California Community Care Coordination Collaborative II - Kickoff Webinar January 2015

1. California Community Care
Coordination Collaborative II
Kick-off Webinar
January 6, 2015

2. • Welcome
– Holly Henry, PhD, Manager of Program Research
• Project Overviews
– Contra Costa California Community Care Coordination Collaborative (7 Cs)
– Orange County Care Coordination Collaborative for Kids (OCC3 for Kids)
– San Mateo County Care Coordination Learning Community
– Alameda County CCS/Behavioral Health Services Integrated Care
Coordination Project
– San Joaquin County 5Cs Project
– Ventura County (VC-Pact)
• Discussion and Details for In-Person Meeting
AGENDA

3. Contra Costa California Community Care
Coordination Collaborative (7 Cs)
Barbara Sheehy, MS
Administrator
California Children's Services Contra Costa County

4. Contra Costa County
Contra Costa California
Community Care Coordination Collaborative

5. Key Coalition Members
 California Children’s Services
 Kaiser Permanente
 Regional Center of the East Bay
 Care Parent Network
 First 5 Contra Costa
 Special Education Local Plan Areas
 Early Start/Head Start
 Contra Costa Regional Medical
Center
 Contra Costa Mental Health
 We Care Services for Children
 Contra Costa Health Plan
 Contra Costa Public Health Nursing
 John Muir Health
 Early Childhood Mental Health
 Center for Early Intervention on
Deafness
 Contra Costa Child Care Council

6. Project Goals
 Initial Project
 Each month key county agencies discussed challenges to
providing care coordination for children with special health
care needs and suggestions for improvement.
 Drafted a consent form that agencies use to refer cases to
our re-launched Roundtable meetings.
 Developed job description for a Children’s Service System
Coordinator.
 Secured funding from the Kaiser Community Foundation to
fund our Children’s Service System Coordinator.

7. Project Goals Continued
 Current Grant Period
 Fully implement care coordination system including a data
collection and evaluation plan.
 Develop and implement a Leadership Team to share
responsibilities across coalition partners.
 Develop and implement a family experience component to
keep the family at the center of care coordination efforts.
 Share the 7 Cs project experience and mentor a new 5Cs
project.

8. Main Project Activities
 Enhance Roundtable meetings by providing a leadership
presence at each meeting; continue to identify and recruit
meeting participants; begin to collect data at each meeting;
and identify systems issues to pass on to 7 Cs and possibly
Early Childhood Leadership Alliance.
 Develop a family experience model, including recruiting and
training family participants, and schedule and implement
family experience meetings with 7 Cs partners.
 Integrate our new Children’s Service System Coordinator into
our Roundtable and 7 Cs meetings. Work to secure continued
funding for that position.

9. Major Challenges Anticipated
 Securing additional funds for our Children’s Service
System Coordinator position beyond December 2015.
 Continue to recruit agencies to participate at our
Roundtable meetings, and to have participants refer
complex cases to discuss.
 Assure the referral chain for identifying and seeking to
resolve systems issues works as planned.

10. Orange County Care Coordination Collaborative for Kids
(OCC3 for Kids)
Rebecca Hernandez, MSEd
Program Manager
Help Me Grow Orange County

11. Key Collaborative Participants:
• American Academy of Pediatrics, California Chapter IV
• California Children’s Services
• CalOptima
• Center for Autism and Neurodevelopmental Disorders
• Children and Families Commission of Orange County, including representatives of
Bridges Maternal Child Health Network and School Readiness Nurses
• CHOC Children’s Hospital
• CHOC Children’s Foundation
• Comfort Connection Family Resource Center
• Early Development Assessment Center
• Family Support Network
• Help Me Grow Orange County
• OC Department of Education, Center for Healthy Kids and Schools
• OC Health Care Agency, Children and Youth, Behavioral Health Services
• OC Health Care Agency, Public Health Nursing
• OC Social Services Agency, Children and Family Services Division
• Regional Center of Orange County
Orange County Care Coordination
Collaborative for Kids (OCC3 for Kids)

12. OCC3 For Kids Phase II Goals
Phase I Overarching Goal:
To improve overall care for children and families with special health care
needs by creating a collaborative care coordination system in Orange
County.
Phase II Goals:
1. Strengthen communication and collaboration among agencies providing
services to CSHCN
2. Implement system-level care coordination in Orange County for CSHCN
3. Ensure the OCC3 collaborative and system-wide care coordination
continue beyond the LPFCH grant funds

13. Phase II Activities
• Continue to work on systems issues through the OCC3 for Kids monthly
gatherings
• Develop a mechanism to improve inter-agency coordination for specific
cases where CSHCN need a higher level of care coordination
• Publicize the CSHCN screening and referral protocol
• Continue to create a culture and common language of collaboration and
coordination
• Maximize staff time and resources by focusing on the efficiencies of care
coordination in the face of complex health and social services for CSHCN
and their families
• Create a sustainable care coordination entity in Orange County

14. 14
Anticipated OCC3 for Kids Challenges
As we move into Phase II, several potential
challenges were identified that include:
• Continuing to secure participation by insurance
plans including CalOptima
• Barriers during the rollout of the screening tool
• Ensuring adequate % of FTE for our
countywide Care Coordinator as awareness
and demand increase
Thank you
Rebecca Hernandez, MSEd
Project Director, OCC3 For Kids
Rhernan2@uci.edu

15. San Mateo County Care Coordination Learning Community
Cheryl Oku
Program Manager
Watch Me Grow Demonstration Site
Community Gatepath

16. San Mateo Learning Collaborative
January 6, 2015
LPFCH 5Cs II Webinar

17. Key Coalition Members
• California Children’s Services
• Community Gatepath
• Family Resource Center
• First 5 San Mateo County
• Golden Gate Regional Center
• San Mateo Co. Office of Education
• San Mateo Medical System
• Stanford Children’s Health and LPCH
• Includes 28 participating agencies and families

18. Project Goals
• Strengthen the existing system of care coordination through a
collaborative learning community
• Increase access to coordinated, effective, family-centered services in
the medical home
• Develop a model of care coordination in the medical home that is
replicable and sustainable
• Increase communication between medical providers and community-
based services
• Increase access to information and resources for families and
providers who coordinate care for CSHCN

19. Project Activities
– Systems Change Group
• Cross training and information sharing
• Workgroups: care coordination tool and exploration of
central telephone access
– Community Care Coordination in Pediatric Clinics
– Medical Provider Group focused on children with
complex health care needs

20. Major Challenges Anticipated
• Sustaining the group momentum and focus
on care coordination as a strategy for
improving the system of care
• Sustainability for clinic care coordination
• Family participation
• Medical provider engagement

21. Alameda County CCS/Behavioral Health Services Integrated
Care Coordination Project
Katie Schlageter, MS-HCA
Administrator, California Children’s Services
Deputy Division Director, Family Health Services
Alameda County Public Health Department
Presented by:
Francine Crockett

22. Contact:
Francine Crockett
Francine.Crockett@acgov.org

23. PROJECT GOALS
• Organize a multi-disciplinary coalition of key stakeholders to
coordinate service systems for California Children’s Services (CCS)
children with both medically complex conditions and behavioral
health care needs.
• Improve access for CCS-enrolled children to behavioral health
services through development and use of referral protocols, pathways
and forms by key service system stakeholders, particularly CCS and
Behavioral Health (BH).
• Enhance care coordination among key service providers to ensure
that CCS patients are receiving the right care at the right time and at
the right place.
• Improve participation and training of behavioral health
providers in serving CCS children through implementation of clear
protocols to enhance billing and reimbursement for behavioral health
services through CCS.

24. MAIN ACTIVITIES
 Hire a consultant to act as Project Coordinator and convene Coalition Steering
Committee (SC) & facilitate, coordinate support project activities.
 Organize and conduct monthly SC meetings which include cross-agency
presentations to educate one another about memberships’ respective programs.
 Identify barriers and strengths regarding current referral system and pathways;
identify additional types of BH services needed; and compile cross-institutional
knowledge of organizations and capacity of behavioral health providers to work
with children and youth with complex medical conditions.
 Develop report and present findings of strength and gap analysis.
 Develop multi-system referral pathways to the appropriate community
behavioral health service for each CCS client for whom a need is identified.
 Pilot new referral system and determine satisfaction with materials.
 Assess billing gaps, gather data on types of services provided and amount
billed/paid and train providers on billing/claims processes for undocumented
clients.

25. ANTICIPATED CHALLENGES
 The short time frame in which to develop a cross-sector plan to
achieve broad system changes.
 Lack of providers with experience or training in treating the mental
health needs of children and youth with complex medical conditions.
 Very few culturally appropriate mental health providers.
 Lack of data on the unmet mental health needs of CCS clients.
 Lack of cross-institutional understanding of available behavioral
health resources and the appropriate pathways for accessing these
services.
 Lack of understanding among behavioral health providers regarding
what mental health services are covered by CCS and how payment can
be obtained.

26. COALITION MEMBERS
 Behavioral Health Care Services
 California Children’s Services
 Center for Healthy Schools and Communities
and School Based Health Clinics
 Developmental Disabilities Council
 Developmental Pediatricians
 Family Resource Network
 Juvenile Justice Center
 Medical Home Project
 Regional Center of the East Bay
 Special Education Local Plan Areas (SELPAs)
 Through the Looking Glass
 UCSF Benioff Children’s Hospital Oakland

27. San Joaquin County 5Cs Project
Ann Cirimele
Executive Director
Family Resource Network

28. 5Cs San Joaquin

29. 5Cs San Joaquin
• Key Coalition Members
– Family Resource Network (Project Director)
– First 5 (Fiscal Agent)
– Parents
– Valley Mountain Regional Center
– Medical Agencies
• CCS, hospitals, Health Plan of San Joaquin
– Special Education (3 SELPAs)
– Community-Based Organizations
• Child Abuse Prevention Council of San Joaquin
• Head Start
• Family Resource and Referral Center

30. 5Cs San Joaquin
• Project Goals
– Build a county-wide inter-agency network of
professionals who provide quality service to
families of children birth to age 5 with special
health care needs via an improved care
coordination system.

31. 5Cs San Joaquin
• Project Goals (continued)
– Expand formal and informal collaboratives into a
formal, documented network.
– Create a Memorandum of Understanding to be
used throughout the county so that all 5Cs
agencies can interact effectively with one another.

32. 5Cs San Joaquin
• Main Project Activities
– Health Navigator within each agency
• Offer local trainings on role of Health Navigator
– Monthly meetings and case sharings
– Deliverables
• Fact Sheet on local Transportation Services
• Fact Sheet on Payer of Last Resort
• Workbook on Agency Eligibility Criteria
• Trainings on these topics

33. 5Cs San Joaquin
• Major Challenges Anticipated
– Current financial/contractual limitations of local
agencies
– Agencies’ on-going commitment and ability to
follow through with the project
– Agencies’ ability to provide manpower to attend
meetings and participate in 5Cs activities and
deliverable development

34. Ventura County VC-Pact
Patty Chan, OTR, LMPA
Public Health Division Manager
CMS Administrator
County of Ventura, Public Health Department
Presented by: Myra Medina

35. VC-Pact
Key Coalition Members
 Ventura County Health Care Agency/Public Health
(CHDP, CCS, PH Home Visitation Program)
 County of Ventura – Human Services Agency:
Children and Family Services; Probation Agency;
Behavioral Health
 Gold Coast Health Care Plan
 Families of CSHCN
 Tri-Counties Regional Center
 Primary Care Professional Association
Representative
 Other: Strategies, Aspiranet, Rainbow Connection

36. VC-Pact
Project Goals
 Establish a sustainable, family-
centered, coordinated coalition with
existing resources and collaborative
relationships to improve Ventura
County’s local systems of care for
children with special health care needs.
 Develop a method of evaluation which
illustrates impact on the target
population.

37. VC-Pact
Main Project Activities
 Screening and Referral Process
(Documented)
 Memorandum of Understanding
between Coalition member
 Assessment Tool (identifying
eligible youth)
 Pre-Project MAPPs
 Post-Project MAPPs

38. VC-Pact
Major challenges anticipated
 Assuring family centered care is a
constant in the system
 Aligning goals of the participating
agencies
 Getting referrals to the coalition

39. Contra
Costa
Orange San
Mateo
Alameda San
Joaquin
Ventura
Securing
ongoing
funding for
CC activities
X X X X
Recruiting
and retaining
agencies
X X X X X X
Referral
chain
X X X
Family
engagement
X X X
SHARED CHALLENGES