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Care Coordination for Children, Young Adults, and Their Families

Care Coordination for Children, Young Adults, and Their Families. objectives for today. Participants will leave with an understanding of: FamilyCare Health and OHP Care Coordination programs available for children, young adults, and families who are capitated to FamilyCare Health

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Care Coordination for Children, Young Adults, and Their Families

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  1. Care Coordination for Children, Young Adults, and Their Families

  2. objectives for today Participants will leave with an understanding of: • FamilyCare Healthand OHP • Care Coordination programs available for children, young adults, and families who are capitated to FamilyCare Health • Wraparound planning process • When to consider making a referral to Wraparound or Intensive Care Coordination (ICC)

  3. FamilyCare Health is a CCO FamilyCare Health is a Coordinated Care Organization (CCO) We provide integrated patient-centered care to approximately 120,000 Oregonians covered by OHP/Medicaid

  4. FamilyCare health points of contact • Member Navigation: First point of contact for members calling with questions • Provider Navigation: First point of contact for providers calling with questions • Service Coordination: Connects members to resources and services • Care Coordination: • Physical Health • Children’s Behavioral Health (ICC) • Wraparound

  5. Intensive Care Coordination • Assists children, youth, and families who are experiencing complex needs and multi-system involvement through care planning development • Ensures the right care is being provided at the right time, in the right place, by the right person • Family and youth driven, strengths based, and culturally and linguistically appropriate • Ratio of 1:30 Coordinator to Family • Meetings held as needed for a period of 1 to 6 months

  6. Wraparound Care Coordination • A formalized, research-based model of care coordination • Adheres to 10 guiding principles • Adheres to a structured team planning/facilitation process • Meetings held monthly for a period of 6 to 18 months on average • Extensive individual and group training and coaching • Ratio of 1:15 Coordinator to Family • Access to Family Partner

  7. Familycare health Wraparound program • Awarded the System of Care Wraparound Initiative (SOCWI) April 2014 • Implementation of Wraparound Program in October 2014 • Serves up to 120 youth and their families • Contracts with Oregon Family Support Network (OFSN) for 2 Family Partners • 8.5 Wraparound Care Coordinators • Wraparound Coach

  8. Who to refer? • ICC or Wraparound: • FamilyCare Health is primary OHP health plan • 3 to 17 years old • Elevating risk-disrupting activities of daily living • Wraparound only: • Youth is involved in two ormore systems • Youth and family interest *Higher levels of mental health treatment can be accessed without enrollment in ICC or Wraparound

  9. Referrals To make a referral for ICC or Wraparound • Call 503-222-2880 and request a Children’s Behavioral Health Intake Coordinator. They will assist you in the referral process and answer any questions you may have. To make a referral for Specialty Mental Health Services • Download the Request for Mental Health and Chemical Dependency Authorization form from the FamilyCare Health website and submit for review by the Utilization Management Department.

  10. Wraparound Case Example • Johnny is a 15-year-old male • Parents and youth interested in Wraparound • Involved in Juvenile Justice, Child Welfare, Mental Health, and Special Education • Referred by Juvenile Justice Worker • Primary concerns: Johnny recently ran away from foster home and was arrested for assault. His mother is homeless and unemployed after divorce from his father. History of DV, physical abuse, and neglect. Both parents are in recovery from drug/alcohol addiction.

  11. Engagement phase Preparing the team to work together • Orient youth and family to process and principles • Identify safety needs and create plan to address • Explore strengths and needs with family • Identify team members • Consider ground rules and meeting characteristics important to family • Gather information about strengths and needs from other team members • Write up Strengths and Needs Discovery and share with team • Schedule initial team meeting

  12. Plan Development Team collaborates to build the Plan of Care • Family shares their Vision • Team creates Mission • Team identifies Strengths and Needs • Team prioritizes needs • Team creates goals for prioritized needs • Team brainstorms strategies to meet needs • Team agrees on action steps necessary to implement strategies and commits to completion of assigned actions • Team reviews/creates Safety Plan

  13. Plan implementation Team meets monthly to review and update plan • Ten Principlesare followed • Team completes actions and reports outcome • Barriers to implementation of strategies are problem solved • New strategies are identified • Care Coordinator and family partner meet with family throughout the month to support them in completing actions steps and engaging in identified strategies

  14. Transition • Team celebrates successes • Care Coordinator and Family Partner prepare the family and team to progress towards successful achievement of the family vision

  15. Questions?

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