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Care Coordination Program
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  1. Care CoordinationProgram Misty VanCampen, RN CCM

  2. 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. 

  3. 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

  4. Medically Complex • Chronic/severe health conditions • Significant family-identified service needs • Functional limitations • High health resource utilization

  5. 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)

  6. Care Giver =Care Coordinator • Medication Errors • Lost to follow up • Fragmented Care • Literacy issues • Compliance issues • Stress and Fatigue

  7. 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.

  8. Vision We serve over 10 thousand complex medically fragile children

  9. 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

  10. Data • Data Repository

  11. Referral Criteria

  12. Return On Investment

  13. 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.

  14. Services • Identify • Coordinate • Home visits • Collaborate • Assist • Advocate • Educate

  15. Team Approach Specialists Schools Pharmacy Primary Care Physicians Home Health Companies Community Resources

  16. Prepare Know your Patients

  17. MCCM Worklist Work lists • CACO ER • Initial • Maintenance

  18. Activities • Activities

  19. Capturing Activity Data

  20. Windshield Survey Assess the Surroundings: • Type of dwelling • Access points to care (pcp, UCC) • Dental • Food • Parks • Safety • Socioeconomic • Crime • Hazards: waste, industrial pollution

  21. Home Visit Medication Reconciliation Identify Barriers

  22. Assessment Psychosocial and Medical Case Management Assessment

  23. 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

  24. School • Navigating the Education System • Information on ARD meetings (IEP) • Advocating education (IDEA, 504b) • Assist with Individualized Health Plan (example: seizure, asthma, etc…)

  25. Coordinated Care

  26. Success Story

  27. Patient Plan DME Nursing MDCP Medicaid Programs Community Resources Catholic Charities, SAVE, 211 Dental Physician Clinic Visits School Care Coordination

  28. 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

  29. Tough Questions End of Life Planning DNR Hospice

  30. Bridge the Gap Palliative Care and Hospice Case Studies

  31. Results: ROI

  32. 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

  33. Questions