Care Coordination for Children, Young Adults, and Their Families

objectives for today Participants will leave with an understanding of: FamilyCare Health and OHP Care Coordination programs available for children, young adults, and families who are capitated to FamilyCare Health Wraparound planning process When to consider making a referral to Wraparound or Intensive Care Coordination (ICC)

FamilyCare Health is a CCO FamilyCare Health is a Coordinated Care Organization (CCO) We provide integrated patient-centered care to approximately 120,000 Oregonians covered by OHP/Medicaid Coordinate the delivery of physical health care, mental health, chemical dependency services, and oral health care Strategize and develop programs to meet the Triple Aim of improved health, better care, and lower costs Engage community members and healthcare providers in improving the health of the community and addressing disparities Develop provider network to meet physical and behavioral health needs

FamilyCare health points of contact Member Navigation: First point of contact for members calling with questions Provider Navigation: First point of contact for providers calling with questions Service Coordination: Connects members to resources and services Care Coordination: Physical Health Children’s Behavioral Health (ICC) Wraparound Chronic conditions include: Diabetes, Asthma, Hypertension, COPD, Depression/Anxiety/Substance Use w/Chronic Condition, HIV, Maternity

Intensive Care Coordination Assists children, youth, and families who are experiencing complex needs and multi-system involvement through care planning development Ensures the right care is being provided at the right time, in the right place, by the right person Family and youth driven, strengths based, and culturally and linguistically appropriate Ratio of 1:30 Coordinator to Family Meetings held as needed for a period of 1 to 6 months

Wraparound Care Coordination A formalized, research-based model of care coordination Adheres to 10 guiding principles Adheres to a structured team planning/facilitation process Meetings held monthly for a period of 6 to 18 months on average Extensive individual and group training and coaching Ratio of 1:15 Coordinator to Family Access to Family Partner As a result, Wraparound is now listed as "research-based" on several major inventories of child and family interventions and strategies, including that of the influential Washington State Institute for Public Policy. The research base for Wraparound continues to expand and, as a result, Wraparound is likely to be more consistently referenced as an "evidence-based" model in the years to come.

Familycare health Wraparound program Awarded the System of Care Wraparound Initiative (SOCWI) April 2014 Implementation of Wraparound Program in October 2014 Serves up to 120 youth and their families Contracts with Oregon Family Support Network (OFSN) for 2 Family Partners 8.5 Wraparound Care Coordinators Wraparound Coach Been around nationally since… Currently being implemented in ___ states and ____ countries Been in Oregon in different forms since___ Expanded statewide in Oregon via House Bill ___ in 2015 Housed in each of the CCOs across the state

Who to refer? ICC or Wraparound: FamilyCare Health is primary OHP health plan 3 to 17 years old Elevating risk-disrupting activities of daily living Wraparound only: Youth is involved in two or more systems Youth and family interest *Higher levels of mental health treatment can be accessed without enrollment in ICC or Wraparound As of January 2016 unembedded service access from care coordination (ISA discontinued)

Referrals To make a referral for ICC or Wraparound Call 503-222-2880 and request a Children’s Behavioral Health Intake Coordinator. They will assist you in the referral process and answer any questions you may have. To make a referral for Specialty Mental Health Services Download the Request for Mental Health and Chemical Dependency Authorization form from the FamilyCare Health website and submit for review by the Utilization Management Department. Referrals for Wraparound will be reviewed for determination of eligibility at the local Wraparound Review Committees. Once approved by Wraparound Review Committee, the family is assigned to a Wraparound Care Coordinator who then begins engagement phase.

Wraparound Case Example Johnny is a 15-year-old male Parents and youth interested in Wraparound Involved in Juvenile Justice, Child Welfare, Mental Health, and Special Education Referred by Juvenile Justice Worker Primary concerns: Johnny recently ran away from foster home and was arrested for assault. His mother is homeless and unemployed after divorce from his father. History of DV, physical abuse, and neglect. Both parents are in recovery from drug/alcohol addiction. Refer to handout on phases

Engagement phase Preparing the team to work together Orient youth and family to process and principles Identify safety needs and create plan to address Explore strengths and needs with family Identify team members Consider ground rules and meeting characteristics important to family Gather information about strengths and needs from other team members Write up Strengths and Needs Discovery and share with team Schedule initial team meeting Johnny

Plan Development Team collaborates to build the Plan of Care Family shares their Vision Team creates Mission Team identifies Strengths and Needs Team prioritizes needs Team creates goals for prioritized needs Team brainstorms strategies to meet needs Team agrees on action steps necessary to implement strategies and commits to completion of assigned actions Team reviews/creates Safety Plan

Plan implementation Team meets monthly to review and update plan Ten Principles are followed Team completes actions and reports outcome Barriers to implementation of strategies are problem solved New strategies are identified Care Coordinator and family partner meet with family throughout the month to support them in completing actions steps and engaging in identified strategies jonny

Transition Team celebrates successes Care Coordinator and Family Partner prepare the family and team to progress towards successful achievement of the family vision Johnny’s successes

Questions?