Welcome to CC4C Webinar for Care Managers & Supervisors The sound is being broadcast via your computer. Please be sure that your computer sound is turned on. You should hear music, although the sound may come and go, which is NOT indicative of problems. The quality of the sound will improve once the webinar starts at 9:30 a.m. If you are not able to hear via the computer, you can call the meet-me number at 919-233-4708. But, we only have a limited number of spaces available on that phone line. If you call into to the meet-me number, it is important that you mute your phone so that others can clearly hear the webinar audio. 1
January 5, 2017 CC4C Webinar for Care Managers & Supervisors
CC4C Key Messages 3
Messaging / Explaining CC4C Services 4
Messaging / Explaining CC4C Services 5
Messaging / Explaining CC4C Services 6
Messaging / Explaining CC4C Services 7
Messaging / Explaining CC4C Services Common comments indicated: Description of services is tailored to audience Specific information is shared with audiences Talking points are desired to be used with different audiences 8
Messaging / Explaining CC4C Services Based on: feedback results, and concerns from community partners that some CC4C programs explained services differently the CC4C Work Group decided that standard key messages should be developed and used by all CC4C staff The CC4C Script and Key Messages document was provided to you as a webinar handout. It is also available in the CC4C Toolkit in both of the following folders: Section 04 Best Practices Section 09 Outreach Materials 9
CC4C Key Messages What is CC4C: CC4C is a care management service for children ages 0-5 years that may need added services or support Some examples of services or support that can be provided: Medical support (health needs) Linkage to resources (community and other available resources or services) Assistance in meeting the child s treatment plan as provided by the primary care clinician or specialist Parent/ family education regarding health and social needs Assistance in setting child-centered goals and meeting those goals Support of families to overcome obstacles in meeting the child s needs, and minimizing the impact of adverse life event 10
CC4C Key Messages The target population for this program include Children with special health care needs Children who have experienced adverse life events or toxic stress Children who have been in the neonatal intensive care unit 11
Who are CC4C care managers: CC4C Key Messages CC4C care managers are registered nurses or social workers who work closely with the child s primary care provider regardless of insurance coverage; CC4C care management is also a service provided by Medicaid (if applicable) as part of the child s benefits Where: CC4C care managers may be employed by the local health department or local CCNC network; CC4C care managers can meet with the patient and family in the home, community, medical provider s office and by phone. When: The CC4C CM may meet, or contact family weekly, monthly, or as needed to meet the child s needs 12
CC4C CM Call to Parent Script CC4C Key Messages My name is. I am a care manager and work with (child s name and insurance, or provider). I see that may have (add reason for referral, such as a visit to the ED, visit to medical provider, concerns about development, is in foster care etc..) Please tell me more about and how things have been going with him/ her. 13
CC4C Key Messages Expected next steps: review these new messages at your local agency and/or regional meetings, and determine if the messages currently being shared are consistent with the key messages contained in CC4C Script and Key Messages document All locally-developed outreach materials should be reviewed and revised, if needed, to align with this document All CC4C staff are expected to share messages when describing CC4C services to families and community partners that are consistent with those contained in this document We all need to explain CC4C services the same way to families & community partners 14
WIC Experiences & Best Practices 15
WIC Experiences & Best Practices Feedback 16
23 write-in responses to the question if the local CC4C program has a strong relationship with WIC: Indicate that the relationship with WIC ranges from not good to great WIC Experiences & Best Practices Feedback Provide details to explain the response 17
WIC Experiences & Best Practices Feedback 18
113 write-in responses to the question asking how often CC4C staff meet with local WIC staff: As needed (30) Daily (24) Weekly (21) Monthly (8) Unknown (7) Informally & individually (5) Very infrequent (2) Formal presentation annually (2) During management meetings (1) All the time (1) WIC Experiences & Best Practices Feedback Clarification re: meeting vs talk individually (2) 19
WIC Experiences & Best Practices Feedback 20
WIC Experiences & Best Practices Feedback 21
Lessons learned: WIC Experiences & Best Practices Feedback Many CC4C programs have developed & implemented creative strategies to promote collaboration with WIC; submitted strategies organized in the following sections are provided as a webinar handout: Strengthening the Relationship with WIC staff Increasing Effective CC4C Referrals from WIC Enlisting WIC Staff s Help in Finding/Engaging CC4C Clients Ensuring Coordinated, Effective Care A few CC4C programs desire a stronger relationship with WC 22
Next Steps: Local Level: WIC Experiences & Best Practices Feedback Review the strategies handout and determine if strategies can be implemented NOW to strengthen the WIC-CC4C relationship Discuss WIC relationship and strategies at regional meetings to identify additional local practices and strategies that could strengthen WIC- CC4C relationship State Level: Continue the efforts started by OBCM to jointly collaborate with state WIC leadership Work with state WIC leadership to develop a best practices document 23
WIC Experiences & Best Practices Feedback Goal of WIC-CC4C Collaboration: It's a win-win situation. The relationship helps with continuity of care for the clients and ability to mesh and connect care without fragmentation 24
Adverse Life Events / Toxic Stress 25
Child s Medicaid Assigned in One County Child Lives in Another County CC4C services are based on county of residence Children will appear on the Current CCNC and TC Priority List - CC4C posted in the IC based on the county of the child s Medicaid, which in the majority of cases is the same as county of residence If a child s Medicaid is assigned to your county but the child is actually living in a neighboring county, the child will still appear on the Priority Report for your county The Standards Report list all children engaged in CC4C; the county of the child s Medicaid enrollment is included in this report; those children whose Medicaid enrollment is other than the county engaging the child in CC4C are highlighted in yellow 26
Child s Medicaid Assigned in One County Child Lives in Another County When the child s Medicaid is assigned to one county but the child is living in another county, the following terms are used: HOME County: county where Medicaid is currently assigned HOST County: county where child is currently living 27
Child s Medicaid Assigned in One County Child Lives in Another County There are mainly two basic reasons that a child s Medicaid is assigned in the HOME county, but the child is living in the HOST county: 1. The child previously lived and received services in the HOME county and then moved to the HOST county; the child is not in DSS custody 2. The child was taken into DSS custody in the HOME county and then placed in a foster/kinship care in the HOST county; when a child is in foster care, the Medicaid is typically assigned to the county where DSS has custody 28
29 HOME County CC4C CM Where Child s Medicaid is Assigned Ultimately responsible Determine if the child is engaged in CC4C services in the HOST county If the engaged, contact the HOST county CC4C CM to discuss: Possibility of the HOST CC4C CM assisting family in changing Medicaid Possibility for claims review or other tasks if child is a designated as priority on the Priority Report If not engaged, contact the HOST county CC4C CM to discuss whether the HOME and./or HOST CC4C CM can best meet the child s needs HOST County CC4C CM Where Child is Actually Living Assist, if needed, and/or take the lead in arranging needed services in HOST county, including: Assessing reason for Medicaid assignment in HOME county and Sharing with the family the benefits of CCNC Medical Home enrollment following guidance at bottom of page 4 in the Using the CCNC TC Priority Report for CC4C Nov 2015 document Assisting family in changing Medicaid assignment, if desired. If child is identified as possibly experiencing toxic stress or adverse life events, also follow the guidance for reason 2 on next slide. Examples of CC4C Roles Reason 1 Child previously lived and received services in the HOME county and then moved to the HOST county; the child is not in DSS custody Partnering = SUCCESS
30 Ultimately responsible Home County CC4C CM Where Child in DSS Custody Establish an ongoing communications with DSS SW regarding child s needs, including medical care and plan for reunification Host County CC4C CM Where Child lives in FC Assist with arranging a services in host county, including medical home, if needed. Assist in obtaining past medical information Conduct a face-to-face visit, if needed. Conduct an initial or continuing LSP with the biological parent as indicated, following the LSP Frequently Asked Questions in the CC4C Toolkit. Work with local DSS staff in getting new MH on Medicaid card. Communicate frequently with Host CC4C regarding info gained from DSS SW & others in HOME community. Conduct an initial LSP (new parent-child dyad), if indicated, following the LSP Frequently Asked Questions in CC4C Toolkit. Link Home County DSS SW with MH to obtain the new MH NPI number and locater code, if needed Communicate all info obtained in HOST county back to Home CC4C CM Follow the guidance in the HOME-HOST CC4C CM Talking Points for FC-Kinship document Examples of CC4C Roles Reason 2 The child was taken into DSS custody in the HOME county and then placed in a foster/kinship care in the HOST county Partnering = SUCCESS January 2017 CC4C Webinar
CC4C staff are expected to follow the guidance in the HOME-HOST CC4C CM Talking Points for FC-Kinship document This document was provided as a webinar handout 31
HOME-HOST CC4C CM Talking Points for FC-Kinship Document A warm exchange must occur between the HOST county CC4C CM and the HOME county CC4C CM In areas where counties have developed a standard process for this exchange, the exchange may occur by CMIS messaging But, for counties who do not have this relationship OR the CMIS messaging has not been effective, a care manager from both the HOME and HOST county must have a phone conversation to determine the most appropriate manner by which CC4C services will be provided Both the HOME and HOST CC4C care managers must review the Talking Points document prior to the phone call and be prepared to discuss 32
HOME-HOST CC4C CM Talking Points for FC-Kinship Document Remember: The decision as to who will be primary CC4C CM is to be made jointly The decision should be based on which CC4C CM can best support the family/guardian to: identify the red flags of toxic stress/adverse life events work with the family/guardian to develop a plan to meet identified needs and ensure healthy outcomes for the child 33
Resources The Using the CCNC TC Priority Report for CC4C Nov 2015 document: Contains a section entitled A Child listed on a Priority Population Report That Actually Lives in Another County that begins on page 5 Includes the same language as found on slides 29 & 30 Can be accessed In the CC4C Tool Kit in the Informatics Center using the following path: Home > CC4C Tool Kit File Share > CC4C Toolkit Jan 2015 > Section 04 - CC4C Best Practices > Priority Report 34
Resources Fostering Health NC Best Practices for CCNC & CC4C Contains Section K Case Management Across County Lines on page 4. Reflects that the ultimate case management responsibility remains with the HOME county (where the child was taken into custody), but healthcare services will need to be rendered in the HOST county where the child will live. Can be accessed in the Best Practices Section of the NC Fostering Health online library at http://www.ncpeds.org/fh-online-library-all-files. 35
ASQ in CMIS The ASQ form posted in CMIS is the original ASQ, and NOT the ASQ-3 Only the ASQ-3 should be used to complete page 5 of the LSP Do NOT enter ASQ-3 results in the ASQ form in CMIS Screen shot of Patient Demographic Page 36
CC4C Performance Assessment 37
Performance Assessment Each local LCME must complete the annual performance assessment Document will be sent by email to all CC4C supervisors by the CC4C network lead in late January LCME will complete the performance assessment by March 1, 2016 and upload the document to the IC as instructed in the attached email Document should be a collaborative process and include discussions with CC4C staff, LCME leadership and the local health director 38
Performance Assessment As part of the performance assessment, each LCME will set measurable goals for the program to meet over the next six months and the actions necessary to meet those goals At the conclusion of the six months, the LCME will be asked to evaluate the actions and progress toward meeting the set goals and set goals for the next six months. 39
Data Dashboard Measures CC4C Data Dashboard Measure 1: Percent of children contacted Current benchmark: 5% New benchmark: 7.5% CC4C Data Dashboard Measure 2: Percent of children actively care managed (heavy/ medium/ light) Current benchmark: 3% New benchmark: 5.5% 40
Performance Improvement Process Performance Improvement Process will be implemented in early winter (late January/ February) Counties will be notified by email if they are included in the performance improvement process Will include data dashboard results for the April to September 2016 timeframe Will be based upon the new baseline targets Measure 1: 7.5% Measure 2: 5.5% 41
CC4C Updates 42
CC4C Standards Report The CM Standards Report CC4C: Provides a broad-brush, high level and more efficient way of assessing whether CC4C CM Standards are being met based on CMIS documentation Is intended to be the first step in a QI process that includes case reviews to assure continuous quality improvement in CM service provision and documentation Should be used at least monthly by supervisors to review caseloads and look for completeness of documentation in CMIS Is to be used by care manager s based on expectations set by each local supervisor 43
CC4C Standards Report The CC4C Standards Report Explanations and Actions document was shared during the November 2015 CC4C webinar This document was provided as a webinar handout and is available in the CC4C toolkit using the following path: Home > CC4C Tool Kit File Share > CC4C Toolkit Jan 2015 > Section 03 - CMIS and IC > CMIS > CMIS Instructional Docs - Reports > CC4C Standards Report-Explanations and Actions Nov 2015.pdf 44
CC4C Standards Report The Standards Report can be used to assess the following requirements that are NOT flagged with yellow highlighting in the report: CHA: View only the cases in heavy & medium case status using the CC4C Case Status Column and then look at CHA Update (Most Recent) Column the CHA must be updated every 30 days Goals: View only the cases in heavy & medium case status in the CC4C Case Status Column and then look at the Goal Date (Most Recent) Column - the goal must be updated every 30 days Goals: View only the cases in light case status in the CC4C Case Status Column and then look at the Goal Date (Most Recent) Column - all patients in light case status most have a goal, and the goal must be updated every 90 days 45 November 2016 CC4C Webinar
46 Medicaid Resources 2016 Health Check Program Guide includes: Periodicity Schedule Required Exam Elements Link to Immunization Schedule Health Check Coordinator Directory includes: HCC assigned to each county organized by network Contact info for each HCC https://dma.ncdhhs.gov/medicaid /get-started/find-programs-andservices/health-check-and-epsdt
Updated Case Review Tool 47 Screen shot of item 1.A. in initial Case Review Tool (in black) and the revised 1.A. (in red). The revised, updated Case Review Tools (both scored & unscored) are provided as a webinar handout; also updated as handouts for the CRT training and placed in Section 06 of the toolkit 47
CC4C Toolkit The following downloadable chapters, found in Section 14 of the CC4C Toolkit, have been effective January 4, 2016: Section 2-Contracts and Agreements: Fundamental Expectations of CC4C Network Lead added Section 03 CMIS & IC Part A: Standards Report Slides from 110515 CC4C Webinar added Section 04 Best Practices: CC4C Script and Key Messages, WIC Collaboration Strategies and HOME-HOST CC4C CM Talking Points added 48
CC4C Toolkit The following downloadable chapters, found in Section 14 of the CC4C Toolkit, have been effective January 4, 2016: Section 5 Toxic Stress, LSP, Foster Care: Best Practices or CCNC & CC4C, Parent & Caring Adult Handout, HOME-HOST slides from January 2017 Webinar and HOME-HOST CC4C CM Talking Points for FC-Kinship added Section 06-Supervision: Typo in the CC4C Supv Guidance Nov 2016 document corrected; also, Case Review Tools updated Section 09-Outreach Materials: CC4C Script and Key Message and WIC Collaboration Strategies added 49
CC4C Toolkit The following downloadable chapters, found in Section 14 of the CC4C Toolkit, have been effective January 4, 2016: Section 16 Linking Families to Resources: Parenting-Family Support Slides from Sept 2015 CC4C Webinar that were updated Aug 2016 have been added Section 17 CC4C Webinars: Compiled Webinar Agendas with Registration Links Since Sept 2014 50
2017 CC4C Webinar Schedule CC4C Webinars are held at 9:30 a.m. on the first Thursday every other month in the odd-numbered months. The webinar schedule for the remainder of the year is as follows: Thursday, Mar 2 at 9:30 am Thursday, May 4 at 9:30 am Thursday, July 6 at 9:30 am Thursday, Sept 7 at 9:30 am Thursday, Nov 2 at 9:30 am 51
Tiered System to Gain & Apply CC4C Information WEBINAR Overview of a specific CC4C topic REGIONAL NETWORK MEETINGS More details related to CC4C topic & discussion of network application 52 LHD CALL, MEETING OR SITE VISITS Review details related to CC4C topic & discussion of county application Goal: Ensure info is understood & applied in order to improve health outcomes & decrease cost, thus meeting Performance Measures
Questions? If you insert questions in the webinar evaluations, we are not able to follow up with you directly Reach out to your: Supervisor, Regional child health nurse consultant, and/or Local CC4C network lead 53
PLEASE register to demonstrate your participation in today s webinar and provide feedback by clicking on link below The registration /evaluation / survey link is: https://www.surveygizmo.com/s3/3264357/cc4c-webinar- Registration-January-2017 If it doesn t work the first time, give it a second and try again Key to success: Promptly use Webinar Talking Points in Staff & Regional Meetings to apply info shared today Next Webinar: Thursday, March 2, 2017 at 9:30 a.m. 54