1. Child/Youth Care Management 2015 training

2. WELCOME!

3. Attendance Procedures Thursdays, March 26 – May 14, 9 AM – 4:30 PM Training participation is a work day PLEASE ARRIVE ON TIME Attendance will be taken at 9AM Sign out at the end of the day A copy of the attendance sheet will be sent to your supervisor

4. Schedule Day 1—room 327 ALL OTHER DAYS—room 201 2 sessions a day Mornings—9AM – 12PM Lunch 12 – 1PM Afternoons—1PM – 4:30PM FOCUS GROUP, last day of training (May 14 th )

5. Overall Training Goals To equip care coordinators with skills to serve children and youth in the Health Home environment. To prepare care coordinators for a more collaborative approach to service planning and provision. To understand the purpose of Health Homes. To understand the role of the care coordinator. To provide resources that be referred back to and used in the field.

6. What is a Health Home? A Health Home is a vehicle for a providing care management to children and adults enrolled in Medicaid who have chronic medical conditions. It is not a physical place! It is a means of holistically coordinating all of the individual’s care, including physical health, behavioral health, and social services.

7. How is a Health Home Structured? The structure of the Health Home consists of 3 main parts i. Lead Health Home - This is the agency that is responsible for the operations of the Health Home and is ultimately responsible for the outcomes of those enrolled in it. ii.“Downstream” Care Managers - These are the organizations that will provide direct Health Home services to enrollees, such as care coordination. iii.The Rest of the Health Home Network - Each lead Health Home is responsible for assembling a network of other direct services providers needed to serve children with chronic conditions (e.g., PCP’s & specialists, hospitals, mental health clinics, day treatment programs, RTF’s, substance use services, family & youth peer support services, voluntary foster care agencies, youth development providers, providers of Early Intervention services, etc).

8. Who qualifies for a Health Home? Children and adolescents must meet the following criteria: Enrolled in Medicaid and Have 2 chronic conditions OR 1 chronic condition (if it is HIV or Serious Emotional Disturbance) OR have trauma and are at risk for another condition and Meet appropriateness criteria established by the State.

9. What are the 6 Core Services Provided by Health Homes? 1.Comprehensive care management The comprehensive assessment of health home members’ needs with an individual care plan carried out through specific interventions designed to provide coordinated, efficient, quality care to achieve the care plan goals and optimize health outcomes for people with complex health issues and needs

10. What are the 6 Core Services Provided by Health Homes? 2.Care coordination and health promotion Activities which engage and retain health enrollees in care Ensure identification, planning, and management of services and Increase appropriate lab monitoring and annual physicals (amongst other health promoting efforts) 3.Comprehensive transitional care from inpatient to other settings, including appropriate follow-up Health Home providers will have a system in place by which they are promptly notified of an individual’s admission or discharge from an inpatient setting Service provision focused on corresponding with providers working in inpatient settings This may include, but is not limited to, participation in discharge planning, linkage and post-discharge follow-up

11. What are the 6 Core Services Provided by Health Homes? 4.Individual and family support For children, this component includes involvement of authorized representatives Focus is on individual care plans which should reflect the individual youth and family/caregiver preferences 5. Referral to community and social support services Occurs on an as needed basis Collaborative process with community based, youth serving providers; care manager coordinates referral process, access, engagement follow-up and provision of services

12. What are the 6 Core Services Provided by Health Homes? 6. Use of HIT to link service HIT – Health Information Technology Utilized “as feasible and appropriate” Goal is to use HIT to link youth to services, and to facilitate communication amongst network providers HIT should also be used as a mechanism for Care Managers to create, document and update individual care plans

13. PRE-ASSESSMENT Case Study: Carla and Mrs. Johnson

14. Contacts Christine Kim Training Coordinator Silberman School of Social Work 212-396-7619 ck666@hunter.cuny.edu Child Tilden Administrative Assistant, Training Department Silberman School of Social Work 212-396-7606 mtilden@hunter.cuny.edu