family-centered action plan partners for children provider training 2013 jill abramson, m.d., mph...
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Family-CenteredFamily-Centered Action Plan Action Plan
Partners For Children
Provider Training 2013
Jill Abramson, M.D., MPHSharon Lambton, RN, MSN
Galynn Thomas, RN, MSN
PFC Provider TrainingPFC Provider Training
OverviewOverview Care Coordination/CCSNL/CommunicationCare Coordination/CCSNL/Communication
Family-Centered Action PlanFamily-Centered Action Plan Services/BillingServices/Billing Federal Assurances/ Health & WelfareFederal Assurances/ Health & Welfare Agency Responsibilities/SummaryAgency Responsibilities/Summary
What happens before What happens before
the F-CAP begins?the F-CAP begins?
Pre F-CAPPre F-CAP
Child referred to CCSNL – signed referralChild referred to CCSNL – signed referral
Medical eligibility - Level of Care Medical eligibility - Level of Care determination completeddetermination completed
Child/family meets with CCSNLChild/family meets with CCSNL
PFC Family /Child Agreement - signedPFC Family /Child Agreement - signed
Pre F-CAPPre F-CAP
Freedom of Choice - signedFreedom of Choice - signed
PFC Provider chosenPFC Provider chosen
Child enrolled in the PFC by CCSNLChild enrolled in the PFC by CCSNL
Agency notified by CCSNL.Agency notified by CCSNL.
COMPREHENSIVE CARE PLANCOMPREHENSIVE CARE PLAN
Family-Centered Action Plan Family-Centered Action Plan (F-CAP)(F-CAP)
Comprehensive Care PlanComprehensive Care Plan
CommunicationCommunication
Comprehensive Care PlanComprehensive Care Plan
F-CAPF-CAP PurposePurpose HistoryHistory DevelopmentDevelopment SectionsSections FrequencyFrequency
F-CAP PurposeF-CAP Purpose
Purpose: comprehensive family-centered Purpose: comprehensive family-centered care plan identifying needs, describing care plan identifying needs, describing goals and desired servicesgoals and desired services
– ChildChild– FamilyFamily– Circle of SupportCircle of Support– Care CoordinatorCare Coordinator
F-CAP PurposeF-CAP Purpose
Integration of child/family/care Integration of child/family/care providers:providers:– GoalsGoals
– Medical objectivesMedical objectives
Help the child successfully and Help the child successfully and
safely, live in the community.safely, live in the community.
Comprehensive Care PlanComprehensive Care Plan
Family-CenteredFamily-Centered Parent/family present at all stagesParent/family present at all stages
– Initial Development Initial Development
– InterimInterim
– 60 Day Assessments60 Day Assessments
– 6 Month Full F-CAP Revision6 Month Full F-CAP Revision
Comprehensive Care PlanComprehensive Care Plan
Serves the child across many settingsServes the child across many settings– HomeHome
– SchoolSchool
– HospitalHospital
– OutpatientOutpatient
– CommunityCommunity
– OtherOther
Comprehensive Care PlanComprehensive Care Plan
The Care Plan identifiesThe Care Plan identifies– The IssuesThe Issues
– The GoalsThe Goals
– The ResourcesThe Resources
– The Services that support the goals.The Services that support the goals.
F-CAP HistoryF-CAP History
HistoryHistory
Key documentKey document
F-CAP DevelopmentF-CAP Development
Who participates: Who participates:
– ChildChild Family Family
– Circle of Support Care CoordinatorCircle of Support Care Coordinator
– CCSNLCCSNL
F-CAP DevelopmentF-CAP Developmentcontinuedcontinued
Who participates continuedWho participates continued
– Special Care CenterSpecial Care Center
– PhysicianPhysician
– Counselor Counselor
– Expressive Therapist(s)Expressive Therapist(s)
F-CAP Development F-CAP Development continuedcontinued
Who is responsible for completion?Who is responsible for completion?
– Care CoordinatorCare Coordinator
– CCSNLCCSNL
F-CAP Development F-CAP Development continuedcontinued
Collaborative, Coordinated effortCollaborative, Coordinated effort
Care Coordinator Care Coordinator
F-CAP SectionsF-CAP Sections
– Patient InformationPatient Information
– Health & Symptom ManagementHealth & Symptom Management
– Health & Safety (Federal Assurance)Health & Safety (Federal Assurance)
– Family Social InformationFamily Social Information
– Home Environment Evaluation Home Environment Evaluation
– Goals and PlansGoals and Plans
– ServicesServices
– Family ToolsFamily Tools
F-CAP SectionsF-CAP Sections
Patient InformationPatient Information
– DemographicDemographic
– DiagnosisDiagnosis
– Health care providersHealth care providers
– Other agenciesOther agencies
F-CAP SectionsF-CAP Sections
Health & Symptom ManagementHealth & Symptom Management
– Medical historyMedical history
– Physical assessmentPhysical assessment
Review of systemsReview of systems
– Rehabilitation potentialRehabilitation potential
– Education medical treatmentEducation medical treatment
Medical treatment goalsMedical treatment goals
– Goals specific to medical treatmentGoals specific to medical treatment
F-CAP SectionsF-CAP Sections
Health & Safety – Federal AssuranceHealth & Safety – Federal Assurance
– Risk factorsRisk factors
InterventionIntervention
PlanPlan
– EducationEducation
– Risk of abuse, neglect, or exploitationRisk of abuse, neglect, or exploitation
– Discussion and reminder to child & familyDiscussion and reminder to child & family
Health & WelfareHealth & Welfare
ExamplesExamples
– Reports to agenciesReports to agencies
– Education begins with the CCSNLEducation begins with the CCSNLSets the tone – non threateningSets the tone – non threatening
– Every F-CAP reviewEvery F-CAP review
F-CAP SectionsF-CAP Sections
Family / Social InformationFamily / Social Information
– CaregiverCaregiver
– ChildrenChildren
– AdultsAdults
– Circle of SupportCircle of Support
F-CAP SectionsF-CAP Sections
Family / Social InformationFamily / Social Information
– Spiritual beliefs/ religious beliefsSpiritual beliefs/ religious beliefs
– Traditional health care beliefsTraditional health care beliefs
– Contextual and cultural issuesContextual and cultural issues
Family / Social InformationFamily / Social Information
– PsychosocialPsychosocial
ChildChild
FamilyFamily
SiblingsSiblings
– Observations/ impressions/ concernsObservations/ impressions/ concerns
– Plan and specific goalsPlan and specific goals
F-CAP SectionsF-CAP Sections
F-CAP SectionsF-CAP Sections Home Environment EvaluationHome Environment Evaluation
– Home & neighborhoodHome & neighborhood
– Local notificationsLocal notifications
– DMEDME
– Pets/ PestsPets/ Pests
– Back-up emergency planBack-up emergency plan
– Plan to address any needsPlan to address any needs
F-CAP SectionsF-CAP Sections Goals and PlanGoals and Plan
– Child’s goalsChild’s goals
– Family & Circle of Support goalsFamily & Circle of Support goals
– Care Coordinator goalsCare Coordinator goals
– Services to meet goalsServices to meet goals
– Identification - safety measuresIdentification - safety measures
F-CAP SectionsF-CAP Sections
Goals and Plan-Goals and Plan- Family- Centered Team Meeting (FCT) Family- Centered Team Meeting (FCT)
– Different from the Agency Interdisciplinary Different from the Agency Interdisciplinary meetingmeeting
– In the home or parent choiceIn the home or parent choice
– Who attends?Who attends?
– Reports/ Expressive Therapist /PhysicianReports/ Expressive Therapist /Physician
F-CAP SectionsF-CAP Sections
Goals and Plan – FCT MeetingGoals and Plan – FCT Meeting
– Reflects the child & family goalsReflects the child & family goals
– Identifies differences in goals & resolution of Identifies differences in goals & resolution of
differencesdifferences
– Facilitates integration of goalsFacilitates integration of goals
– Identifies & documents all who participatedIdentifies & documents all who participated
F-CAPF-CAP
Determine if Care Coordination is Determine if Care Coordination is anticipated to beanticipated to be::
– High ComplexityHigh Complexity
– High RiskHigh Risk
– Mainly for Support & ManagementMainly for Support & Management
F-CAP SectionsF-CAP Sections
ServicesServices
– Partners for ChildrenPartners for Children
– State PlanState Plan
– EPSDT Supplemental ServicesEPSDT Supplemental Services
– CommunityCommunity
F-CAP SectionsF-CAP Sections
Family ToolsFamily Tools Physician, Care Coordinator & CCSNL Physician, Care Coordinator & CCSNL
SignaturesSignatures Physician sign off sectionPhysician sign off section
Comprehensive Care PlanComprehensive Care Plan
Who besides Care CoordinatorWho besides Care Coordinator
may review the F-CAP?may review the F-CAP?Other agency staffOther agency staffCCSNLCCSNLCCS Medical ConsultantCCS Medical ConsultantReferring physician or PCPReferring physician or PCPState PFC staffState PFC staffAny who have integral part in health care of Any who have integral part in health care of childchild
F-CAP FrequencyF-CAP Frequency
Initial F-CAP within 14 days of referral from CCSNLInitial F-CAP within 14 days of referral from CCSNL
Full F-CAP every 6 monthsFull F-CAP every 6 months
Every 60 days F-CAP addressing at Every 60 days F-CAP addressing at
minimum, sections: minimum, sections:
– 2-A, 4, 7, 8 and 9-B2-A, 4, 7, 8 and 9-B
F-CAP Frequency cont.F-CAP Frequency cont.
Interim F-CAP neededInterim F-CAP needed
– When F-CAP no longer meets the needsWhen F-CAP no longer meets the needs
– When there are changes in condition or goalsWhen there are changes in condition or goals
Note: Note: All subsequent reviews are based on the All subsequent reviews are based on the
date the initial F-CAP was started.date the initial F-CAP was started.
F-CAP SubmissionF-CAP Submission
Review Summary Sheet DocumentReview Summary Sheet Document– Purpose of documentPurpose of document
InitialInitial 6-Month 6-Month 60-Assessment60-Assessment Interim AssessmentInterim Assessment Time Frame – within 14 days of meeting Time Frame – within 14 days of meeting
with family.with family.
F-CAP Submission cont.F-CAP Submission cont.
Physician signaturePhysician signature Physician review - futurePhysician review - future
F-CAP SummaryF-CAP Summary
Care plan developed by child/family, care Care plan developed by child/family, care coordinator, with input from CCSNL, other coordinator, with input from CCSNL, other providersproviders
Future changesFuture changes
– F-CAP Revision F-CAP Revision
SummarySummary
F-CAPF-CAP PurposePurpose HistoryHistory DevelopmentDevelopment SectionsSections FrequencyFrequency
PFC Provider TrainingPFC Provider Training
OverviewOverview Care Coordination/CCSNL/CommunicationCare Coordination/CCSNL/Communication Family-Centered Action PlanFamily-Centered Action Plan
Services/BillingServices/Billing Federal Assurances/ Health & WelfareFederal Assurances/ Health & Welfare Agency Responsibilities/SummaryAgency Responsibilities/Summary
CCSNL Contact InformationCCSNL Contact Information
AlamedaAlameda
– Joanna King (510) 267-3248Joanna King (510) 267-3248
FresnoFresno Elizabeth Manfredi ( 559) 600-6552Elizabeth Manfredi ( 559) 600-6552
Los AngelesLos Angeles
– May Randolph - (626) 569-3997May Randolph - (626) 569-3997
MarinMarin
– Victoria Harter – (415) 473-6824Victoria Harter – (415) 473-6824
CCSNL Contact Information cont.CCSNL Contact Information cont. MontereyMonterey
– Kathie Yoshiyama (831)Kathie Yoshiyama (831)
Orange County Orange County
– Vicki Munzing - (714) 347-0346Vicki Munzing - (714) 347-0346
San DiegoSan Diego
– Cynthia Fera (858) 966-7829Cynthia Fera (858) 966-7829
San Francisco San Francisco
– Victoria Young – (415) 575-5758Victoria Young – (415) 575-5758
CCSNL Contact Information cont.CCSNL Contact Information cont.
Santa ClaraSanta Clara– Vickie Dunn (408) 793-6248Vickie Dunn (408) 793-6248
Santa CruzSanta Cruz– Heather Allen (831) 763-8918Heather Allen (831) 763-8918
SonomaSonoma– Anna Evenson (707) 565-4503Anna Evenson (707) 565-4503
Family Centered Action PlanFamily Centered Action Plan
QuestionsQuestions