Care CoordinationProgram

Misty VanCampen, RN CCM

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. 

Medically Complex Child

Technologically Dependent

Developmentally Delayed

Congenital Genetic Anomalies

Chronic Complex Conditions

Physically ChallengedMedically Fragile Disabled/

Disability

Gifted Child

Children with special health care needs

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)

Care Giver =Care Coordinator

Medication Errors Lost to follow up Fragmented Care Literacy issues Compliance issues Stress and Fatigue

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.

Vision

We serve over 10 thousand complex medically fragile children

GenesisOct. 2012

Nov. 2012

Dec.2012

Feb. 2013

Jan. 2013

• 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

• 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 Data Repository

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 ApproachSpecialists

Primary Care Physicians

Pharmacy

Comm

unity Resources

Home Health Companies

Schools

Prepare

Know your Patients

MCCM WorklistWork lists

• CACO ER• Initial• Maintenance

Activities Activities

Capturing Activity Data

Windshield SurveyAssess 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 applicationCommunity Living Assistance Support Services (CLASS)Home and Community Based Services (HCS) – MHMRPersonal Care Services (PCS)

• DevelopmentalECI – under age 3 PT/OT/ST – over age 3 (under age 3 if aggressive therapy

needed) and need for additional services

• Mental HealthCounseling referralsTherapist or psychiatrist referralsMHMR 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

Care Coordinatio

n

Success Story

Plan

DMENursing

School

MDCPMedicaid Programs

Clinic Visits

Physician

Patient

Care Coordination

Dental

Community ResourcesCatholic Charities, SAVE, 211

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