Care Coordination with Medical Homes
Care Coordination with Medical
Homes
T H E M A R I O N C O U N T Y E X P E R I E N C E
J U D Y C L E A V E , M P H , R N
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
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
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!!!
Woodburn Pediatric Case Managers
Judith, Marcy, Rhoda
Developmental Disabilities Team
Marion County CaCoon Staff
CHAOS Case Managers
Lisa and Elizabeth
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.
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
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
DD Case Management
Case Managed Clients
(3/1/14)
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
Notable Characteristics of
DD
Very complex array of services
Funding and service availability changes frequently
Challenging for public health nurses to be knowledgeable about service eligibility.
Public Health Nurse Case Management
Clients Served
CaCoon 2012:
195 clients
892 visits
CaCoon 2013:
244 clients
1,209 visits
Notable Characteristics
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.
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.
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.
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.)
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.
Contact Information
J U D Y C L E A V E , M P H , R N
P R O G R A M S U P E R V I S O R
E A R L Y C H I L D H O O D N U R S I N G S E R V I C E S ,
I M M U N I Z A T I O N S
M A R I O N C O U N T Y H E A L T H D E P A R T M E N T
3 1 8 0 C E N T E R S T . N E
S A L E M , O R 9 7 3 0 1
J C L E A V E @ C O . M A R I O N . O R . U S
5 0 3 - 3 6 1 - 2 6 9 3
