Kern County Medically Vulnerable Care Coordination Project: June 2010

Wednesday, June 30, 2010

3 Month Pilot Begins

With the support of our local funding partners, we launched our pilot on June 1st. During the three month pilot period (June, July and August): A core group of partners representing Kern County Public Health Nursing, Kern Regional Center, California Children’s Services, MVIP, Kern County SELPA, KCSOS, BCSD, and Caring Corner are holding weekly MVI case review meetings every Thursday at 9 a.m. The Case Review Committee hears presentations from hospital NICU nursing/discharge staff (5 - 10 minutes each) of NICU cases that nursing staff believe require additional discussion and support besides normal case management.

The full MVI Workgroup continues to meet on the FIRST Thursday of every month at First 5 Kern so we can:

1. Fine tune the MVI case selection and review process
2. Streamline reporting procedures throughout the pilot period and beyond
3. Continue to discuss MVI needs
4. Meet existing and new partners and share news
5. Hear informational presentations.

Project Outcomes

1. Identify and treat more medical and developmental conditions earlier to make a measurable difference.
2. Support local services that already exist to achieve greater effectiveness.
3. Streamline access to, and maintenance of, health insurance.
4. Save money on at-risk infants and children and better serve all children.
5. Focus on individual cases to develop best practices of care coordination.
6. Build strong, long-term provider partnerships to sustain a system of care coordination that is practical, affordable, and responsive to changing conditions.
7. Use research and longitudinal data to document results.
8. Help other locales replicate the Kern County model.

Care Coordination Process Defined

The MVCCP uses a triage model to coordinate services among health, education and social service partners based on each child’s medical prognosis, developmental track, support system, and other needs, as determined by case reviews and regular assessments.

To that end, we implement the following ongoing activities:
1. Convene bi-weekly meetings.
2. Focus on the health literacy of MV families and providers to make appropriate health decisions.
3. Implement a one page acuity form to expedite and receive referrals.
4. Provide training to pediatric providers in using simple screening and referral tools to identify conditions and access local resources.
5. Focus on a child’s appointment history to ensure consistent follow-up.
6. Help alleviate service backlogs that can negatively impact the timely provision of key services.
7. Maintain a record of MV cases and highlight the importance of regular screenings to identify and treat medical and developmental issues.
8. Monitor follow-up activities between families and providers based on identified and anticipated needs.

Participating Organizations

The MVI Workgroup is comprised of leaders from:

- First 5 Kern
- Hospitals: Kern Medical Center; Mercy Hospitals of Bakersfield; San Joaquin Community Hospital; Children’s Hospital Central California; Mattel Children's Hospital UCLA
- Insurers: California Children’s Services; Health Net; Kaiser Permanente; Kern Health Systems
- Kern County Departments: Human Services (Child Protective Services and Foster Care); Mental Health; Public Health Services (Black Infant Health (BIH), ER, Foster Care, Maternal, Child, and Adolescent Health (MCAH), Public Health Nursing)
- Kern Regional Center
- School Districts: Bakersfield City School District; Kern County Superintendent of Schools (44 Districts represented)
- Clinics: Clinica Sierra Vista; National Health Services; Sagebrush Pediatric/Family Practice
- Family Resource Centers throughout Kern County
- Local agencies and Institutions: Cal State Bakersfield; Caring Corner; Clinica Sierra Vista; Community Action Partnership Kern County; Garden Pathways; Head Start; Henrietta Weill Memorial Child Guidance Clinic; H.E.A.R.T.S. Connection; Hoffman Hospice; March of Dimes; Mended Little Hearts; MVIP; National Children’s Study – Kern County; 2-1-1 Kern; WIC.

First 5 Kern acts both as a funder and fiduciary for the organization, hosting meetings, and reporting on the results of all grants.

All local organizations are invited to participate, including parent support organizations, medical and dental providers, child care representatives, local community based and faith based organizations, and other agencies, as part of this county-wide effort.

Kern County Medically Vulnerable Care Coordination Project

Wednesday, June 30, 2010

3 Month Pilot Begins

MVCCP

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Project Outcomes

Care Coordination Process Defined

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