinator and convene Coalition Steering
Committee (SC) & facilitate, coordinate support project activities.
Organize and conduct monthly SC meetings which include cross-agency presentations to educate one another about memberships’ respective programs.
Identify barriers and strengths regarding current referral system and pathways; identify additional types of BH services needed; and compile cross-institutional knowledge of organizations and capacity of behavioral health providers to work with children and youth with complex medical conditions.
Develop report and present findings of strength and gap analysis.
Develop multi-system referral pathways to the appropriate community behavioral health service for each CCS client for whom a need is identified.
Pilot new referral system and determine satisfaction with materials.
Assess billing gaps, gather data on types of services provided and amount billed/paid and train providers on billing/claims processes for undocumented clients.
ANTICIPATED CHALLENGES The short time frame in which to develop a cross-sector plan to
achieve broad system changes.
Lack of providers with experience or training in treating the mental health needs of children and youth with complex medical conditions.
Very few culturally appropriate mental health providers.
Lack of data on the unmet mental health needs of CCS clients.
Lack of cross-institutional understanding of available behavioral health resources and the appropriate pathways for accessing these services.
Lack of understanding among behavioral health providers regarding what mental health services are covered by CCS and how payment can be obtained.
COALITION MEMBERS Behavioral Health Care Services
California Children’s Services
Center for Healthy Schools and Communities and School Based Health Clinics
Developmental Disabilities Council
Developmental Pediatricians
Family Resource Network
Juvenile Justice Center
Medical Home Project
Regional Center of the East Bay
Special Education Local Plan Areas (SELPAs)
Through the Looking Glass
UCSF Benioff Children’s Hospital Oakland
San Joaquin County 5Cs Project
Ann Cirimele
Executive Director
Family Resource Network
5Cs San Joaquin
5Cs San Joaquin
• Key Coalition Members– Family Resource Network (Project Director)
– First 5 (Fiscal Agent)
– Parents
– Valley Mountain Regional Center
– Medical Agencies
• CCS, hospitals, Health Plan of San Joaquin
– Special Education (3 SELPAs)
– Community-Based Organizations
• Child Abuse Prevention Council of San Joaquin
• Head Start
• Family Resource and Referral Center
5Cs San Joaquin
• Project Goals
– Build a county-wide inter-agency network of professionals who provide quality service to families of children birth to age 5 with special health care needs via an improved care coordination system.
5Cs San Joaquin
• Project Goals (continued)
– Expand formal and informal collaboratives into a formal, documented network.
– Create a Memorandum of Understanding to be used throughout the county so that all 5Cs agencies can interact effectively with one another.
5Cs San Joaquin
• Main Project Activities
– Health Navigator within each agency
• Offer local trainings on role of Health Navigator
– Monthly meetings and case sharings
– Deliverables
• Fact Sheet on local Transportation Services
• Fact Sheet on Payer of Last Resort
• Workbook on Agency Eligibility Criteria
• Trainings on these topics
5Cs San Joaquin
• Major Challenges Anticipated
– Current financial/contractual limitations of local agencies
– Agencies’ on-going commitment and ability to follow through with the project
– Agencies’ ability to provide manpower to attend meetings and participate in 5Cs activities and deliverable development
Ventura County VC-Pact
Patty Chan, OTR, LMPA
Public Health Division Manager
CMS Administrator
County of Ventura, Public Health Department
Presented by: Myra Medina
VC-Pact
Key Coalition Members
Ventura County Health Care Agency/Public Health (CHDP, CCS, PH Home Visitation Program)
County of Ventura – Human Services Agency: Children and Family Services; Probation Agency; Behavioral Health
Gold Coast Health Care Plan Families of CSHCN Tri-Counties Regional Center Primary Care Professional Association
Representative Other: Strategies, Aspiranet, Rainbow Connection
VC-Pact
Project Goals
Establish a sustainable, family-
centered, coordinated coalition with existing resources and collaborative relationships to improve Ventura County’s local systems of care for children with special health care needs.
Develop a method of evaluation which
illustrates impact on the target population.
VC-Pact
Main Project Activities
Screening and Referral Process (Documented)
Memorandum of Understanding between Coalition member
Assessment Tool (identifying eligible youth)
Pre-Project MAPPs
Post-Project MAPPs
VC-Pact
Major challenges anticipated
Assuring family centered care is a constant in the system
Aligning goals of the participating agencies
Getting referrals to the coalition
ContraCosta
Orange San Mateo
Alameda San Joaquin
Ventura
Securingongoing funding for CC activities
X X X X
Recruitingand retaining agencies
X X X X X X
Referral chain
X X X
Family engagement
X X X
SHARED CHALLENGES