DSI STEERING COMMITTEE June 20 th, 2018 TODAY S MEETING Introductions Review Meeting Minutes Review Today s Agenda: Follow-up to Care Coordination Discussion of Transition Work Updates on DSCI Update from CDS Partner Updates Adjourn 1
CARE COORDINATION: NEXT STEPS Work with key stakeholders on developing a care coordination curriculum to include how to improve referrals and access to care coordination between early childhood disciplines and patient-centered medical homes for children with and without special healthcare needs Develop 3 online training modules on care coordination that can serve as a cross sector approach to initial care coordination Leverage the content from the care coordination educational modules to develop education content around developmental screening and care coordination Organize and conduct the recordings of the modules Host the modules for on demand access in our Learning Management System. They will be on demand modules that organizations will be able to view at any time SAVE THE DATES FOR MEETINGS Sub-group will meet on September 6 th from Noon-3 likely at Maine Quality Counts Care Coordination Module Content Test Training will be held on November 28 th from 9-3 in either Manchester or Augusta.stay tuned 2
TOP MODULE TOPICS BY VOTE Topic Approaches to Care Coordination: Blended/Dedicated/Independent/Distributed Models of Coordination how this plays out in the referral and response process; avoiding duplication, confusion, falling through the gaps Multi-system families: When there are multiple Care Coordinators, programs, services and needs Documentation of care coordination; Record management 10 The Why and How of Effective Coordination Services 9 Overview of disabilities, developmental delay and chronic health conditions, behavioral health issues of young children Family Centered/Focused/Driven/Directed Systems of Coordination: Understanding the Similarities; Balancing the Differences Votes 20 15 8 8 APPROACHES TO CARE COORDINATION: BLENDED/DEDICATED/INDEPENDENT/DISTRIBUTED MODELS OF COORDINATION HOW THIS PLAYS OUT IN THE REFERRAL AND RESPONSE PROCESS; AVOIDING DUPLICATION, CONFUSION, FALLING THROUGH THE GAPS Define and promote care coordination within your system Identify and address barriers to access Inform the care team In collaboration with patient and family, school, care givers, providers and other members of the care team Engaging practitioners for team approach Identify which resources are already in place or available, who s already engaged and how do they already help Identify other entities/approaches and philosophies Identify options to address the need Work with patient to determine course of action and assign responsibilities Close the loop- follow up with patient based on previously agreed upon plan/contract with patient Specify who is doing what (role clarification) 3
MULTI-SYSTEM FAMILIES: WHEN THERE ARE MULTIPLE CARE COORDINATORS, PROGRAMS, SERVICES AND NEEDS Definitions and description of system Navigation Communication and collaboration Release of Information Time Management Multi-tasking Team Meetings Set of Goals Boundary Management Funding Streams Networking Prioritization SOP for Employer Protective factors Knowing resources Personal outreach to providers/building relationships Increasing cultural humility Education and awareness Self-care Role as navigation educator/empowerment of client DOCUMENTATION OF CARE COORDINATION; RECORD MANAGEMENT Intake/Assessment/Eligibility/Authori zations Demographic Release/HIPAA/FERPA Plan of Care Shared Treatment Planning Electronic Medical Record Progress Notes: Nature of contact, family preference for contact, risk benefit statements, writing notes how to, frequency, intensity, duration, text messaging Outcome measures Shared data between agencies/agreements may need to involve attorneys Compliance with billing and records Need to know vs nice to know Signatures/credentials Discharge planning Who has access to records and information Comprehensive assessment safety planning PSA social assessment Rights of recipients Natural and community supports 4
ADOLESCENT TRANSITION WORK Stephen Meister, MD, MHSA, FAAP Nancy Cronin MA April 14, 2018 5
Maine AAP Focus Groups Many medical providers are unaware that families and young adults struggle with transitioning successfully into adult providers for services such as Routine healthcare Specialty healthcare Psychiatric Medication Management Mental Health Services Maine AAP Survey Highlights 62% (n=42) faced challenges when trying to transition a patient. Comments included Difficulty finding an adult providers who understood disorders and/or able to care for kids with complicated needs Challenged when adult provider provided inappropriate care such as removing all medications Family or patient reluctance Lack of system-wide standards for transition process Limited providers accepting new patients 6
Maine AAP Survey Highlights 70% (n=50) either didn t know, or only somewhat knew, best practice methods of treatment and transition planning for youth with DD 82% (n=50) felt that transition is either very important or critically important When asked what their feelings/attitude around treating and preparing this population for a transition (n=50) 14% responded that they are very comfortable with their knowledge and the process 46% responded that they have a knowledge base but are not totally confident 22% responded that they are fairly confident but want to learn more 18% responded that they are not confident or comfortable at this time MDDC Transitioning Youth to Adult Health Care Leading the way in transitioning Youth with Special Health Care Needs (Ages 14-26) to adult Healthcare. 7
Transitioning Youth to Adult Health Care Skills They Need To Transition Calling in a prescription refill Scheduling appointments Speaking up at the Doctor s Office Managing medication Make and keep follow-up visits Determine methods to track health progress Work with your doctor to set health goals Personal Hygiene Self Care (i.e. taking medications on schedule) Preventing secondary conditions Managing medications What to do when there is an emergency Wellness Sexuality TRANSITION OF CARE QC will be bringing together stakeholders to form a work group and hold 4 two-hour sessions on the topic of Transition of Care for adolescents with special health care needs focusing on ages 12-16 and 16-18 year old transition in the primary care office. These sessions will help guide an environmental scan to identify what resources currently exist for transition of care and to identify the gaps while establishing action steps to be included in an implementation plan As a result QC will recommend implementation activities that will build/enhance a system for those adolescents with special health care needs to transition to adult health care 8
TRANSITION OF CARE QC is currently in the process of reaching out to stakeholders This group of stakeholders will help to complete the environmental scan on what currently exists as well as to identify gaps in care Based on the gaps identified, the committee will recommend areas of focus for future work and measures for future quality improvement TO JOIN THE ADOLESCENT TRANSITION WORKGROUP If you are interested in joining the workgroups, please email Kayla Cole by July 1 st so we can add you to emails and calendar invitations or sign up with link. An introductory informational call will be held on Wednesday July 25 th from Noon-1 via zoom: https://zoom.us/j/5211733487 Workgroup Meetings: Meetings will be located at Quality Counts in Manchester. Participants will also have an option to join virtually. September 26, 2018: 10 am 12 pm at 16 Association Drive, Manchester ME October 31, 2018: 10 am 12 pm at 16 Association Drive, Manchester ME December 5, 2018: 10 am 12 pm at 16 Association Drive, Manchester ME January 23, 2019: 10 am 12 pm at 16 Association Drive, Manchester ME 9
DSCI UPDATES Next meeting is July 11th QI Updates Mercy- Expanding the project to Family Medicine. They are working on implementation in three practices including Windham which has a large peds population. The challenge is waiting for the transition to a new HER. Mercy is also mailing out their ASQs before hand for parents to complete with their children at home. Greater Portland Health- a recent workflow change is that providers can now print release forms from the EMR rather than having paper copies. GPH has also added the social worker contact information to the referral with a note to contact the social worker if not able to reach the family rather than closing the referral DSCI UPDATES Martin s Point- Working on their CDS referral process and reviewing workflows from other practices that have tuned up their dev screening and CDS referral process. They plan to reevaluate all previous referrals as part of their PDSA cycle. MMP-Have a designated person for all MMP reaching out to patients/families that are referred to CDS to spend more time discussing the referral with the family. They are doing this in hopes of increasing the CDS contact rate with families. MMP is also now sending out M-CHAT electronically through patient portal before appointments Share MMP Data 10
PARTNER UPDATES 11