David Jefferson, Northwest Frontier ATTC Oregon Health & Sciences University

Transcription

1 David Jefferson, Northwest Frontier ATTC Oregon Health & Sciences University 1

2 Traci Rieckmann, PI Denna Vandersloot, Director Jennifer Verbeck, Admin John Porter, Trainer Shaun Ramirez, Admin Lynn McIntosh, ADAI Steve Gallon, Former PI 2

3 Review of research leading to a Care Coordination model The role of a Care Coordinator Key work elements Understanding service domains A working model 3

4 Care Coordination is a service that connects youth and their families to comprehensive behavioral health services and community resources. New York Care Coordination Program 4

5 The heart of the program is youth centered individualized service planning and assistance in securing access to services to help individuals in their recovery and transition to healthy community living. New York Care Coordination Program 5

6 The deliberate organization of patient care activities between two or more participants involved in a patient s care to facilitate the appropriate delivery of health care services Improving Chronic Care-Supported by Robert Wood Johnson 6

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8 Leadership understanding of HCR and ROSC Loss of funding More accountability by funders ($$ and outcomes) Previous program was expensive and outcomes undermined Community assessment findings by Gino Aisenberg, Ph.D., University of Washington, June Service gap, youth who have already received services 8

9 We need model that will: Connect families to resources Connect law enforcement and school staff to ensure coordinate services Coordinate mental health services at schools Bridge gaps in services Remove service barriers and enhance communication across systems Help parents link with services after completion of programs 9

10 School connected and family based Asset based model Increased opportunities and exposure to positive role models Provide jobs and meaningful activities for youth Promote good attachment, quality mentorship opportunities and programs 10

11 Stabilize Behaviors and Disorders HOME School and Home are Productive 11 HEALTH Individuals and Families COMMUNITY Increase Meaning PURPOSE Family is Core

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13 1. Enhance Access and Continuity 2. Identify and Manage Patient Populations 3. Plan and Manage Care 4. Provide Self Care and Community Support 5. Track and Coordinate Care 6. Measure and Improve Performance 13

14 Medical Substance Use Disorders Adolescent s with Special Needs- Development Disabilities Mental Health 14

15 1. Patient- and familycentered 2. Proactive, planned, and comprehensive 3. Promotes self-care skills and independence 4. Emphasizes crossorganizational relationships 15

16 Assessment Continuous Monitoring Goal Setting Care Planning Making Care Coordination A Critical Component Of The Pediatric Health System: A Multidisciplinary Framework Richard C. Antonelli, Jeanne W. Mcallister, And Jill Popp ical%20component/1277_antonelli_making_care_coordination_critical_final.pdf 16

17 Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes Care planning process driven by a compassionate, robust partnership between provider, client, and their family Evidence-based practice and clinical decision-support tools guide decision making Providers in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement 17

18 Washington Care Coordination Medical Home Identified lead coordinator Partnership with the family that meets the child s needs Collaborative, coordinated, with ongoing process Culturally competent at every step Assures smooth transitions between systems and services 18

19 Substance Use Disorders Accessible Comprehensive/Appropriate to Need Coordinated/Systemically Integrated Effective/Practical Flexible Age/Developmentally Appropriate Family Focused/Involved Recovery Focused 19

20 Transition to Independence Process (TIP) System A Community-Based Model for Improving the Outcomes of Youth and Young Adults with Emotional Behavioral Disorders 20

21 Mental Health Peer and Family Driven Care is Coordinated and Integrated Person-Centered Planning Family Education and Support Mental/Physical Health Integration 21

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23 Skagit County Community Services Mt Vernon, Washington 23

24 Primary Care Clinics LYNCS Youth Care Coordination Model SUD Services Community Health Centers Child Serving Agencies Client Service Plan Care Coordinator Community Mental Health Services Juvenile Justice Transition Services Educational Institutions 24

25 Admission Process Youth & Family Substance Use Disorders Legal System LYNCS Care Coordinator Point of Access School Community Health Mental Health Interview Source Interview Youth Interview Family Other Review Program Review Referral Information Assess for Appropriateness Yes No Set up Meeting with LYNCS Care Coordinator Refer to Another Program 25

26 CC Meeting One CC Meeting Two CC Meeting Three Engagement Explore youths interest in program Explain program: Voluntary Frequency of Contact Service Planning Coaching and Mentoring Care Conference More engagement Invite back for second meeting Engagement Explore Desires and Goals Explain Care Team concept and who they might invite Invite to sign up for program Sign consent for services Obtain Releases of Information Additional Records Request Short term goals Engagement Review interest and progress Ask what they thought about their care team Ask about next steps Meet family Meet care team Service Plan Case Management Initial Outcome Evaluation 26

27 Substance Use Disorders Mental Health Treatment Juvenile Justice Education System Individual Education Plan Transition Domains: family school work setting vocation and career educational opportunities housing 27

28 Service Planning Case Management Care Conferences Families Professionals Youth designated care team Care Coordination Coaching 28

29 Motivational Interviewing Service Planning Client Centered Services Shared Decision Making Care Conference Planning and Execution Developmental and Cultural Competency High quality Communication Skills Service Domains and Systems 29

30 Program Orientation Program Evaluation Youth Centered Care Planning Care Management Activities Care Conference Meetings 30

31 Improved physical, emotional and behavioral health Improved family functioning Improved educational outcomes Reduced admissions to acute care programs Reduced number of new legal problems and re-incarceration 31

32 Jennifer Kingsley, Director Jolene McEachran, Youth Program Supervisor Sarah Hinman, SUD County Coordinator Rebecca Clark, Mental Health Program Coordinator Bob Hicks, Operations Manager LYNCS Team 32

33 End Q & A 33

34 David Jefferson, MSW Northwest Frontier Addiction Technology Transfer Center Oregon Health and Sciences University Department of Public Health and Preventive Medicine School of Medicine 3181 Sam Jackson Park Rd. Portland, OR