1. Care Coordination Program Misty VanCampen, RN CCM

2. 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.

3. Medically Complex Child Technologically Dependent Developmentally Delayed Congenital Genetic Anomalies Chronic Complex Conditions Physically Challenged Medically Fragile Disabled/ Disability Gifted Child Children with special health care needs

4. Medically Complex  Chronic/severe health conditions  Significant family-identified service needs  Functional limitations  High health resource utilization

5. 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)

6. Care Giver = Care Coordinator  Medication Errors  Lost to follow up  Fragmented Care  Literacy issues  Compliance issues  Stress and Fatigue

7. 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.

8. Vision We serve over 10 thousand complex medically fragile children

9. Genesis Oct. 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

10. Data  Data Repository

11. Referral Criteria High ED Visits High Inpatient Admissions High Cost to the System Multiple Specialists CCMC Primary Service Area

12. Return On Investment

13. 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.

14. Services  Identify  Coordinate  Home visits  Collaborate  Assist  Advocate  Educate

15. Team Approach Specialists Primary Care Physicians Pharmacy Community Resources Home Health Companies Schools

16. Prepare Know your Patients

17. MCCM Worklist Work lists CACO ER Initial Maintenance

18. Activities  Activities

19. Capturing Activity Data

20. Windshield Survey Assess the Surroundings:  Type of dwelling  Access points to care (pcp, UCC)  Dental  Food  Parks  Safety  Socioeconomic  Crime  Hazards: waste, industrial pollution

21. Home Visit Medication Reconciliation Identify Barriers

22. Assessment Psychosocial and Medical Case Management Assessment

23. Referrals for Medical/Developmental/Mental Health Medical Medicaid Waiver Programs – MDCP- Money Follows the Person application Community Living Assistance Support Services (CLASS) Home and Community Based Services (HCS) – MHMR Personal Care Services (PCS) Developmental ECI – under age 3 PT/OT/ST – over age 3 (under age 3 if aggressive therapy needed) and need for additional services Mental Health Counseling referrals Therapist or psychiatrist referrals MHMR services

24. School Navigating the Education System Information on ARD meetings (IEP) Advocating education (IDEA, 504b) Assist with Individualized Health Plan (example: seizure, asthma, etc…)

25. Coordinated Care Care Coordination PCP CommunityDME/ Home Health Specialists

26. Success Story

27. Plan DME Nursing School MDCP Medicaid Programs Clinic Visits Physician Patient Care Coordination Dental Community Resources Catholic Charities, SAVE, 211

28. 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

29. Tough Questions End of Life Planning DNR Hospice

30. Bridge the Gap Palliative Care and Hospice Case Studies

31. Results: ROI

32. 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 - 2011Characteristics Of Hospitalizations For Patients Who Use A Structured Clinical Care Program For Children With Medical Complexity  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 http://www.nolo.com/legal-encyclopedia/special-education-law-29626.html

33. Questions