Kern County Medically Vulnerable Care Coordination Project

Monday, September 3, 2012

UPDATED DECEMBER 10, 2012

Our November 1, 2012 Fall Conference was a great success! Our topic was:

The Impact of Premature Birth:
Lessons Learned Serving Premature Infants

and their Families

We had 165 participants, including: Physicians; 90 RNs; Social workers; Insurers; Case managers; Foster parents; Therapists; Clinicians; Parent educators; Child care providers; and many other community organization representatives.

Conference Outcomes: Focus on Premature Birth:

o Learned the biological and health dimensions of prematurity

o Met diverse local and regional partners

o Shared practical strategies and tools

o Defined common issues and solutions

o Helped to enhance the system of health care and support services in the region

The Day’s Panel Presentations:

Introduction: The Impact of Premature Birth in Kern County

· Marc R. Thibault, MA, MVCCP Project Director

· Gail Davidson, RN, MVCCP Care Coordinator

Infant-Family Mental Health Panel

· Isabell B. Purdy, PhD, NNP, CPNP, Assistant Clinical Professor of Pediatrics, Neonatology & Developmental Biology, David Geffen School of Medicine and UCLA Medical Center

· Mary Alice Melwak, PhD, CPNP, CNS, CCRN, UCLA Medical Center, NICU High Risk Infant Follow-up Clinic

Panel on Substance Exposed Infants and Children

· Lily Alvarez, Behavioral Health Administrator, Kern Co Mental Health Department

· Ranjit Padhy, M.D., UCLA Assistant Clinical Professor, Child & Adolescent & Adult Outpatient Services

· Michelle Curioso, PHN, KC MCAH Coordinator

· Felicia Skaggs M.S. MFTI, Supervising MH Clinician Kern County Gate Team/West Kern/SART

Specialty Care Panel

· Tony Pallitto, MSA-HCM, Administrator, California Children's Services, Kern County (CCS)

· Shellby Dumlao, Supervising PHN III, CCS

· Loalea Underwood, PHN II, Case Manager, CCS

· Robert Flores, Fiscal Support Technician, CCS

· Gary Frazier, Vice President of Business Development, Bakersfield Memorial Hospital

Panel on Substance Exposed Infants and Children

Specialty Care Panel

Infant-Family Mental Health Panel

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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, September 3, 2012

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