CaCoon Program Orientation
for New PHNs - Part 1
October 3, 2013
CaCoon Program Orientation –
Two Webinars
Second Annual CaCoon Program Orientation
For PHNs New To CaCoon
#1 Webinar
October 3rd, 2013, 9am – 11am
Review CaCoon and Professional Practice
#2 Webinar
October 22nd, 2013, 9am – 11am
Review resources, documentation and evaluation
CaCoon Program Orientation Goal
…to increase the confidence and
competence of newer CaCoon Public Health
Nurses related to services for children and
youth with special health needs.
Objectives for Today’s Webinar:
Review
• History of federal and state programs for children and youth with
special health needs (CYSHN)
identify one thing learned about CYSHN Title V
• History and purpose of the CaCoon Program
identify the purpose of the CaCoon program
• Public Health Nursing
identify public health nursing populations
• CaCoon Program Eligibility and Standards
recognize how CaCoon clients are eligible for the program
know where to find the standards for CaCoon
• CaCoon Public Health Nursing Practice
Understand two principles of Professional Growth Progression
Recognize risks in Therapeutic/Helping Relationships in CaCoon
History of federal and state programs
for children and youth with special health needs
(CYSHN)
History
of one
federal
andabout
state
programs
for
identify
thing learned
CYSHN
history
children and youth with special health
needs (CYSHN)
HN Title V
History of Services to Children with
Special Health Needs
• 1900’s: Statewide services delivered to a specific subset of CYSHN
supported by the University of Oregon, later called OHSU, often
free.
• 1935 Title V of the Social Security Act : Enabled each state to
extend and improve services for locating crippled children, and
provided for medical, surgical, corrective and other services and
facilities for diagnosis, hospitalization and aftercare. (purpose)
• Crippled Children’s Services separate from Maternal Child Health
Services.
• 1989 Maternal Child Health Bureau (MCHB) began the block grant
to the states.
1987 Federal MCH focus shifted to
community-based services
80 year time span
Omnibus Budget and Reconciliation Act of 1989
• Redefined mission & function of State CSHCN programs
• Care coordination added as a targeted service
• Promote and provide family-centered, community-based, coordinated
care for CSHCN
• Facilitate the development of community-based systems of services
7
1989 New Definition of Children with
Special Health Care Needs
Children with special health care needs
(CSHCN) are defined as:
"those who have or are at increased risk for a chronic
physical, developmental, behavioral, or emotional
condition and who also require health and related
services of a type or amount beyond that required by
children generally”
No longer ‘crippled children”
Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB)
“Insurance” to assurance…
DIRECT
HEATH CARE
SERVICES:
(GAP FILLING)
Examples:
Basic Health Services,
and Health Services for
CSHN
ENABLING SERVICES:
Examples:
Transportation, Translation, Outreach
Respite Care, Health Education, Family
Support Services, Purchase of Health
Insurance, Care Management, Coordination
with Medicaid, WIC, and Education
POPULATION-BASED SERVICES:
Examples:
Newborn Screening, Lead Screening, Immunization,
Sudden Infant Death Syndrome Counseling, Oral Health,
Injury Prevention, Nutrition
And Outreach/Public Education
Since 1997 the conceptual
framework for the services of
the Federal Title V Maternal and
Child Health Block Grant is
envisioned as a pyramid with
four tiers of services and levels
of funding that provide
comprehensive services for
mothers and children, including
children with special health care
needs. The model displays the
uniqueness of the MCH Block
Grant, which is the only Federal
program that provides services
at all levels.
INFRASTRUCTURE BUILDING SERVICES:
Examples:
Needs Assessment, Evaluation, Planning, Policy Development,
Coordination, Quality Assurance, Standards Development, Monitoring,
Training, Applied Research, Systems of Care and Information Systems
History, funding and purpose of the
CaCoon Program
identify the purpose of the CaCoon program
CaCoon started as pilot program
1987-25 years ago
CaCoon was established under a MCH SPRANS grant in 1987
(Special Projects of Regional and National Significance)
Public health nursing fit the target activities of the new MCH directive
Piloted in Four counties in 1989-1991, went statewide in 1992
Promatoras added in 4 counties with a high proportion of Hispanic families 1995
2010 recognized as a Promising Practice by Association of Maternal Child Health Programs
In 2012, CaCoon evaluation demonstrated effectiveness
Oregon Center for Children and Youth with Special Health Needs
CaCoon = CAre COordinatiON
• OCCYSHN contracts with County Health Departments to
identify and provide PHN home visiting care coordination
to families of CSHN.
purpose
• Each county has a designated Public Health Nurse
CaCoon Coordinator. Many have several PHNs serving
CaCoon families along with Promotora and community
health workers since 1991 have gone from 36 to 150 nurses
• Each County is funded differently based on the projected
number of children with special health conditions.
CHANGE IS COMING!
Funding for CaCoon:
Title V Block Grant: At this time
• Federal Maternal Child Health Bureau (MCHB) provides
a block grant to each state
• Federal dollars are matched with state dollars in a 4:3
ratio
• 70% of the combined funds are used for general MCH
populations
• 30% of funds must serve children with special health
needs (CSHN)
Funding for CaCoon:
Title V Block Grant
• General MCH dollars
go to the Oregon Health Authority
(OHA), Center for Prevention and Health Policy, to serve general
populations through programs such as Babies First! and Maternity
Case Management
70%
• Children with Special Needs dollars
go to Oregon
Center for Children and Youth with Special Health
Needs(OCCYSHN), located at OHSU for programs such as CaCoon or
Child Development and Rehabilitation Center 30%
Funding for CaCoon
• Contracts to local Health Departments (LHDs) from
OCCYSHN (state dollars)
• Targeted case management (Federal dollars w county
match. This is changing)
• County general funds (very limited)
• Grants, other local sources of funding
• CCO partnerships, with fee for services and contracts
OHSU/IDD/CDRC/OCCYSHN
Affordable Care Act and Title V CYSHN
2013
Federal funding for Title V changing
How: we don’t know
State of Oregon Health Transition
POPULATION-BASED SERVICES
Many changes, not all known
Examples:
Newborn Screening, Lead Screening, Immunization,
Sudden Infant Death Syndrome Counseling, Oral Health,
Injury Prevention, Nutrition
And Outreach/Public Education
INFRASTRUCTURE BUILDING SERVICES:
Examples:
Needs Assessment, Evaluation, Planning, Policy Development,
Coordination, Quality Assurance, Standards Development,
Monitoring,
Training, Applied Research, Systems of Care and Information
Systems
CaCoon Program
Practice, Standards and Eligibility
Identify one element of CaCoon PHN practice
Recognize how CaCoon clients are eligible for the program
Know where to find the standards for CaCoon
Identify a risk of boundary crossing in home visiting
Public Health Nursing
An Element of CaCoon
Public Health Nursing is the practice of
promoting and protecting the health of
populations using knowledge from nursing,
social and public health sciences
(APHA, Public Health Nursing Section, 1996.)
Public Health Nursing
Public health nurses integrate community
involvement and knowledge about the entire
population with personal, clinical understandings
of the health and illness experiences of individuals
and families within the population.
Cornerstones of Public Health Nursing
Public Health Nursing
• Population based
• Grounded in social justice
• Focus on greater good
• Focus on health promotion and
prevention
• Does what others cannot or
will not
• Driven by the science of
epidemiology
• Organizes community resources
• Long-term commitment to the
community
•
•
•
•
•
•
•
Relationship based
Grounded in an ethic of caring
Sensitivity to diversity
Holistic focus
Respect for the worth of all
Independent action
Standard of practice defined by
nurse practice law
Cornerstones of PH Nursing, Minnesota
Department of Health, revised 2007
Public Health Nurses serve
Vulnerable Populations*
• Economic: poverty and link to hazardous environments and
inadequate nutrition
• Educational: ability to understand health information and make
informed choices
• Social: support system
• Health status: physical, biological, psychological
• Health risk: lifestyle, environmental
From the North Carolina Institute for Public Health
* Power differentials in systems of care increase vulnerability*
Children with special health needs
a vulnerable population
• Complex physical and developmental needs
• 73% of CaCoon clients have more than one risk factor
(ORCHIDS data FY2010)
• Difficulty accessing care because of finances,
transportation, geography, health complexity
• Families often living in poverty; Child’s condition requires
difficult choices
CaCoon PHNs
• Identify (outreach and case finding)
• Link to health services (case manager)
• Develop or revise programs to meet
client needs
• Educate on health promotion
• Provide direct care
• Advocate for programs and services to meet client
needs
From the North Carolina Institute for Public Health
From University of Minnesota Public Health Intervention Wheel
CaCoon Care Coordination…
our unique contribution
Standard Practice
CYSHN care coordination within the context of
comprehensive nursing process
Data Collection-systematic, objective and subjective
Nursing Assessment-standardized
Plans of Care-focused on measurable outcomes
Monitoring/evaluating POC, effectiveness of interventions
Modifying plan of care as needed
Specific outcomes oriented
Interventions delivered within therapeutic nurse relationship
What is Care Coordination?
Care coordination is a process that links children with
special health care needs and their families to services and
resources in a coordinated effort to maximize the potential
of the children and provide them with optimal health care.
Committee on Children With Disabilities. “Care Coordination: Integrating Health and Related Systems of Care for Children With Special
Health Care Needs.” Pediatrics 104.4 (1999). Pediatrics Web. 11 January 2013 Accessed
http://pediatrics.aappublications.org/content/104/4/978.full.
Care Coordination…
• provides timely access to services, continuity of care,
family support, strengths-based rather than deficit-based
thinking
• is accomplished everyday by families with and for their
children and youth, but support is beneficial
• is in partnership with the family
• requires critical funding and protected time
• requires tested tools, strategies and advocacy
CaCoon: More than Case Management
• “Case Management” is a common role throughout
communities and systems of care
• Families with CYSHN often have multiple case managers
• Each case manager provides services within the context
of their employee goals, experience, knowledge and
education
• Case management might be viewed as gate keeping or
restricting services
• Families and CaCoon nurses must navigate the system
without marginalizing roles
Skills needed for CaCoon:
Technical skills
screeners/assessments, documentation,
resource collection, travel, safety
Personal-Social Skills
family engagement, self awareness, cultural competence,
personal/professional skills,
ability to ask for help
Critical Thinking Skills
developing plan, monitoring and adjusting the plan, anticipatory
planning, practice management, self-management
CaCoon Novice to Expert
CaCoon Novice to Expert
CaCoon is partnership
to support coping and growth
in difficult times
1. Acknowledge difficulties
2. Change brings resistance from many avenues
3. Change begins with planning and moves to action
4. Positive change happens when there is hope and optimism
about the future
5. Positive tone and persistent commitment to facilitating growth
supports change
6. Ability to recognize any movement toward change
motivates more change
6. Acknowledge early when supports are no longer needed
7. Recognize many people value the shared experience so much they
will want to “stay in touch’ to share on-going success or
challenges they have over come
Interpersonal skills =
the helping relationship
CaCoon provides a therapeutic relationship
First Competency: Self-knowledge
Second Competency: Strategic Vision
Third Competency: Risk-taking and creativity
Four competency: Interpersonal and communication effectiveness
First Competency: Self-knowledge
Fifth competency: The ability to inspire
Second Competency: Strategic Vision
Third Competency: Risk-taking and creativity
Four competency: Interpersonal and communication effectiveness
Two common circumstances can produce
blurring of boundaries:
Over helping—doing for clients what they are able
to do themselves or going beyond the wishes/needs of clients
Controlling—asserting authority and assuming
control of clients “for their own good”
Narcissism—having to find weakness, helplessness,
and/or disease in clients to feel helpful, at the expense of recognizing and
supporting clients’ healthier, stronger, and more competent features
(Pilette et al., 1995)
CaCoon Eligibility
• BabiesFirst! / CaCoon Eligibility List
– aka the “A/B” list
• Use of the B90 code
• No financial or health insurance eligibility limitations
• CaCoon serves children birth through 20 years of age
• Counties determining age priorities
Eligibility Criteria – CaCoon B Codes
Diagnosis
Very High Risk Medical Factors
B1. Heart Disease
B2. Chronic Orthopedic Disorders
B3. Neuromotor disorders including cerebral palsy and brachial palsy
B4. Cleft lip and palate and other congenital defects of the head, face
B5. Genetic disorders, e.g. cystic fibrosis, neurofibromatosis
B6. Multiple minor anomalies
B7. Metabolic disorders, e.g. PKU
B8. Spina Bifida
B9. Hydrocephalus or persistent ventriculomegaly
B10. Microcephaly and other congenital or acquired defects of the CNS
B12. Organic speech disorders, e.g. dysarthia/dyspraxia
B13. Hearing Loss
B23. Traumatic Brain Injury
B24. Fetal Alcohol Spectrum Disorder
B25. Autism, autism spectrum disorder, e.g. PDD,Asperger’s
B26. Behavioral or mental health disorder with developmental delay
B28. Chromosomal disorders, e.g. Down syndrome
B29. Positive Newborn Blood Screen
B30. HIV, seropositive conversion
B31. Visual Impairment
B16. Intraventricular hemorrhage (grade III or IV) or periventricular
leukomalacia (PVL) Or chronic subdurals
B17. Perinatal asphyxia accompanied by seizures
B18. Seizure disorder
B19. Oral-motor dysfunction requiring specialized feeding
program e.g. Failure to Grow, Organic-Non-organic (medical
diagnosis), gastrostomy, nasogastric
B20. Chronic lung disorder, e.g. tracheostomies, ventilator
B21. Suspect neuromuscular disorder, e.g. abnormal Neuromotor
exam at NICU Discharge
Developmental Risk Factors
B22. Developmental Delay
Other
B90. Other chronic conditions not listed
B Codes in ORCHIDS and charting
• Our state data system is only as good as the
information entered
• There can be multiple B codes with A codes
• In BabiesFirst! there cannot be B codes.
• In CaCoon there can be both A and B
The more codes entered, the more we know about
the clients in CaCoon
CaCoon Minimum Standards of
Program Performance
It is the responsibility of each nurse providing CaCoon services,
to ensure that program standards are met for each family served.
1. The local health department will assure initial contact with CaCoon referrals within 10
business days of receiving. Initial contact may be by telephone or other means.
2.
If need the local health department establishes and maintains a triage system that
acknowledges the most vulnerable children with special health needs. Priority is given to
families with:
a. A newborn with a disability
b. A newly diagnosed infant/child with a disability
c. Children with increased nutrition risk (e.g., children with congenital cardiac defects, cleft
lip and palate, or cystic fibrosis)
d. Families having difficulty accessing or coordinating their child’s care and services
3. The LHD CaCoon program meets a minimum number of visits per year.
Each LHD will be given the target number of annual visits that are expected.
CaCoon Minimum Standards of Program
Performance, continued
4. Families considered part of the CaCoon Nurse’s active caseload receive home
visits on a frequency related to assessed need, no less than one face to face
contact every three months. PHN visiting will correspond to the needs of the
client and family assessed and assumes a mixed population of tier.
5. All CaCoon Nurses performs or assures that children and their families receive
the following minimum assessments (See Assessment Tools in Chapter 6):
a. Family assessment.
b. Developmental assessment (use of a developmental screen for this
population would be selective and for the purpose of monitoring,
teaching or documenting progress).
c. Child health assessment to include monitoring of vision and hearing
(includes follow-up of hearing results from the newborn screening
including hearing and vision screening).
d. Nutrition assessment – using CYSHN screening tool or equivalent.
e. Tier level assessment
f. Safety assessment appropriate for CSHN
CaCoon Minimum Standards of Program
Performance, continued
6 The client data record reflects evidence of care coordination, cultural
competency and family partnership, and use of Tier Level data to develop a
plan of care which is periodically reevaluated with the family and changed
according to objective criteria or demonstrated and documented need.
7 PHNs serving CaCoon clients assure linkage to essential support and care
services such as F2F, CCO ICM, PCP/Specialty Care, SSI, DD, MH
8. Encounter data is entered into the ORCHIDS database.
9
The LHD supervisor assures that CaCoon is represented at the county
Local Interagency Coordinating Council (LICC) or planning group that
assumes the mandate of LICC.
CaCoon Minimum Standards of Program
Performance, continued
10 A CaCoon Nurse Coordinator is designated by the Nursing Supervisor (refer to
CaCoon Subaward Contract Attachment C-1 for role expectations).
11 Counties will report child find activities which ensure families and community
organizations are aware of services available through the local CaCoon program.
Counties not meeting one or more standards will write a plan of correction which
they and OCCYSHN will monitor. Inability to reach and/or maintain standards may,
at OCCYSHN’s discretion, result in loss of annual subaward contract renewal.
Filed at your local health department, refer to you manual
CaCoon Practice
in action
•
•
•
•
You will manage your own practice
You will have your own clients
You will manage your own charts
You will assure your own capability to
appropriately work with CaCoon clients and their
families
• You must ask for what you need to succeed
Case Finding: Referral
Common Referral Sources
• WIC
• Primary care provider
• Hospital- could be NICU, well baby, other inpatient
• Other LHD Clinics- immunization
• Early intervention
• EHDI
Common Referral Problems:
•
Not contacting the family within 10 days of referral
•
Not identifying the vulnerability of the client
•
Not staying in touch with the referral source
Pre-visit planning
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Review referral
Secure complete contact information
Determine if child has a specific and/or new diagnosis
Determine what services the child is already receiving
Determine urgency of referral
Clarify priorities
• Seek supervisory support!
Pre-visit planning, cont.
• Ensure you understand the child’s diagnosis
• Find information about conditions
– You do not need to know everything
– You do need to know where to find the information
– Anyone can do a simple web search-do a professional search!
• Contact the family within 10 days, sooner if possible
Engaging Families
telephone contact
• The initial contact is critical to the establishment of a
trusting relationship
• Explain who you are, what you do and your professional
boundaries
• Explain the reason for the referral
• Explain services and offer home visit
• Ask if families have immediate concerns or other
questions
Are you concerned about anything today or recently?
How is feeding working out? Follow the lead given.
Engaging Families
Parent goal is to minimize their perceived
vulnerability (Jack et al, 2005)
• Overcoming fear
• Building trust - mutual trust grows over time
• Seeking mutuality - shared power, dropping the ‘expert’
nurse role
• Affirming intrinsic abilities
• Partnership in achieving goals
Jack, Susan M, DiCenso, Alba & Lohfeld, Lynne. “A Theory of Maternal Engagement with Public Health
Nurses and Family Visitors.” Journal of Advanced Nursing 49.2 (2005): 182–190. Journal of Advanced Nursing
Web. 11 January 2013 Accessed http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2004.03278.x/full
The First Visit
in the home
• Use an interpreter if needed!
• Welcome other people the parent may have invited
• Engage the parent as a partner in helping their child
– You are working with the parent, not delivering a
– service to the parent
• Explain what will happen during this and subsequent
visits
• Affirm the positive you see, search for it diligently!
Used with permission. ©The Honor Society of
Nursing, Sigma Theta Tau International
Getting to know CaCoon
•
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•
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The CaCoon Manual
CaCoon Library in LHD
Online resources
People in your community
Providers at tertiary centers
Your CaCoon Nurse Consultants
Your MCH Nurse Consultants
TIME!
We are all in the process of learning
• Know and accept where you as a learner
• Ask for what you need to be more effective
• Vulnerable clients can be harmed through inappropriate ‘helping’,
CaCoon’s goal is empowerment
• Nurses can impede their professional growth and skill by not
protecting professional boundaries.
• Nurse practice law demands patient/client protection.
• It is YOUR responsibility as the professional home visitor to take the
lead in ‘doing no harm’
Questions?
• Next time topics:
• Care plan development
• Documentation
• Resources
• Other needs?.............................
Questions?
Next webinar
October 22nd, 9-11am
Send questions, topics of
interests for the 22nd
Be watching for the survey monkey
CaCoon support to local health departments
• State CaCoon Nurse Consultants for the 36 counties
who:
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monitor program services
evaluate data for 36 counties
provide program orientation
provide ongoing support
train PHN’s
work closely with the OHA/Center for Prevention & Health
Promotion
We share a workforce with OHA
OCCYSHN Staff
OCCYSHN Director
Marilyn Hartzell M.Ed.
CaCoon Nurse Consultant
Candace Artemenko RN,BSN
artemenk@ohsu.edu / 541-673-3842
Administrative Assistant
Matthew Gonzalez, BA
gonza@ohsu.edu/ 503-4942902