Ideas on how to improve care coordination in California came flying fast when 18 members of the California Community Care Coordination Collaborative (5Cs) met January 9 to report on progress in their regions (shown in orange on the map at left). One speaker offered innovative suggestions on how to pay for care coordination. Another discussed how to create easy-to-use single topic resource lists for parents and providers, while a third described a project to develop an assessment and referral protocol for use by all care coordinators across a county health system.
The Collaborative, which is funded by the Lucile Packard Foundation for Children’s Health, operates in nine counties across the state. Members of the seven regional coalitions meet together as a learning collaborative to promote more effective coordination of services in their locales, and to reduce barriers that prevent the health care system from functioning well for children and families. Participants work toward solutions and resources that will be shared with stakeholders throughout the state. Here are highlights of each coalition's current projects:
- Responding to its community’s needs, the Contra Costa County coalition developed a job description for a care coordinator and is identifying funding for the position.
- The Care Coordination Team in Fresno County is working with five families and an academic research center to pilot test a chronic care telephone app that will allow families of CSHCN to maintain up-to-date medical information, appointments, specialty care, discharge summaries, contact information, and pharmacy information in one central location.
- Kern County is using public health nurses to provide Targeted Case Management (TCM) for 20 families that have high-levels of need.
- Just a few months into its care coordination work, Monterey County is developing goals and objectives for its coalition and still expanding its membership.
- In Orange County, pilot testing is under way at four sites to refine a Risk Assessment Tool that providers can use to determine family and child risks that may influence their need for care coordination.
- San Mateo’s county coalition has spearheaded efforts to merge two county-wide groups interested in systems change for CSHCN, and will begin promoting care coordination policy recommendations members have developed.
- The coalition in Shasta, Siskiyou and Trinity counties is developing tip sheets for families to address issues that are frequently encountered when navigating the new Medi-Cal managed care health plan in their region.
Each county coalition is at a different phase in its work and has unique local circumstances to address, but several issues that need to be addressed at the health care system level are becoming clear. These system level issues include:
- Potential changes in the California Children’s Services (CCS) program in 2016
- Delays in obtaining care
- Mental health issues among CSHCN
- Use of consent forms to allow communication across agencies
- Gap in services at age 3 when children transition from Early Start
- Funding for High Risk Infant Follow-Up Programs
- Transitions in care and services at age 18 and 21
Effectively addressing most of these system level issues will require leadership by state and county officials and continuing interest by advocates for children such as those participating in the California Community Care Coordination Collaborative.
For more information about the 5Cs, email Holly Henry, PhD, at firstname.lastname@example.org