1. Care Coordination for Children, Young Adults, and Their Families

2. 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)

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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)

9. Referrals To make a referral for ICC or Wraparound
Call 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. Questions?