2018 Report: NPM 11 Medical Home

National Performance Measure 11: Percent of children with special health care needs having a medical home.

 

Report on Strategies and Activities October 2017– Sept 2018

Strategy 11.1: Support regional care integration by implementing a regional, team-based approach to cross-systems care coordination based on modifying AHRQ’s (2011) medical neighborhood strategy.  

OCCYSHN continued to support the regional quality improvement (QI) efforts of three Regional Approach to Child Health (REACH) teams in Central, Eastern, and Southern Oregon. Teams implemented Plan Do Study Act (PDSA) cycles to improve systems of care for CYSHCN.

OCCYSHN continued to provide support specific to the needs of each team, and helped them align REACH with public health modernization and LPHA accreditation efforts. Staff conducted an environmental scan on modernization activities before half-day REACH workshops. The scan provided information on other QI activities happening across the state that might align with REACH work, and improved OCCYSHN’s technical assistance to the teams. OCCYSHN hosted group and team-specific conference calls monthly, and provided additional technical assistance as-needed. OCCYSHN monitored REACH teams’ progress toward goals, and reviewed their PDSA cycles.

In spring and summer 2018, OCCYSHN facilitated half-day project planning workshops for the Southern and Central Oregon teams at their local sites. During these sessions, REACH teams reviewed data sets for information about medical and social complexity, family-centered care, and culturally and linguistically appropriate services for CYSHCN in their areas. They identified barriers, gaps, and redundancies in local systems of care. These assessments informed their aims for the next year (see Plan Section 11.1).

After they achieved their goal of establishing a policy that allows siblings of CYSHCN to travel with a parent using Medicaid-assisted transportation to medical appointments, the Eastern Oregon team indicated they would not pursue REACH in the next contract year, due to lack of capacity. They plan to strengthen their shared care planning work by developing new partnerships and infrastructure.

 

ESM: Number of REACH teams that created a plan by which care information for targeted CYSHCN is shared between healthcare providers and educators.

ESM PROGRESS: One team (Southern Oregon) chose to focus on this issue in 2016-17. They worked on developing a HIPAA/FERPA-compliant release of information (ROI). No teams chose to work on ROIs in 2017-2018.

Strategy 11.2: Improve CYSHCN family members’ ability to better understand and actively participate in their child’s health care decision-making by educating them about Medical Home concepts, REACH, SPOCs, HCT, and CLAS.

During the project year, 8 Parent Partners in 4 regions staffed the ORF2FHIC phone lines (both English and Spanish) 5 days a week. They also conducted workshops for families, and helped develop materials for families. They participated in monthly trainings on community-based services and health care finance topics, along with partner staff from Providence Swindells Center. Sixteen family events served 214 families in 7 communities. Outreach included 3 online events and 2 conferences that drew statewide audiences.

OCCYSHN trained Parent Partners on using topic-specific “conversation starters” in their phone support with families. ORF2FHIC developed these prompts to ensure Parent Partners provide peer support that addresses core MCH performance measures. Workshops and trainings focused on three key topics – Health Care Advocacy, Planning for A Healthy Transition, and Resources and More. The Family Involvement Program (Family Involvement Program) updated content to reflect policy and program changes in the state. They also revised workshop materials based on feedback from program participants. ORF2FHIC developed a packet of handouts for workshop participants that includes a note sheet/problem tracker, a referral sheet for follow up, a list of vetted Oregon family support organizations, and a list resources mentioned in the presentation. Each training event included the following specific elements: short didactic, guided discussion, activity, demonstration of the ORF2FHIC website, and short introduction to the birth anomaly resource materials.

The Family Involvement Program held its annual Parent Partner training in Portland. Topics included updates to the Oregon Health Plan and other CYSHCN systems, newborn screening, and birth anomalies programs. An OCCYSHN staff member presented on health equity and racism. The training also covered data collection requirements, and the roles and responsibilities of Parent Partners. The meeting gave OCCYSHN staff a chance to meet Parent Partners.

The Family Involvement Program collaborated with other OCCYSHN staff in shared care planning (see Strategy 12.2) and Regional Approach to Child Health team (see Strategy 11.1) development. The Family Involvement Program Manager helped plan and implement OCCYSHN Regional Meetings, where she presented to LPHA partners about the family perspective on shared care planning. She wrote a family guide to shared care planning, and with Systems and Workforce Development staff co-produced a voice-over PowerPoint training for community teams. The ORF2FHIC conducted 4 listening sessions on the topic of shared care planning (see Strategy 11.1). During these discussions families shared their experience with and perception of shared care planning. They talk about how shared care planning might help or hinder them, and which professionals they might want to include in the process. Although most parents were comfortable with shared care planning, some expressed reservations. Family Involvement Program staff compiled families’ de-identified responses and shared them with OCCYSHN and public health staffs to inform program development.

 

 

Strategy 11.3: Improve payer and provider responsiveness to CYSHCN by providing or supporting workforce development opportunities focused on the CYSHCN population and their care needs.

Shared care planning (see Strategy 12.2) is essential to developing workforce responsiveness to CYSHCN needs. OCCYSHN implemented 4 workforce development activities, in addition to Strategy 12.2, detailed below. 

Provider Training from the Family Involvement Program

The Family Involvement Program Manager attended all OCCYSHN Regional Meetings to facilitate a 45-minute presentation and discussion focused on engaging families in shared care planning. Sessions included family perceptions of shared care planning, gleaned from statewide listening sessions (see Strategy 11.2). Sessions also included an exploration of parent-professional partnerships, and the vital role professionals play as family allies. OCCSYHN’s Family Involvement Program provided training and information to a variety of professional healthcare organizations, including LEND Training Cohort, OHSU Pediatric Cardiology, Institute on Development & Disability/Doernbecher Social Work Departments, Doernbecher Family Life Program, Emergency Medical Services for Children, and the Oregon Medicaid Advisory Committee. Family Involvement Program staff also provided feedback to OHSU Gabriel Park Family Practice about family engagement materials. Family Involvement Program staff wrote Parent Partner job description templates for community and health programs, including Salem Hospital and the Autism Identification Teams (see below). The Family Involvement Program Manager provided one-to-one technical assistance to health care providers in Coos Bay and Medford on employing peer navigators in their practices. New opportunities for partnerships arose throughout the program year, including ORF2FHIC specific outreach to social workers from 6 culturally-specific organizations in the Portland metro region.

CaCoon

OCCYSHN contracted with 33 LPHAs to implement public health nurse home visiting services in 34 of Oregon’s 36 counties. CaCoon served 1,358 CYSHCN in 7,889 visits; 89% of CYSHCN served were insured through Medicaid. Transition-aged youth ≥ 12 years made up 12% of CYSHCN served by CaCoon. Technical assistance to LPHAs to facilitate their county-level work remained a key function for OCCYSHN. CaCoon orientation for new public health nurses consists of a PowerPoint-based curriculum and assessment, and participation in a 30-60 minute three-way phone call with each nurse’s supervisor and OCCYSHN’s Care Coordination Specialist to discuss the new nurse’s knowledge of CYSHCN needs, and to plan for continuous improvement of their CaCoon practice. Through June 2018, two new nurses completed the CaCoon and shared care planning orientation. Our Care Coordination Specialist continued to connect LPHAs to OHA guidance on Targeted Case Management (TCM) billing. Additionally, OCCYSHN partnered with the OHA-MCH Nurse Team through monthly meetings that promote and support alignment across home visiting programs, which is important given overlap in the local public health nurse workforce.

Most LPHAs reported meeting most CaCoon standards in the first of their now-annual CaCoon Accountability Reports (2016-2017). When agencies reported challenges in meeting a given standard, they provided thoughtful feedback on opportunities for improvement. Challenges included: (1) time, bandwidth and experience barriers to integrating shared care planning into CaCoon practice, (2) lack of condition-specific educational opportunities, and (3) lack of experience with youth transition to adult health care. OCCSYHN conducted individual discussions with LPHAs to begin addressing each of these barriers, an effort which will continue into the next fiscal year.

Coffee Time Webinars

In partnership with OHSU’s Department of Pediatrics, OCCYSHN supported distance-learning opportunities for Oregon health care providers in the form of monthly “Coffee Time” webinars.  The webinars offered continuing medical education credits for physicians. OHSU Pediatrics staff provided administrative support to market and conduct the webinars. OCCYSHN’s Medical Consultant chaired the planning committee, which identified topics and speakers. In FY18, there were 9 Coffee Time webinars. Each lasted 35 minutes and included an instructional presentation followed by questions and answers. Topics included depression screening, iron deficiency, dental issues in CYSHCN, and adverse childhood events. Presenters used case reports to demonstrate key points, provide resources, and discuss issues impacting CYSHCN and their families. Attendance ranged from 23 to 48 professionals per webinar.

ACCESS

In 2013, HRSA awarded OCCYSHN a State Implementation Grant for Improving Services for Children and Youth with Autism Spectrum Disorder (ASD). OCCYSHN’s grant effort was called Assuring Comprehensive Care through Enhanced Service Systems for Children with Autism and Other Developmental Disabilities (ACCESS). The ACCESS project supported development of 8 community-based teams of educational and medical professionals who conducted comprehensive diagnostic evaluations for young children at risk for ASD. Teams included Parent Partners to provide peer support to families, and family perspective to professionals. ACCESS teams. The goal of ACCESS was to provide coordinated autism evaluation at the community level to improve early diagnosis, referral and entry to ASD services. ACCESS emphasized culturally appropriate, family centered care.

HRSA funding for ACCESS ended in December 2016. However, 6 teams continued their work with assistance from OCCYSHN staff and other OHSU faculty, in the absence of external funding. Given the teams’ efficacy in increasing access to care for children and their families, OCCYSHN provided FTE support for OHSU faculty to provide guidance and consultation to the remaining teams in 2018. OCCYSHN did a brief needs assessment survey of ACCESS teams. Staff identified (a) autism education, and (b) infrastructure for telehealth and telepractice as high priorities. OHSU’s Institute of Development and Disability (IDD) autism clinic director consulted with each ACCESS team. OCCYSHN provided grants to teams in Clatsop, Coos, and Jackson Counties to hire Parent Partners. OCCYSHN hosted two topical webinars and one 2-hour virtual workshop to provide the sustained teams with additional technical assistance. Finally, OCCYSHN began to build telehealth and telepractice infrastructure for the existing teams.

 

 

Strategy 11.4: Enhance local community infrastructure to implement child health teams by providing consultation and technical assistance to Community Connection Network teams to become self-sustaining.

Two of 9 Community Connection Network teams continued functioning as successful cross-sector communities of practice following the discontinuation of OCCYSHN funding: Coos Bay and Clatsop. Lessons learned from CCN teams provided a basis for OCCYSHN’s shared care planning strategy (see Strategy 12.2). As shared care planning developed, OCCYSHN explored ways to (a) build upon the work of sustained CCN teams, (b) support additional teams as they reestablish themselves, and (c) provide technical assistance on implementing “standing teams” for shared care planning (elaborated on in the FY2020 plan section of this report).

Strategy 11.5: Integrate state systems of services for CYSHCN and their families through cross sector collaboration, workforce and system infrastructure development.

With the conclusion of the HRSA D70 State Implementation Grant, Enhancing Systems of Services for CYSHCN, OCCYSHN’s efforts to integrate systems at the state level during FY18 focused primarily on continuing our collaboration with the 211 Information Center (211info). The grant provided an opportunity to formalize a partnership between OCCYSHN’s Family Involvement Program (Family Involvement Program), ORF2FHIC, and 211info. The goal of this partnership was to increase referrals to ORF2FHIC when it was likely that a caller was the parent or provider of a CYSHCN, and to ensure that 211info had appropriate information to share with CYSHCN-related callers.

211info administers a voluntary follow-up survey to callers, to collect data about whether referrals met caller’s needs. OCCYSHN and 211info collaborated on revising the survey questionnaire to measure the D70 grant’s Shared Resource aim. After the grant ended, OCCYSHN, ORF2FHIC, and 211info continued their partnership. OCCYSHN continued collecting survey data, and provided professional development to 211info staff. The ORF2FHIC Coordinator trained 211info staff on who might benefit from ORF2FHIC services and how to access those services. Additionally, the ORF2FHIC Coordinator collaborated with 211info on website modifications that improved linkages to ORF2FHIC. OCCYSHN’s Assessment and Evaluation team worked with 211info to revise the follow-up survey to capture additional information on the types of needs families had. The Assessment and Evaluation team established quarterly meetings with 211info’s Child Care Line Manager and Lead Data Analyst to review and discuss follow-up survey and referral data. Assessment and Evaluation staff also worked with 211info to collect these data from the Maternal and Child Health call line.

The D70 grant allowed OCCYSHN to establish a CYSHCN Advisory Board to (a) provide input into OCCYSHN’s D70 grant, and (b) serve as a networking and information-sharing venue about state level efforts affecting Oregon CYSHCN and their families (e.g. health care and early learning systems transformations). In FY18, OCCYSHN’s director solicited input from board members on the future function and structure of the group. OCCYSHN determined that going forward, the group would serve as a venue for (1) obtaining state-level partner input on Title V strategies, and (2) collaborating with state-level partners to realize Systems Standards for CYSHCN (AMCHP, 2014). OCCYSHN identified a core group of state-level partners with whom to initiate conversations about realizing this group’s second purpose. The group will be asked to consider domains of systems standards (AMCHP, 2014; AMCHP & NASHP, 2017) as they align with OCCYSHN’s block grant priorities: Medical Home, Access to Care, and Health Care Transition. The advisory group’s new name is the Collaborative to Align Systems for CYSHCN (CASC).

To build capacity to lead strategic statewide planning and advocacy for CYSHCN, OCCYSHN tracked policy to align program efforts, identify threats and opportunities, and prepare for anticipated changes. OCCYSHN staff participated on policy committees, and provided public comment and presentations to inform policymakers. OCCYSHN’s Director participated in Health Share’s (Portland-metro area CCO) regional collaborative focused on kindergarten readiness, and sat on the Oregon Council on Developmental Disabilities. OCCYSHN’s Family Involvement Program Manager served on the state Medicaid Advisory Committee and on OCDD’s Sustaining Families Committee. A Parent Partner participated on the State Interagency Coordinating Council (for Early Intervention and Early Childhood Special Education). OCCYSHN’s Systems and Workforce Development Manager served on the Early Hearing Detection and Intervention (EHDI) program advisory board.

OCCYSHN staff presented information on shared care planning to a Telepractice and Early Learning Hub Event hosted by the Clackamas County Education School District (ESD) in March 2018. OCCYSHN’s A&E Manager provided public comment to Oregon’s Health Plan Quality Metrics (HPQM) Committee to advocate for the inclusion of CYSHCN-specific metrics that align with Title V Block Grant priorities (Supporting Document 1). OCCYSHN continued to partner with the Oregon Pediatric Improvement Partnership (OPIP), whose director is a member of the HPQM Committee. OCCYSHN and OPIP staff successfully presented testimony to the HPQM to ensure that two key metrics tools, the Family Experience of Care Coordination (FECC; Mangione-Smith et al.) survey items and the Pediatric Integrated Care Survey (PICS; Antonelli et al.) were included on the menu of health plan metric options. In February 2018, OCCYSHN staff attended an intensive 3-day training hosted by a prominent Oregon health insurance organization, CareOregon. The event focused on Patient-Centered Primary Care Transformation using the Institute for Healthcare Improvement’s “Coaching for Improvement” model. In addition to gaining a better understanding of primary care engagement and quality improvement and the interaction among the building blocks of primary care. The training improved OCCYSHN’s ability to engage primary care in regional and local care integration efforts.

Strategy 11.6: Conduct ongoing assessment of Oregon’s CYSHCN by developing studies focused on subpopulations of CYSHCN.

Ongoing assessment of Oregon’s CYSHCN consisted of three primary activities, detailed below.

Children with Medical Complexity in Medical Home Practices

OCCYSHN’s Assessment and Evaluation (A&E) unit collaborated with Neal Wallace, PhD, a health economist with the OHSU-PSU School of Public Health. Dr. Wallace and colleagues completed an evaluation of Oregon’s Patient-Centered Primary Care Home (PCPCH) program in September, 2016. The study examined program implementation and outcomes achieved during the first four years of the program. Dr. Wallace led quantitative analyses to examine changes in service utilization and costs for patients cared for in primary care practices identified as PCPCHs compared to patients cared for in non-PCPCH primary care practices. The OCCYSHN A&E Manager (Alison Martin) collaborated with Dr. Wallace in replicating these analyses for Children with Medical Complexity using the Pediatric Medical Complexity Algorithm (Simon et al., 2014). Sara (Sally) Bachman, PhD, and Catalyst Center Principal Investigator at the time, consulted on the project.

Drs. Wallace and Martin worked together to develop the analytic plan. Dr. Wallace computed the analyses and prepared tables of results, which were discussed with Drs. Martin and Bachman. In January 2018, OCCYSHN hosted a meeting of key stakeholders to share preliminary results. Alison and Neal facilitated the meeting. Meeting participants included Sally Bachman, both the Title V and Title V CYSHCN Directors, several CYSHCN Advisory Group members (i.e., PCPCH program manager, Oregon Pediatric Improvement Partnership Director, OHA Health Policy Division Operations and Policy Analyst), and OCCYSHN’s Medical Consultant. Because meeting materials were preliminary, recipients of the results signed non-disclosure agreements. Sally recommended this approach to ensure that OCCYSHN retained control over their dissemination. Sally expressed excitement about this work. She noted that these are the types of questions that Title V CYSHCN agencies should be asking, and these are issues on which Title V CYSHCN should collaborate with State Medicaid.

CYSHCN with Behavioral/Mental Health Conditions

Olivia Lindly, PhD, Kate Lally, MSW/MPH, and OCCYSHN’s A&E Manager revised a manuscript summarizing the analyses using 2009-2010 NS-CSHCN data, and submitted it to the Maternal and Child Health Journal. The review process was disappointing. The journal took an excessive amount of time assigning a reviewer to the article. The authors did not receive feedback in FY2018.

NSCH Results

Assessment and Evaluation staff reviewed NSCH results and presented key information to OCCYSHN staff. The staff initiated planning to collect primary data from subgroups of CYSHCN and their families about which little is known (e.g., CYSHCN who are members of communities of color, CYSHCN who live in foster care, CYSHCN who experience medically complex conditions). Work began on implementing culturally responsive data collection for the 2020 needs assessment.

Strategy 11.7: Develop evidence that may show support for the benefit of care coordination for Oregon CYSHCN by designing a study to evaluate SPOC.

Assessment and Evaluation staff continued to collect and analyze formative evaluation data. Staff modified data collection instruments, disseminated results to LPHA partners, and submitted a presentation proposal about first year findings to a national conference. Assessment and Evaluation staff consulted with Jeannie McAllister, BSN, MS, MHA, about ongoing shared care planning evaluation efforts (see Strategy 12.2).

LPHAs completed a Shared care plan Information Form (SIF) following each shared care planning meeting. SIF data describe the date, the participants, the manner in which participants participated, the facilitator, the reasons for choosing this child for shared care planning, and descriptive information about the child and family. Assessment and Evaluation staff received OHSU Institutional Review Board approval to update the SIF used during year 2 data collection to include each child’s initials.  Combining initials with date of birth will enable OCCYSHN to track SIF data by child over time. In response to feedback from LPHAs, OCCYSHN updated the SIF race/ethnicity question to include more comprehensive race/ethnicity categories that better reflect the complexity of both. We modified the content and timing of annual open-ended survey of LPHA staff. Finally, we included in our IRB protocol the Record of Technical Assistance (TA) form developed in 2016-2017.The form allows Systems and Workforce Development staff to track their TA to LPHAs. Family Involvement Program and Systems and Workforce Developoment staff informed modifications to all data collection instruments.

Dr. Martin and Katharine Zuckerman, MD, MPH, submitted a grant proposal to fund an outcome evaluation pilot of OCCYSHN’s shared care planning work. The proposal scored well but was not awarded funds. Dr. Martin began discussions with OCCYSHN leadership about how we might begin to implement parts of the outcome evaluation design, first focusing on family outcomes. Our 2018-2019 block grant report and the current document’s (2019-2020) plan will expand on this outcome evaluation.

OCCYSHN submitted a proposal to CityMatCH to share year 1 evaluation findings specific to adolescent transition. The 2018-2019 block grant report will contain those findings. Assessment and Evaluation staff shared other results during monthly TA webinars with LPHA partners. SIF results follow in Exhibits 11.7.1 through 11.7.4.

• 109 shared care plans for Oregon CYSHCN in 2017-18.
• 88 SIFs were for children birth to 12 years.
• 58 were new shared care plans.
• 30 were re-evaluated shared care plans.
• 21 SIFs were for young adults 12 to ≤ 21 years.
• 10 were new shared care plans.
• 11 were re-evaluated shared care plans.
• 98 SIFs were for CYSHCN identified as complex; that is, ≥2 condition types (medical, behavioral, developmental, social, other).
• CaCoon PHNs most often identified the child or young adult for whom a shared care plan was created.

 

Exhibit 11.7.1 Demographic Characteristics of Oregon CYSHCN Who Received Shared Care Planning, Year 1 (2016-2017) and 2 (2017-2018)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exhibit 11.7.2. Most Frequently Reported Reasons for Creating a Shared Care Plan, Year 1 (2016-2017) and 2 (2017-2018)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exhibit 11.7.3. Types of Required Partners on the CYSHCN’s health team, Year 1 (2016-2017) and 2 (2017-2018).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exhibit 11.7.4. Types of Other Partners on the CYSHCN’s health team, Year 1 (2016-2017) and 2 (2017-2018)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2018 Report: NPM 12 Health Care Transition (HCT)

National Performance Measure 12: Percent of adolescents with special health care needs who received services necessary to make transitions to adult health care.

 

Report on Strategies and Activities October 2017 – Sept 2018

 

Strategy 12.1: Increase the number of family members of YSHCN who are informed about HCT through community conversations and the dissemination of resources based on Got Transition materials.

The ORF2FHIC refined its 90-minute training on health care transition (HCT) and actively promoted it among Oregon family organizations. Twenty-two families attended 3 HCT trainings in 3 communities. A cultural broker in Portland’s Black community was engaged to assess the cultural appropriateness of the training materials. The cultural broker, also the parent of a young adult with special health needs, convened a group of Black parents of CYSHCN. They assessed the materials and provided input. Overall, the group gave the materials high marks. They offered suggestions about the physical layout of the materials, and the images used. Family Involvement Program staff and the cultural broker revised the materials to better serve Black parents.

The Family Involvement Program trained ORF2FHIC Parent Partners on HCT during their annual training. The Parent Partners had no lived experience with HCT, because their children were younger. The training covered the collaboration required for a successful transition, using Got Transition youth and parent readiness checklists, and minors’ rights to request or refuse health care. At the request of the physician champion in a primary care medical home, Parent Partners reviewed that practice’s transition “birthday letters” and offered suggestions.

ORF2FHIC collected HCT materials aimed at families, youth, and providers and shared them on the newly revamped website (https://www.ohsu.edu/oregon-family-to-family-health-information-center/resources-health-care-transition). The Family Involvement Program shared the transition pages with social workers, nurses, and other providers. Additionally, ORF2FHIC highlighted the updated page of HCT materials on its Facebook page.

Strategy 12.2: Enhance cross systems care coordination for CYSHCN by building county public health workforce capacity to lead or participate in shared care planning that includes transition-aged youth.

OCCYSHN continued to support cross-systems care coordination as an evidence-informed strategy to address the health and related needs of CYSHCN. OCCYSHN continued implementing an LPHA-led shared care planning strategy, and gave individualized TA that addressed the unique needs of each LPHA. LPHA contracts directed that shared care planning teams must minimally include representatives from the family, public health, primary care, education, mental health and a payer. Contracts continued to specify that a required number of plans be created or re-evaluated. Twenty percent of the plans were required to serve children/youth with complex needs, and 20% were required to address health care transition for a child 12 years or older. Contracts required that a specific number of SPOCs be re-evaluations of previously developed plans. Formative evaluation data collected from LPHAs helped staff offer more direct, specific and collaborative support.

OCCYSHN’s care coordination home-visiting program, CaCoon, (see Strategy 11.3) remained an important foundation for shared care planning. Using our previously created crosswalk of CaCoon Standards, shared care plan “essential elements,” and the Systems Standards for CYSHCN (AMCHP, 2014) OCCYSHN developed an enhanced understanding of how both CaCoon and shared care planning help achieve these standards. CaCoon and shared care planning align with initiatives for public health modernization and accreditation, both important drivers for LPHA change. This alignment between Title V strategies and Oregon public health modernization reinforced shared care planning as a tool for defining a new role for public health, extending care coordination beyond what primary care providers can do.

LPHA Technical Assistance

To engage LPHAs and their community partners, OCCYSHN hosted 4 OCCYSHN Regional Meetings between April and June 2017. The meetings were in Tualatin, Roseburg, La Grande, and Bend. The theme “Come to the Table for Kids with Special Health Needs.” The agenda featured (a) facilitated shared learning activities, (b) listening sessions to build OCCYSHN’s understanding of what works well and where the barriers are in the shared care planning and home-visiting work and establish a dialogue between OCCYSHN and our community partners, and (c) opportunities to inform and engage new shared care planning partners in each community. The Family Involvement Program (Family Involvement Program) Manager led discussions on family-centered goal setting in shared care planning, and on the updated ORF2FHIC website. OCCYSHN’s Director presented on strategies for engaging primary care in shared care planning.

OCCYSHN provided monthly TA webinars for LPHAs implementing shared care planning. The webinar format encouraged cross-LPHA communication. Topics included discharge planning, assessment and evaluation, collaborating with primary care and Developmental Disability services, family and youth goal-setting, and lessons learned to date from shared care planning implementation. The webinars aimed to support shared care planning work while building an authentic learning community. Materials and highlights were emailed to participants afterwards, and shared online. To inform improvements to web-based LPHA support, OCCYSHN surveyed partners about their technological capacity. The results informed changes to our webinar platform.

OCCSYHN updated the Shared Care Planning Handbook to make it more concise, accurate, and accessible. In response to requests for TA on engaging other community partners in shared care planning, OCCYSHN developed a customizable PowerPoint presentation for LPHAs to use for outreach. This and other resources for LPHAs were posted on OCCYSHN’s shared care planning web page.

In response to LPHA concerns about a lack of local infrastructure to support shared care planning, OCCYSHN provided one-time additional funds to each contracted LPHA. The funds supported LPHAs to build partnerships, secure tools and technology, and fine-tune processes for shared care planning.  OCCYSHN provided project planning templates and individual consultations on using the infrastructure funds. OCCYSHN’s Director and Systems and Workforce Development Manager visited Columbia County in summer 2018 to discuss the use of the additional funds. LPHAs will report to OCCYSHN on their use of the infrastructure funds in September 2019.

Technical Assistance to OCCYSHN

In February 2018, OCCYSHN began contracting with Jeanne W. McAllister, BSN, MS, MHA, a national expert on family-centered care coordination for CYSHCN. The contract allowed OCCYSHN to continue monthly TA conference calls that were originally funded with MCHB TA funds. With the new contract, the TA calls were split between OCCYSHN’s Systems & Workforce Development and Assessment & Evaluation teams. Topics included increasing family-centeredness with quality improvement approaches, and supporting LPHA partners in shared care planning for health care transition. In addition, OCCYSHN staff engaged in professional development, including participation in an Ambulatory Care Consortium and a Diversity and Inclusion Task Force, among others. OHSU Inter-Professional Educational opportunities enhanced our agency in supporting team based care coordination.

ESM 1: Percent of shared care plans initiated or re-evaluated by county public health departments contracting with OCCYSHN that serve transition-aged youth 12 years and older. The FY18 objective was 15%, and 19.3% of shared care plans created or re-evaluted served CYSHCN in this age group.

ESM 2: Percent of the shared care plans that are initiated or re-evaluated for youth that address transition planning. Our FY18 objective was Our FY18 objective was 85%, and 66.7% of shared care plans addressed transition planning (see Form 10 for more detail).

Strategy 12.3: Increase the capacity of adult providers to provide care for transitioning YSHCN by conducting professional development activities using Got Transition resources with 4 adult practices.

OCCYSHN staff collaborated on two quality improvement transition projects with OHSU partners. First, through a memorandum of understanding, OCCYSHN worked with OHSU Family Practice on a 6-month quality improvement project to establish a transition policy using the Got Transition framework in an FQHC. With QI support from OCCYSHN and the vetting of language by Family Involvement Program, the practice successfully developed and implemented a transition policy and process for sending “birthday letters” to patients at ages 13, 15 and 18. The letters described changes to the way health care is provided as the youth develops. Second, OCCYSHN provided consultation to a complex care and transition QI project with OHSU Doernbecher Children’s Hospital General Pediatrics, (a) developing appropriate informational resources for families through OCCYSHN’s Family Involvement Program, (b) sharing lessons learned from content experts in transition, (c) connecting the quality improvement team to additional information and resources, and (d) identifying surveys about family experiences of care from which to draw items for the project.

Further, OCCYSHN collaborated with OHSU Institute on Development and Disability’s Lifespan Transition Clinic. The clinic provides assessment of transition needs and works with families and youth referred from general pediatric and pediatric specialty clinics to identify their transition goals. OCCYSHN facilitated warm hand-offs to LPHA-based public health nurses implementing shared care planning, as needed. OCCYSHN staff also participated in the OHSU Transition Task Force, which included adult providers. The purpose of participation was to (a) share information and ideas, and (b) identify opportunities for leveraging OCCYSHN’s work.

CMC CoIIN Project

To align with our state Title V CYSHCN priority, Oregon’s CoIIN project focuses on health care transition. FY18 overlapped with CoIIN project year 1 and 2. During this time, our CoIIN Advisory Team solidified our problem statement and completed our root cause analysis. Our problem statement is “young adults with medical complexity and their families are not adequately prepared for, or supported in, the transition from pediatric to adult healthcare.” We completed our root cause analysis by conducting an environmental scan. Three family representatives serve on the Advisory Team; the Family Involvement Program Manager and two external Family Representatives, Ana Valdez and BranDee Trejo. Essential data for the scan came from 12 interviews conducted by Ana and BranDee, both of whom participated in OHSU’s Institutional Review Board-required study team trainings and project-specific data collection trainings conducted by Assessment and Evaluation staff. All three family members recruited potential parents and screened them for study eligibility. Simultaneously, other Advisory Team members (OCCYSHN’s System and Workforce Development Manager, Medical Consultant, and Katharine Zuckerman, MD) completed a scan of existing HCT resources to identify those that might be applicable to developing our quality improvement project once the environmental scan was completed.

Other Transition Activities

• OCCYSHN staff used the American Academy of Pediatrics’ Health Care Transition Extension for Community Healthcare Outcomes curriculum, which increased internal capacity to support HCT partnerships.
• As part of its work with the OHSU Transition Task Force, in October 2017, OCCYSHN partnered with the OHSU Department of Pediatrics, OHSU’s University Center for Excellence in Developmental Disabilities, and the Institute on Development & Disability to successfully host a Transition to Adult Healthcare conference for physicians, care coordinators, residents and medical students throughout the state.

 

Strategy 12.4: Increase pediatric provider awareness of transition services by incorporating HCT assessment into adolescent well visits.

OCCYSHN continued to explore with the OHA Adolescent and School Health the integration of HCT assessments into adolescent well visit guidance, but schedule constraints limited our ability to progress.

OCCSYHN participated in 2 OHSU HCT workgroups (see Strategy 12.3) and informed the development and modification of clinical workflows to include HCT assessments during well-visits.