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Care CoordinationProgram Misty VanCampen, RN CCM
Objectives • Commitment to teamwork among health care providers, school districts, government programs increasing the quality of care provided to the patients. • Utilizing community and clinical resources to establish medical home. • Care Coordination bridges the gap between palliative and hospice care.
Medically Complex Child Technologically Dependent Congenital Genetic Anomalies Disabled/ Disability Medically Fragile • Physically Challenged Children with special health care needs Developmentally Delayed Gifted Child Chronic Complex Conditions
Medically Complex • Chronic/severe health conditions • Significant family-identified service needs • Functional limitations • High health resource utilization
At Risk… • Increased risk for • Chronic physical conditions • Chronic developmental conditions • Chronic behavioral conditions, or • Chronic emotional conditions • Require services beyond those of healthy children • Increased health services • Increased social services (American Academy of Pediatrics)
Care Giver =Care Coordinator • Medication Errors • Lost to follow up • Fragmented Care • Literacy issues • Compliance issues • Stress and Fatigue
Promise Cook Children's Promise: Knowing that every child’s life is sacred, it is the promise of Cook Children’s to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.
Vision We serve over 10 thousand complex medically fragile children
Genesis • Approval of program for budget year; Job descriptions for RN Case Manager and Social Worker written Oct. 2012 • RN Case Manager and Social Worker hired for positions • Meetings/ Data Collection/ More Data Collection/ Ohio Project • Overview of program developed Nov. 2012 • MCCM meetings, Meeting with Family Advisory Council • Develop Overview of Program Dec.2012 • Presented to Medical Director Forum • Meetings with Physicians • Initiated first Home Visit • Palliative Care Team Jan. 2013 Feb. 2013 • Meetings with Hospitalists • Live with MCCM • Home Visits • Pharmacy • Clinic meetings
Data • Data Repository
Staffing Model • RN Case Manager for healthcare case management services with emphasis on assessment of health care needs, education, and implementation of the plan of care with continue evaluation. • Social Worker Case Manager to coordinate and provide psychosocial services and resources to meet the needs of the patient and caregiver.
Services • Identify • Coordinate • Home visits • Collaborate • Assist • Advocate • Educate
Team Approach Specialists Schools Pharmacy Primary Care Physicians Home Health Companies Community Resources
Prepare Know your Patients
MCCM Worklist Work lists • CACO ER • Initial • Maintenance
Activities • Activities
Windshield Survey Assess the Surroundings: • Type of dwelling • Access points to care (pcp, UCC) • Dental • Food • Parks • Safety • Socioeconomic • Crime • Hazards: waste, industrial pollution
Home Visit Medication Reconciliation Identify Barriers
Assessment Psychosocial and Medical Case Management Assessment
Referrals for Medical/Developmental/Mental Health • Medical • Medicaid Waiver Programs – MDCP- Money Follows the Person application Community Living Assistance Support Services (CLASS) Home and Community Based Services (HCS) – MHMR Personal Care Services (PCS) • Developmental ECI – under age 3 PT/OT/ST – over age 3 (under age 3 if aggressive therapy needed) and need for additional services • Mental Health • Counseling referrals Therapist or psychiatrist referrals MHMR services
School • Navigating the Education System • Information on ARD meetings (IEP) • Advocating education (IDEA, 504b) • Assist with Individualized Health Plan (example: seizure, asthma, etc…)
Patient Plan DME Nursing MDCP Medicaid Programs Community Resources Catholic Charities, SAVE, 211 Dental Physician Clinic Visits School Care Coordination
Key to Success Physician and Administrative Support Data Collection Home Visits Team work across disciplines: palliative, clinics, hospitalists, neighborhood clinics, home health agencies and DME providers
Tough Questions End of Life Planning DNR Hospice
Bridge the Gap Palliative Care and Hospice Case Studies
References • Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. March, 2011; 127(3): 529-538. • Berry JG, Agrawal RK, Cohen E, et al. The Landscape of Medical Care for Children with Medical Complexity. CHA Special Report. June, 2013. • Berry JG, Agrawal RK, Cohen E, et al. Characteristics Of Hospitalizations For Patients Who Use A Structured Clinical Care Program For Children With Medical Complexity, The Journal Of Pediatrics - 2011 • Tubb, Larry. Cook Children’s Health Care System and The Medically Complex Child, 2014 • http://www.nolo.com/legal-encyclopedia/special-education-law-29626.html Retrieved: 03/25/2014