1. THE MARION COUNTY EXPERIENCE JUDY CLEAVE, MPH, RN Care Coordination with Medical Homes

2. The Client 17 Year Old with Cerebral Palsy Wheelchair bound Unable to communicate verbally Attending special classroom at SKSD Developmental Disabilities case manager CIIS (Children’s Intensive In-Home Services)Medically Fragile Children’s Unit School nurse and other support professionals Medical Home Case Manager Shriners

3. Many Resources/Broken System Communication Devices Interpreter Use System to Track Appointments/Supplies Safety Equipment/Skills Toileting Transition Planning Guardianship Lead Case Manager Communication between Family and Providers Daily use of Electric Wheelchair in Home Family Not Fully Informed of Insurance and Medical Processes Housing Choices

4. Impact on Players Environment of distrust and disrespect Family blamed for system failure Plan made at the table, but poor follow through Client did not get what he needed to develop to his fullest potential All involved were frustrated!!!

5. Woodburn Pediatric Case Managers Judith, Marcy, Rhoda

6. Developmental Disabilities Team

7. Marion County CaCoon Staff

8. CHAOS Case Managers Lisa and Elizabeth

9. Medical Home Case Managers Quality Improvement Initiative through OPIP (Oregon Pediatric Improvement Partnership) CHAOS has employed case managers for many years. Woodburn Pediatrics began their case management through the initiative. Medical Home Case Managers and Public Health Nurses communicate regularly. We are all learning together.

10. Woodburn Pediatrics Case Management Judith and Rhoda:  249 children/families with complex medical/social needs  Ages 6 months to 21 years old Marcy  360 ADHD patients  Ages 4 years to 24 years old

11. CHAOS Case Management Lisa Story and Elizabeth Peasley Caseload managed: 193 0-3 Years Old: 28 4-6 Years Old: 34 7-9 Years Old: 54 10-12 Yrs. Old: 29 13-15 Yrs. Old: 20 16-18 Yrs. Old: 20 19-20 Yrs. Old: 8

12. Case Managed Clients (3/1/14) Notable Characteristics of DD Total All Ages 2,161 Total Adults: 1,560 (18yrs. +) Total 18-20 Yrs: 279 Total 21 & Up: 1,381 Total Children: 601 (0- 17) Children’s Intensive In- Home Supports (CIIS) enrolled: 58 Very complex array of services Funding and service availability changes frequently Challenging for public health nurses to be knowledgeable about service eligibility. DD Case Management

13. Clients Served Notable Characteristics CaCoon 2012:  195 clients  892 visits CaCoon 2013:  244 clients  1,209 visits Evolving billing mechanism for TCM. Increasing number of complex CaCoon clients. Able to visit in home more intensively than DD service. Medical background of nurses. Longstanding presence of CaCoon program. Public Health Nurse Case Management

14. Our Approach Determine what each agency provides for clients. Develop list of services for each agency. Identify clients who enter service with few resources and little partner involvement. Commit to tracking service provision from service entry over time to assure goal attainment. Develop a care plan and identify primary case manager. Track goal acquisition.

15. Barriers to Timely Implementation Sheer number of changes occurring in healthcare reform for all of us. Health Department was going through its first national accreditation process (PHAB visit 1/14) Developmental Disabilities is undergoing huge changes while local staff turnover is high (retirements, etc.) School districts are experiencing huge education system changes at the same time healthcare reform is occurring.

16. What are we missing? Mental health services brought to table School support services brought to table Care plan format that all service providers are comfortable with. (Medical Homes are very busy. Feedback is that care plans must be very simple or medical offices will not be able to use them.)

17. Opportunities We have a new medically complex teen referral to CaCoon services. New referral is involved only with a pediatric practice and the school nurses. We will use knowledge of services to develop care plan and measure acquisition of services. Fall regional conferences give us time to improve our system of care and then report out.

18. JUDY CLEAVE, MPH, RN PROGRAM SUPERVISOR EARLY CHILDHOOD NURSING SERVICES, IMMUNIZATIONS MARION COUNTY HEALTH DEPARTMENT 3180 CENTER ST. NE SALEM, OR 97301 JCLEAVE@CO.MARION.OR.US 503-361-2693 Contact Information