Kern County Medically Vulnerable Care Coordination Project: Learning and Working Together for A Better Future

Monday, December 5, 2011

Learning and Working Together for A Better Future - November 2, 2011

On November 2, 2011, the Kern County Medically Vulnerable (MV) Care Coordination Project brought together 120+ community health professionals from Kern and the Central Valley for a one-day conference at Kern Regional Center.

Purpose of the Conference:

o Focus on Health Literacy – What is it? Why is it the key to better health care?
o Share practical strategies and tools
o Meet diverse local and regional partners
o Define common issues and solutions
o Jointly plan future approaches to enhance the system of health care and support services in Kern County

Panel Presentations:

1. Establishing and Maintaining a Medical Home for MV Children
- Madhu Bhogal, MD, Medical Director, NICU/Pediatrics, Bakersfield Memorial Hospital
- Sudhir Patel, MD, Neonatologist, Kern Medical Center
- Corazon Yuzon, MD, Pediatrician, Clinica Sierra Vista

2. How to Reach “Hard to Reach” Families of MV Children
- Carmen Burgos, Project Manager, Health Consumer Center, Greater Bakersfield Legal Assistance, Inc.
- Julie DePetro, RN, Supervisor, Medically Vulnerable Infant Program, Clinica Sierra Vista
- Jean Roberts, PHN, Kern County Public Health Services
- Hope Youngblood, MSW, Social Worker, Mercy Southwest Hospital

3. Assessing and Treating Pre-K Children with Developmental and Behavioral Challenges
- Tonya Crowder, Marriage and Family Therapist, Henrietta Weill Child Guidance Clinic
- Isabell B. Purdy, PhD, NNP, CPNP, Assistant Clinical Professor of Pediatrics, Neonatology & Developmental Biology, David Geffen School of Medicine and UCLA Medical Center
- Troy Tickle, SELPA Coordinator, Kern County Superintendent of Schools

4. Health Literacy of MV Families and Providers – Resources and Tools to Navigate the System
- Gail Davidson, APRN, BC, MSN, PHN, MVCCP Care Coordinator
- Monique Moreland, RN, PHNII, Foster Care Public Health Nurse
- Diane Nicholls, RNC, MSN, NNP-BC, HRIF Coordinator, KMC
- Javier Parra, Health Education Instructor, Bakersfield Adult School

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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

Monday, December 5, 2011

Learning and Working Together for A Better Future - November 2, 2011

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