Care Coordination Program
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Transcript of Care Coordination Program
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Care CoordinationProgram
Misty VanCampen, RN CCM
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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.
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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
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Medically Complex
Chronic/severe health conditions Significant family-identified service needs Functional limitations High health resource utilization
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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)
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Care Giver =Care Coordinator
Medication Errors Lost to follow up Fragmented Care Literacy issues Compliance issues Stress and Fatigue
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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.
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Vision
We serve over 10 thousand complex medically fragile children
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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
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Data Data Repository
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Referral Criteria
High ED Visits
High Inpatient Admissions
High Cost to the System
Multiple Specialists
CCMC Primary Service Area
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Return On Investment
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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.
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Services Identify Coordinate Home visits Collaborate Assist Advocate Educate
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Team ApproachSpecialists
Primary Care Physicians
Pharmacy
Comm
unity Resources
Home Health Companies
Schools
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Prepare
Know your Patients
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MCCM WorklistWork lists
• CACO ER• Initial• Maintenance
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Activities Activities
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Capturing Activity Data
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Windshield SurveyAssess the Surroundings: Type of dwelling Access points to care (pcp, UCC) Dental Food Parks Safety Socioeconomic Crime Hazards: waste, industrial pollution
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Home Visit
Medication Reconciliation
Identify Barriers
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Assessment
Psychosocial and Medical
Case Management Assessment
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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
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School
• Navigating the Education System• Information on ARD meetings (IEP)• Advocating education (IDEA, 504b)• Assist with Individualized Health Plan
(example: seizure, asthma, etc…)
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Coordinated Care
Care Coordinatio
n
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Success Story
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Plan
DMENursing
School
MDCPMedicaid Programs
Clinic Visits
Physician
Patient
Care Coordination
Dental
Community ResourcesCatholic Charities, SAVE, 211
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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
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Tough Questions
End of Life Planning
DNR
Hospice
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Bridge the Gap
Palliative Care and Hospice
Case Studies
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Results: ROI
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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
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Questions