Kern County Medically Vulnerable Care Coordination Project: 2013

Wednesday, June 19, 2013

MVCCP Staff and Partner Transitions

MVCCP’s first Care Coordinator, Gail Davidson, has retired!
In the last 27 months, she managed over 500 referrals to the project.

Gail was an RN for 34 years, (a nursing professor for 10 years); starting her career in the NICU and finished it helping to change the system of care in Kern County! Thank you for your service, Gail!

Another experienced PHN, Arthur Manalac, RN, has assumed the duties of the Care Coordinator.

Also, our county Director of Public Health Nursing, Lucinda Wasson, is retiring at the end of June, after 35 years. A strong partner and advocate for care coordination, Cindy will be missed!

Transitions like this must be as seamless as possible to sustain our progress! We thank the Kern County Public Health Services Department, for its ongoing commitment to hire wonderful staff to support MVCCP's Care Coordination for Children with Special Health Care Needs.

Gail Davidson and a few of her friends!

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 19, 2013

MVCCP Staff and Partner Transitions

MVCCP

To Make A Referral

About Us

Project Outcomes

Care Coordination Process Defined

Project Support

Participating Organizations

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