1. 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

2. 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

3. 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

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

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

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

7. Have FUN and be INSPIRED!

8. 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

9. 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

10. 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.

11. 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-

12. 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)

13. 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

14. 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

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

16. 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.

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

18. 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

19. 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

20. 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

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

22. 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

23. 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…..

24. 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