Care Coordination Program Misty VanCampen,BSN,RN,CCM
Objectives Define complex care coordination. Discuss the importance of implementing complex care coordination programs in pediatric health care organizations. Describe strategies that may be implemented in a complex care coordination program to facilitate compliance and positive patient outcomes.
Medically Complex Congenital Genetic Anomalies Child Medically Fragile Disabled/ Disability Physically Challenged Children with special health care needs Developmentally Delayed Chronic Complex Conditions Gifted Child Technologically Dependent
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)
Medication Errors Lost to follow up Fragmented Care Literacy issues Compliance issues Stress and Fatigue Care Giver = Care Coordinator
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.
We serve over 10 thousand complex medically fragile children Vision
Genesis Oct. 2012 Nov. 2012 Dec.2012 Approval of program for budget year; Job descriptions for RN Case Manager and Social Worker written RN Case Manager and Social Worker hired for positions Meetings/ Data Collection/ More Data Collection/ Ohio Project Overview of program developed MCCM meetings, Meeting with Family Advisory Council Develop Overview of Program Jan. 2013 Feb. 2013 Presented to Medical Director Forum Meetings with Physicians Initiated first Home Visit Palliative Care Team Meetings with Hospitalists Live with MCCM Home Visits Pharmacy Clinic meetings
Data Repository Data
Referral Criteria High ED Visits High Inpatient Admissions High Cost to the System Multiple Specialists CCMC Primary Service Area
Return On Investment
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
Prepare
MCCM Worklist Work lists CACO ER Initial Maintenance
Activities Activities
Capturing Activity Data
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 )
Coordinated Care PCP Specialists Care Coordination Community DME/ Home Health
Success Story
Patient Plan Dental DME MDCP Medicaid Programs Physician Nursing Community Resources Catholic Charities, SAVE, 211 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
Results: ROI
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
Questions