CaCoon Program Orientationfor New PHNs - Part 1

October 3, 2013

CaCoon Program Orientation – Two Webinars

Second Annual CaCoon Program Orientation

For PHNs New To CaCoon

#1 Webinar October 3rd, 2013, 9am – 11am

Review CaCoon and Professional Practice

#2 Webinar October 22nd, 2013, 9am – 11am

Review resources, documentation and evaluation

CaCoon Program Orientation Goal

…to increase the confidence and

competence of newer CaCoon Public Health

Nurses related to services for children and

youth with special health needs.

Objectives for Today’s Webinar:

Review• History of federal and state programs for children and youth with

special health needs (CYSHN) identify one thing learned about CYSHN Title V

• History and purpose of the CaCoon Program

identify the purpose of the CaCoon program

• Public Health Nursing

identify public health nursing populations

• CaCoon Program Eligibility and Standards

recognize how CaCoon clients are eligible for the program

know where to find the standards for CaCoon

• CaCoon Public Health Nursing Practice Understand two principles of Professional Growth Progression

Recognize risks in Therapeutic/Helping Relationships in CaCoon

History of federal and state programs for children and youth

with special health needs (CYSHN)

HN Title V

History of federal and state programs for children and youth with special health

needs (CYSHN)

identify one thing learned about CYSHN history

History of Services to Children with Special Health Needs

• 1900’s: Statewide services delivered to a specific subset of CYSHN supported by the University of Oregon, later called OHSU, often free.

• 1935 Title V of the Social Security Act : Enabled each state to extend and improve services for locating crippled children, and provided for medical, surgical, corrective and other services and facilities for diagnosis, hospitalization and aftercare. (purpose)

• Crippled Children’s Services separate from Maternal Child Health Services.

• 1989 Maternal Child Health Bureau (MCHB) began the block grant to the states.

Omnibus Budget and Reconciliation Act of 1989

• Redefined mission & function of State CSHCN programs

• Care coordination added as a targeted service

• Promote and provide family-centered, community-based, coordinated care for CSHCN

• Facilitate the development of community-based systems of services

7

1987 Federal MCH focus shifted to

community-based services 80 year time span

 

1989 New Definition of Children with Special Health Care Needs

Children with special health care needs (CSHCN) are defined as:

"those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally”

No longer ‘crippled children”

Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB)

“Insurance” to assurance…

DIRECT HEATH CARE SERVICES:

(GAP FILLING)Examples:

Basic Health Services,

and Health Services for CSHN

ENABLING SERVICES:

Examples:Transportation, Translation, Outreach

Respite Care, Health Education, FamilySupport Services, Purchase of Health

Insurance, Care Management, Coordination with Medicaid, WIC, and

Education

POPULATION-BASED SERVICES:

Examples:Newborn Screening, Lead Screening, Immunization,

Sudden Infant Death Syndrome Counseling, Oral Health,

Injury Prevention, NutritionAnd Outreach/Public Education

INFRASTRUCTURE BUILDING SERVICES:

Examples:Needs Assessment, Evaluation, Planning, Policy Development,

Coordination, Quality Assurance, Standards Development, Monitoring,

Training, Applied Research, Systems of Care and Information Systems

Since 1997 the conceptual framework for the services

of the Federal Title V Maternal and Child Health

Block Grant is envisioned as a pyramid with four tiers of

services and levels of funding that provide

comprehensive services for mothers and children, including children with

special health care needs. The model displays the uniqueness of the MCH

Block Grant, which is the only Federal program that

provides services at all levels.

History, funding and purpose of the CaCoon Program

identify the purpose of the CaCoon program

CaCoon started as pilot program 1987-25 years agoCaCoon was established under a MCH SPRANS grant in 1987

(Special Projects of Regional and National Significance)

Public health nursing fit the target activities of the new MCH directive Piloted in Four counties in 1989-1991, went statewide in 1992

Promatoras added in 4 counties with a high proportion of Hispanic families 1995

2010 recognized as a Promising Practice by Association of Maternal Child Health Programs

In 2012, CaCoon evaluation demonstrated effectiveness

Oregon Center for Children and Youth with Special Health Needs

CaCoon = CAre COordinatiON

• OCCYSHN contracts with County Health Departments to identify and provide PHN home visiting care coordination to families of CSHN. purpose

• Each county has a designated Public Health Nurse CaCoon Coordinator. Many have several PHNs serving CaCoon families along with Promotora and community health workers since 1991 have gone from 36 to 150 nurses

• Each County is funded differently based on the projected number of children with special health conditions.

CHANGE IS COMING!

Funding for CaCoon:Title V Block Grant: At this time

• Federal Maternal Child Health Bureau (MCHB) provides a block grant to each state

• Federal dollars are matched with state dollars in a 4:3 ratio

• 70% of the combined funds are used for general MCH populations

• 30% of funds must serve children with special health needs (CSHN)

• General MCH dollars go to the Oregon Health Authority (OHA), Center for Prevention and Health Policy, to serve general populations through programs such as Babies First! and Maternity Case Management 70%

• Children with Special Needs dollars go to Oregon Center for Children and Youth with Special Health Needs(OCCYSHN), located at OHSU for programs such as CaCoon or Child Development and Rehabilitation Center 30%

Funding for CaCoon:Title V Block Grant

• Contracts to local Health Departments (LHDs) from OCCYSHN (state dollars)

• Targeted case management (Federal dollars w county match. This is changing)

• County general funds (very limited)

• Grants, other local sources of funding

• CCO partnerships, with fee for services and contracts

Funding for CaCoon

OHSU/IDD/CDRC/OCCYSHN

Affordable Care Act and Title V CYSHN 2013

Federal funding for Title V changing

How: we don’t know

State of Oregon Health Transition

Many changes, not all known

INFRASTRUCTURE BUILDING SERVICES:

Examples:Needs Assessment, Evaluation, Planning, Policy

Development, Coordination, Quality Assurance, Standards

Development, Monitoring,Training, Applied Research, Systems of Care and

Information Systems

POPULATION-BASED SERVICES

Examples:Newborn Screening, Lead Screening, Immunization,

Sudden Infant Death Syndrome Counseling, Oral Health,Injury Prevention, Nutrition

And Outreach/Public Education

CaCoon Program

Practice, Standards and Eligibility

Identify one element of CaCoon PHN practice Recognize how CaCoon clients are eligible for the program

Know where to find the standards for CaCoonIdentify a risk of boundary crossing in home visiting

Public Health NursingAn Element of CaCoon

Public Health Nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social and public health sciences

(APHA, Public Health Nursing Section, 1996.)

Public Health Nursing

Public health nurses integrate community involvement and knowledge about the entire population with personal, clinical understandings of the health and illness experiences of individuals and families within the population.

Cornerstones of Public Health Nursing

Public Health Nursing• Population based• Grounded in social justice• Focus on greater good• Focus on health promotion

and prevention• Does what others cannot or

will not• Driven by the science of

epidemiology• Organizes community

resources • Long-term commitment to the

community

• Relationship based • Grounded in an ethic of

caring • Sensitivity to diversity • Holistic focus • Respect for the worth of all • Independent action• Standard of practice defined

by nurse practice law

Cornerstones of PH Nursing, Minnesota Department of Health, revised 2007

Public Health Nurses serveVulnerable Populations*

• Economic: poverty and link to hazardous environments and inadequate nutrition

• Educational: ability to understand health information and make informed choices

• Social: support system

• Health status: physical, biological, psychological

• Health risk: lifestyle, environmental

From the North Carolina Institute for Public Health

* Power differentials in systems of care increase vulnerability*

Children with special health needs a vulnerable population

• Complex physical and developmental needs

• 73% of CaCoon clients have more than one risk factor (ORCHIDS data FY2010)

• Difficulty accessing care because of finances, transportation, geography, health complexity

• Families often living in poverty; Child’s condition requires difficult choices

CaCoon PHNs

• Identify (outreach and case finding)• Link to health services (case manager)• Develop or revise programs to meet

client needs• Educate on health promotion• Provide direct care• Advocate for programs and services to meet

client needs

From the North Carolina Institute for Public Health

Population-Based

System-Focused

Population-Based

Community-Focued

Population-Based

Individual- Focused

From University of Minnesota Public Health Intervention Wheel

CaCoon Care Coordination…our unique contribution

CYSHN care coordination within the context of comprehensive nursing process

Data Collection-systematic, objective and subjective

Nursing Assessment-standardized

Plans of Care-focused on measurable outcomes

Monitoring/evaluating POC, effectiveness of interventions

Modifying plan of care as needed

Specific outcomes oriented

Interventions delivered within therapeutic nurse relationship

Standard Practice

What is Care Coordination?

Care coordination is a process that links children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care.

Committee on Children With Disabilities. “Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs.” Pediatrics 104.4 (1999). Pediatrics Web. 11 January 2013 Accessed http://pediatrics.aappublications.org/content/104/4/978.full.

Care Coordination…

• provides timely access to services, continuity of care, family support, strengths-based rather than deficit-based thinking

• is accomplished everyday by families with and for their children and youth, but support is beneficial

• is in partnership with the family

• requires critical funding and protected time

• requires tested tools, strategies and advocacy

CaCoon: More than Case Management

• “Case Management” is a common role throughout communities and systems of care

• Families with CYSHN often have multiple case managers

• Each case manager provides services within the context of their employee goals, experience, knowledge and education

• Case management might be viewed as gate keeping or restricting services

• Families and CaCoon nurses must navigate the system without marginalizing roles

Skills needed for CaCoon:

Technical skillsscreeners/assessments, documentation, resource collection, travel, safety

Personal-Social Skillsfamily engagement, self awareness, cultural competence, personal/professional skills, ability to ask for help

Critical Thinking Skillsdeveloping plan, monitoring and adjusting the plan, anticipatory planning, practice management, self-management

CaCoon Novice to Expert

CaCoon Novice to Expert

CaCoon is partnership to support coping and growth in difficult times

1. Acknowledge difficulties2. Change brings resistance from many avenues3. Change begins with planning and moves to action4. Positive change happens when there is hope and optimism about the future5. Positive tone and persistent commitment to facilitating

growth supports change6. Ability to recognize any movement toward change motivates more change7. Acknowledge early when supports are no longer needed8. Recognize many people value the shared experience so

much they will want to “stay in touch’ to share on-going success or

challenges they have over come

First Competency: Self-knowledge

Second Competency: Strategic Vision

Third Competency: Risk-taking and creativity

Four competency: Interpersonal and communication effectiveness

CaCoon provides a therapeutic relationship

Interpersonal skills = the helping relationship

First Competency: Self-knowledge

Second Competency: Strategic Vision

Third Competency: Risk-taking and creativity

Four competency: Interpersonal and communication effectiveness

Fifth competency: The ability to inspire

Two common circumstances can produce blurring of boundaries:

Over helping—doing for clients what they are able

to do themselves or going beyond the wishes/needs of clients

Controlling—asserting authority and assuming

control of clients “for their own good”

Narcissism—having to find weakness, helplessness,

and/or disease in clients to feel helpful, at the expense of recognizing and

supporting clients’ healthier, stronger, and more competent features

(Pilette et al., 1995)

CaCoon Eligibility

• BabiesFirst! / CaCoon Eligibility List – aka the “A/B” list

• Use of the B90 code

• No financial or health insurance eligibility limitations

• CaCoon serves children birth through 20 years of age

• Counties determining age priorities

Eligibility Criteria – CaCoon B Codes

DiagnosisB1. Heart DiseaseB2. Chronic Orthopedic DisordersB3. Neuromotor disorders including cerebral palsy and brachial palsyB4. Cleft lip and palate and other congenital defects of the head, faceB5. Genetic disorders, e.g. cystic fibrosis, neurofibromatosisB6. Multiple minor anomaliesB7. Metabolic disorders, e.g. PKU

B8. Spina BifidaB9. Hydrocephalus or persistent ventriculomegalyB10. Microcephaly and other congenital or acquired defects of the CNSB12. Organic speech disorders, e.g. dysarthia/dyspraxiaB13. Hearing LossB23. Traumatic Brain InjuryB24. Fetal Alcohol Spectrum DisorderB25. Autism, autism spectrum disorder, e.g. PDD,Asperger’sB26. Behavioral or mental health disorder with developmental delayB28. Chromosomal disorders, e.g. Down syndromeB29. Positive Newborn Blood ScreenB30. HIV, seropositive conversionB31. Visual Impairment

Very High Risk Medical FactorsB16. Intraventricular hemorrhage (grade III or IV) or periventricular leukomalacia (PVL) Or chronic subdurals

B17. Perinatal asphyxia accompanied by seizures

B18. Seizure disorder

B19. Oral-motor dysfunction requiring specialized feeding program e.g. Failure to Grow, Organic-Non-organic (medical diagnosis), gastrostomy, nasogastric

B20. Chronic lung disorder, e.g. tracheostomies, ventilator

B21. Suspect neuromuscular disorder, e.g. abnormal Neuromotor exam at NICU Discharge

Developmental Risk FactorsB22. Developmental Delay

Other

B90. Other chronic conditions not listed

B Codes in ORCHIDS and charting

• Our state data system is only as good as the information entered

• There can be multiple B codes with A codes

• In BabiesFirst! there cannot be B codes. • In CaCoon there can be both A and B

The more codes entered, the more we know about the clients in CaCoon

CaCoon Minimum Standards of Program Performance

It is the responsibility of each nurse providing CaCoon services, to ensure that program standards are met for each family served.

1. The local health department will assure initial contact with CaCoon referrals within 10

business days of receiving. Initial contact may be by telephone or other means.

2. If need the local health department establishes and maintains a triage system that acknowledges the most vulnerable children with special health needs. Priority is given to families with:

a. A newborn with a disabilityb. A newly diagnosed infant/child with a disabilityc. Children with increased nutrition risk (e.g., children with congenital cardiac

defects, cleft lip and palate, or cystic fibrosis)d. Families having difficulty accessing or coordinating their child’s care and

services

3. The LHD CaCoon program meets a minimum number of visits per year.

Each LHD will be given the target number of annual visits that are expected.

CaCoon Minimum Standards of Program Performance, continued

4. Families considered part of the CaCoon Nurse’s active caseload receive home visits on a frequency related to assessed need, no less than one face to face contact every three months. PHN visiting will correspond to the needs of the client and family assessed and assumes a mixed population of tier.

5. All CaCoon Nurses performs or assures that children and their families receive the following minimum assessments (See Assessment Tools in Chapter 6):

a. Family assessment.

b. Developmental assessment (use of a developmental screen for this population would be selective and for the purpose of monitoring, teaching or documenting progress).

c. Child health assessment to include monitoring of vision and hearing (includes follow-up of hearing results from the newborn screening including hearing and vision screening).

d. Nutrition assessment – using CYSHN screening tool or equivalent.

e. Tier level assessment

f. Safety assessment appropriate for CSHN

CaCoon Minimum Standards of Program Performance, continued

6 The client data record reflects evidence of care coordination, cultural competency and family partnership, and use of Tier Level data to develop a plan of care which is periodically reevaluated with the family and changed according to objective criteria or demonstrated and documented need.

7 PHNs serving CaCoon clients assure linkage to essential support and care services such as F2F, CCO ICM, PCP/Specialty Care, SSI, DD, MH

8. Encounter data is entered into the ORCHIDS database.

9 The LHD supervisor assures that CaCoon is represented at the county Local Interagency Coordinating Council (LICC) or planning group that assumes the mandate of LICC.

CaCoon Minimum Standards of Program Performance, continued

10 A CaCoon Nurse Coordinator is designated by the Nursing Supervisor (refer to CaCoon Subaward Contract Attachment C-1 for role expectations).

11 Counties will report child find activities which ensure families and community organizations are aware of services available through the local CaCoon program.

Counties not meeting one or more standards will write a plan of correction which they and OCCYSHN will monitor. Inability to reach and/or maintain standards may, at OCCYSHN’s discretion, result in loss of annual subaward contract renewal.

Filed at your local health department, refer to you manual

CaCoon Practice in action

• You will manage your own practice• You will have your own clients• You will manage your own charts• You will assure your own capability to

appropriately work with CaCoon clients and their families

• You must ask for what you need to succeed

Case Finding: Referral

Common Referral Sources• WIC• Primary care provider• Hospital- could be NICU, well baby, other inpatient• Other LHD Clinics- immunization• Early intervention• EHDICommon Referral Problems:• Not contacting the family within 10 days of referral• Not identifying the vulnerability of the client • Not staying in touch with the referral source

Pre-visit planning

• Review referral • Secure complete contact information• Determine if child has a specific and/or new

diagnosis• Determine what services the child is already

receiving• Determine urgency of referral • Clarify priorities

• Seek supervisory support!

Pre-visit planning, cont.

• Ensure you understand the child’s diagnosis

• Find information about conditions– You do not need to know everything– You do need to know where to find the information– Anyone can do a simple web search-do a professional

search!

• Contact the family within 10 days, sooner if possible

Engaging Familiestelephone contact

• The initial contact is critical to the establishment of a trusting relationship

• Explain who you are, what you do and your professional boundaries

• Explain the reason for the referral• Explain services and offer home visit • Ask if families have immediate concerns or other

questions Are you concerned about anything today or recently? How is feeding working out? Follow the lead given.

Engaging Families

Parent goal is to minimize their perceived vulnerability (Jack et al, 2005)

• Overcoming fear

• Building trust - mutual trust grows over time

• Seeking mutuality - shared power, dropping the ‘expert’ nurse role

• Affirming intrinsic abilities

• Partnership in achieving goalsJack, Susan M, DiCenso, Alba & Lohfeld, Lynne. “A Theory of Maternal Engagement with Public Health Nurses and Family Visitors.” Journal of Advanced Nursing 49.2 (2005): 182–190. Journal of Advanced Nursing Web. 11 January 2013 Accessed http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2004.03278.x/full

The First Visit in the home

• Use an interpreter if needed!• Welcome other people the parent may have

invited• Engage the parent as a partner in helping their

child – You are working with the parent, not delivering a – service to the parent

• Explain what will happen during this and subsequent visits

• Affirm the positive you see, search for it diligently!

Used with permission. ©The Honor Society of Nursing, Sigma Theta Tau International

Getting to know CaCoon

• The CaCoon Manual• CaCoon Library in LHD• Online resources• People in your community• Providers at tertiary centers• Your CaCoon Nurse Consultants• Your MCH Nurse Consultants• TIME!

We are all in the process of learning

• Know and accept where you as a learner

• Ask for what you need to be more effective

• Vulnerable clients can be harmed through inappropriate ‘helping’, CaCoon’s goal is empowerment

• Nurses can impede their professional growth and skill by not protecting professional boundaries.

• Nurse practice law demands patient/client protection.

• It is YOUR responsibility as the professional home visitor to take the lead in ‘doing no harm’

Questions?

• Next time topics:

• Care plan development

• Documentation

• Resources

• Other needs?.............................

Questions?

Next webinar

October 22nd, 9-11am

Send questions, topics of

interests for the 22nd

Be watching for the survey monkey

CaCoon support to local health departments

• State CaCoon Nurse Consultants for the 36 counties who:– monitor program services– evaluate data for 36 counties– provide program orientation– provide ongoing support– train PHN’s– work closely with the OHA/Center for Prevention &

Health Promotion

We share a workforce with OHA

OCCYSHN Staff

OCCYSHN DirectorMarilyn Hartzell M.Ed.

CaCoon Nurse ConsultantCandace Artemenko RN,BSN

artemenk@ohsu.edu / 541-673-3842

Administrative Assistant

Matthew Gonzalez, BA

gonza@ohsu.edu/ 503-4942902