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!

Lucile Packard Foundation for Children’s Health funds MVCCP Replication

On November 16, 2012, the Lucile Packard Foundation for Children’s Health, Palo Alto, California announced ^* a two year grant to the Kern County Medically Vulnerable Care Coordination Project (MVCCP) to:

• provide free technical assistance in three California counties
• to assist these counties in replicating the MVCCP care coordination model and toolkit
• to implement a local care coordination project for children 0 – 5 years of age with special health care needs in their county..

For more information, please contact:

Marc Thibault, MVCCP Project Director, at (949) 842-5671 or email marc.thibault.llc@gmail.com.

* http://www.lpfch.org/newsroom/releases/grants_11_16_12.html

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



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

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.

Results of April 29, 2010 Planning Day

The Kern County Medically Vulnerable Infant Workgroup held a day-long planning session on Thursday, April 29 from 8:45 a.m. to 3 p.m. at the Kern County Department of Public Health Services.

Our objectives for the day were to:

1. Define the role of a county-wide care coordinator for Medically Vulnerable Infants (MVI) and their families.
2. Identify a case definition for a Medically Vulnerable Infant.
3. Identify the number of potential cases to be coordinated annually.
4. Define the logistics of coordination – what MOUs, referral and tracking protocols will be needed.
5. Identify what and how case information will need to be tracked.

Results: We had 50 attendees who participated in a sometimes challenging but very productive day because:

1. We were able to have so many new people from key organizations join the conversation and help further establish the care coordination of MVI as a priority in Kern County;

2. We were able to summarize the research conducted to date;

3. We saved an estimated additional year’s worth of monthly meetings to bring a broader group of providers up to speed regarding the need, benefits and strategies for care coordination;

4. We learned from Kirt Emery, Kern County epidemiologist, how to track Kern County MVI births and where some of the greatest need exists in the county for parental support services;

5. We broke into small groups and learned the various perspectives of MVI needs and categories coming from our three major groups of participants:

a. Medical providers (including NICU staff)
b. Developmental/educational providers
c. Community service providers

Next steps are to quickly move forward with what was learned to implement the 90 day pilot beginning in June. To learn more or to participate in any future meetings, please contact Marc Thibault at marc.thibault.llc@gmail.com or call (949) 842-5671.

Background:

Medically vulnerable infants are a growing group of at-risk children, the majority of whom are born prematurely (< 37 weeks gestation period). Preterm infants in 2006 made up 10.7% of California’s birth population* and, according to the Institute of Medicine, in 2005 cost on average $51,600 per preterm infant at birth**. Follow up costs for undetected and untreated medically vulnerable children can run into the hundreds of thousands of dollars annually in lifelong costs. The MVI Workgroup believes medically vulnerable infants in Kern County will continue to present a long term medical priority if not addressed with a timely, coordinated response that addresses the challenging and diverse medical and social service needs they require to mitigate early challenges and measurably improve birth and life outcomes.

Emphasis on primary prevention to address underlying causes of MVI health problems. Although many MVI children (estimated at 100+ annually in Kern County) receive intensive services for many years after birth, the majority of these infants’ (estimated between 200 – 300+ annually) develop conditions that may not appear until 6 months – 2 years after birth or later, long after they have left a Kern County NICU and the support of care managers. However, well established research has shown that certain medical conditions resulting from a shorter gestation period and/or low birth weight are strong medical indicators of future problems and potentially debilitating conditions. Unnecessary delays in need identification and a lack of a coordinated response very often lead to poorer life outcomes that require even greater costs to child and family well-being, and to the county’s healthcare, social service, education, and, too often, criminal justice systems.

Contribute to seamless continuum of care. A Kern County MVI coordination initiative would use a well-defined triage model supported by existing research 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 regular assessments. It is anticipated that a county coordination initiative would mobilize all elements of the community to serve MVI and their families. Sample outcome indicators that are anticipated to be used to track progress for MVI program participants: Better, more timely diagnoses; Health insurance; Regular assessments; Medical home; Access to specialized services; Follow up services; Advocacy activities.

Build community capacity. The MVI Workgroup is dedicated to reaching out and involving all MVI stakeholders. Since its inception in 2008, the workgroup has been composed of representatives from key organizations that have responsibility for assisting and treating Kern County’s medically vulnerable infants, children and their families. Based on the planning period results, potential roles for a county-wide MVI coordinator could include, among other duties: Advocate/Ombudsperson for MVI and their families; Referral committee coordinator, using a triage selection process based on medical, social, behavioral treatment plans; Monitoring follow up activities between families and providers based on identified needs; Alleviate backlogs that negatively impact the timely provision of services; Identification and maintenance of an online resource bank and training curriculum for families, community organizations and providers to understand the benefits of a coordinated county-wide response and prepare them to respond to the needs of MVI and their families.

Emphasize collaborative governance. As part of the planning process, the members of the workgroup will develop a governance plan that will reflect the collaborative nature of the initiative, provide accountability and transparency to its work, and result in an inclusive decision making process to achieve optimum results for children, families and the county of Kern.