Connecting the Circles: Washington State Medical Home Leadership Network & Great MINDS Summit May 10, 2013 Connecting the Circles: Effective Referral and Care Coordination for Families of Children with Developmental Concerns Kate Orville, MPH and Kathy TeKolste, MD UDS Partnerships Meeting June 27, 2013

Summit Stakeholders & Participants Pend Oreille Whatcom San Juan Okanogan Skagit Ferry Stevens Island Clallam Snohomish Chelan Jefferson Douglas Spokane Kitsap Lincoln King Grays Harbor Mason Grant Kittitas Madigan Adams Whitman Thurston Pierce Pacific Franklin Lewis Garfield Yakima Benton Columbia Cowlitz Asotin Wahkiakum Skamania Walla Walla Klickitat Clark- MHLN Teams Community Asset Mapping Coalitions Great MINDS Training Other County Summit Participants LHJs w/UDS Performance Measure 5/10 /2013

Summit Planning Committee MHLN Teams Diane Liebe, MD (Yakima) Kathy Avery, FRC (Kitsap) Callie Moore, PHN (Adams) Pat Shaw, PHN & Melody Scheer (Clark) Sugely Sanchez, Parent, Great MINDS (Snohomish) Family Orgs Susan Atkins P2P Greg Schell Fathers Network Jill McCormick, PAVE F2FHIC State Partners Toni Nunes, WCAAP Kathy Blodgett, ESIT DOH Heather Reed Susan Ray Linda Barnhart, ARNP UW MHPP/LEND Amy Carlsen Kate Orville Kathy TeKolste, MD

Summit Goals Energize efforts implement universal developmental screening across settings, from doctors’ offices to early childhood environments. 

Summit Goals cont… Support care coordination among service providers and families to ensure that screening results and referrals connect children to appropriate services.

Summit Goals Cont… Strengthen community-based networks to improve children’s health and development  

Have FUN and be INSPIRED!

What Our Audience Liked Best Networking and opportunity to learn from others Exposure to new ideas- Oregon, care panel, hearing diff perspectives at breakouts and informal discussion, Collective Impact

Start with the end in mind (child and family outcomes) Developmental Screening, Cross Agency Alignment and Early Learning System Transformation in Oregon Start with the end in mind (child and family outcomes) Prioritize relationships & bringing programs together as a system. Break down silos. Culture of improvement and outcomes Dr. Dana Hargunani, Child Health Director, Oregon Health Authority Jada Rupley, Director, Oregon Early Learning Council

Local differences in lay of land and in solutions Impact of effective leader with vision in ability to connect health care with early learning Advantage of State leadership – Governor, health policy appointment in pediatrics with connection to early learning; health care reform – medical home credentialing, incentives, CCOs Local problem solving (Community Cafes) with blended funding (efficient, accountable, non-duplicative) increases collective impact Local differences in lay of land and in solutions Connecting policy and on-the-ground efforts between health and kindergarten readiness to high school graduation is key Especially of note with discussion will be that we now have Anne Stone from Oregon working at the WCAAP.

Promising Referral & Care Coordination Models Help Me Grow Walla Walla Children’s Center New Patient and Health Advocate Model Ensuring Successful Referrals from Medical Home to Early Intervention No wrong door-

From Developmental Screening to Accessing EI: What Helps Parents Dev concerns ID’d by health providers, family or educators- trusted relationship helps Process is a journey Parents value having provider offer a few key resources (WR, FRC, P2P)

Parents continued…. Parents view PCP as someone who can help parents’ capacity. Value when provider: Speaks to importance of parent’s role in child’s life Engages parents in fully understanding EI services, how helpful, and that don’t need a Dx Ask parents about their concerns and what type/amount of info helpful

Developmental Screening in the Practice Practices love DS after passing the implementation hurdle Doesn’t take extra time, allows time to focus on areas of concern Families appreciate, DS increases family satisfaction Drs. Diane Liebe, Kristi Rice and Nicole Castonguay- Great MINDS trainers Activity sheets

DS Cont…. Solving the interface with health info tech is important There is interest in statewide systematic approach to DS

New Care Coordination Roles Under Managed Care Care coordination support is needed and the MCO-LHJ collaboration is a unique model for approaching this Helpfulness of local, on-ground coordinator Web-based approach and telehealth hold promise Care coordinators WANT to help! How can we build relationships and communication? Donna Borgford-Parnell, Barb Lantz, Stacy Heinle, CHWP Donna supporting new roles for fellow CSHCN PHNs and helping families Communication Network meeting where participants were recruited.

Connecting EI and Medical Homes Connections made are built locally and require local problem solving and flexibility

EI/Medical Home and Families Need to work on cultural outreach to underserved populations – children often ID’d later Language and cultural brokers very helpful

EI/Medical Home and PCPs Care organizers for families Importance of talking with local PCPs about how they want info and to communicate (e.g. phone call if concerns) Some FRCs write summary document for PCPs because IFSP is lengthy for PCPs time

EI/Medical Home Cont… Care organizers for families Importance of talking with local PCPs about how they want info and to communicate (e.g. phone call if concerns) Some FRCs write summary document for PCPs because IFSP is lengthy for PCPs time

Summit Outcomes Referral and Care Coordination: Participants more knowledgeable about issues, activities and roles of stakeholders Increased prioritization of these issues

Opportunities Focus on increased communication between circles (not silos) How do we explain DS and EI in plain English (or other languages?) Help everyone figure out roles

Activities Upcoming Child Health Notes: How to do “Wait and See” Benefits of EI from family perspective Community Asset Mapping UDS in LHJs Statewide UDS Partnerships efforts…..

Connecting the Circles: Effective Referral and Care Coordination What are some practical models that can inspire and help community efforts? Wanted a keynote speaker who could bring information the audience hadn’t been exposed to and address the multi-disciplinary nature of the audience.-- Oregon