THE MARION COUNTY EXPERIENCEJUDY CLEAVE, MPH, RN

Care Coordination with Medical Homes

The Client

17 Year Old with Cerebral PalsyWheelchair boundUnable to communicate verballyAttending special classroom at SKSDDevelopmental Disabilities case managerCIIS (Children’s Intensive In-Home

Services)Medically Fragile Children’s UnitSchool nurse and other support professionalsMedical Home Case ManagerShriners

Many Resources/Broken System

Communication Devices

Interpreter UseSystem to Track

Appointments/SuppliesSafety

Equipment/SkillsToiletingTransition PlanningGuardianshipLead Case Manager

Communication between Family and Providers

Daily use of Electric Wheelchair in Home

Family Not Fully Informed of Insurance and Medical Processes

Housing Choices

Impact on Players

Environment of distrust and disrespectFamily blamed for system failurePlan made at the table, but poor follow

throughClient did not get what he needed to develop

to his fullest potentialAll involved were frustrated!!!

Woodburn Pediatric Case ManagersJudith, Marcy, Rhoda

Developmental Disabilities Team

Marion County CaCoon Staff

CHAOS Case ManagersLisa and Elizabeth

Medical Home Case Managers

Quality Improvement Initiative through OPIP (Oregon Pediatric Improvement Partnership)

CHAOS has employed case managers for many years.

Woodburn Pediatrics began their case management through the initiative.

Medical Home Case Managers and Public Health Nurses communicate regularly.

We are all learning together.

Woodburn Pediatrics Case Management

Judith and Rhoda: 249 children/families with complex medical/social

needs Ages 6 months to 21 years old

Marcy 360 ADHD patients Ages 4 years to 24 years old

CHAOS Case Management

Lisa Story and Elizabeth PeasleyCaseload managed: 1930-3 Years Old: 284-6 Years Old: 347-9 Years Old: 5410-12 Yrs. Old: 2913-15 Yrs. Old: 2016-18 Yrs. Old: 2019-20 Yrs. Old: 8

Case Managed Clients (3/1/14)

Notable Characteristics of DD

Total All Ages 2,161Total Adults: 1,560

(18yrs. +)Total 18-20 Yrs: 279Total 21 & Up: 1,381Total Children: 601 (0-

17)Children’s Intensive In-

Home Supports (CIIS) enrolled: 58

Very complex array of services

Funding and service availability changes frequently

Challenging for public health nurses to be knowledgeable about service eligibility.

DD Case Management

Clients Served Notable Characteristics

CaCoon 2012: 195 clients 892 visits

CaCoon 2013: 244 clients 1,209 visits

Evolving billing mechanism for TCM.

Increasing number of complex CaCoon clients.

Able to visit in home more intensively than DD service.

Medical background of nurses.

Longstanding presence of CaCoon program.

Public Health Nurse Case Management

Our Approach

Determine what each agency provides for clients.Develop list of services for each agency.Identify clients who enter service with few

resources and little partner involvement.Commit to tracking service provision from

service entry over time to assure goal attainment.

Develop a care plan and identify primary case manager.

Track goal acquisition.

Barriers to Timely Implementation

Sheer number of changes occurring in healthcare reform for all of us.

Health Department was going through its first national accreditation process (PHAB visit 1/14)

Developmental Disabilities is undergoing huge changes while local staff turnover is high (retirements, etc.)

School districts are experiencing huge education system changes at the same time healthcare reform is occurring.

What are we missing?

Mental health services brought to tableSchool support services brought to tableCare plan format that all service providers

are comfortable with. (Medical Homes are very busy. Feedback is that care plans must be very simple or medical offices will not be able to use them.)

Opportunities

We have a new medically complex teen referral to CaCoon services.

New referral is involved only with a pediatric practice and the school nurses.

We will use knowledge of services to develop care plan and measure acquisition of services.

Fall regional conferences give us time to improve our system of care and then report out.

J U D Y C L E AV E , M P H , R NP R O G R A M S U P E R V I S O R

E A R LY C H I L D H O O D N U R S I N G S E R V I C E S , I M M U N I Z AT I O N SM A R I O N C O U N T Y H E A LT H D E PA R T M E N T

3 1 8 0 C E N T E R S T. N ES A L E M , O R 9 7 3 0 1

J C L E AV E @ C O. M A R I O N. O R . U S5 0 3 - 3 6 1 - 2 6 9 3

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