Alameda County Committee on Children with Special Needs

Local Coalition Summaries

Alameda County Committee on Children with Special Needs Alameda County

Contact: Laurie Soman, Senior Policy Analyst, Lucile Packard Childrens Hospital

Phone: 510-540-8293 Email:

Project Mission: To develop and implement strategies to promote a “medical home” for children enrolled in the Alameda County California Children’s Services (CCS) Program.

Goal 1: Increase the number of CCS children in medical homes.

Objectives:

1.Identify any children with CCS conditions who do not have an identified primary care provider and link them with a medical home.

2.Ensure that CCS children’s primary care providers are informed of children’s CCS condition and pediatric subspecialists.

Goal 2: Increase primary care physician knowledge of child health and developmental programs.

Objective:

Design and implement an outreach program for primary care providers serving CCS children, building on the current roles of existing public and private programs in the community.

Goal 3: Increase provider willingness to serve children with CCS-eligible medical conditions.

Objectives:

Research, develop and pilot a model for office-based pediatric provider support of the developmental and psychosocial needs of CCS patients and their families, building on the current roles of exiting public and private programs in the community.
Ensure that pediatric providers and CCS families are aware of and linked with local family support services.
Identify financial and policy barriers that impede provider participation in CCS.
Identify gaps in the service system that impede implementation of medical homes.

Goal 4: Increase coordination of CCS, Regional Center, and Supplemental Security Income programs with the medical home.

Objective: Explore strategies to strengthen coordination with the medical home.

Major Activities

Identify CCS children in Alameda County and their providers; identify children with no primary care provider; identify children with a primary care provider but no visit within the last year.
Select random sample of children served by CCS and survey families, primary care physicians, and subspecialists regarding the medical home and its components.
Collect data on existing models of primary care provider office support.
Conduct surveys and focus groups to determine needs of primary care providers serving children with special health care needs.
Collect data on needs of families of children with special health care needs through accessing family satisfaction and other survey information as well as through focus groups.
Identify and collect information on resource materials to be distributed in pediatric settings.
Design and implement outreach program to provide information and link providers to resources.
Design potential model for office-based provider support and plan for implementation.
Work with American Academy of Pediatrics (AAP) to publicize medical home model and the role of primary care provider in a medical home.
Pilot medical home model in selected provider offices in Alameda County.
Collaborate with Children and Families Commission on school readiness activities specific to health care providers.
Identify financial, policy and other barriers to provider involvement with children with special needs.

Contra Costa Health Services Contra Costa County

Contact: Barbara Sheehy, CCS Administrator

California Children Services Contra Costa County Health Services/ Public Health

597 Center Ave., #115, Martinez, CA 94553

Phone: 925-313-6122 Email:

Goals:

1.To develop and sustain a community coalition that promotes systems changes and infrastructure development necessary for successfully implementing the medical home and family-centered care approaches for children with special needs and their families.

2.To expand community partnerships to develop and implement integrated medical home training to parents and families, providers, case coordinators, quality assurers and others involved in establishing a medical home and continuity of care.

3.To provide ongoing support, technical assistance, leadership training, and consultation to participants.

4.To develop, strengthen and sustain partnerships and service linkages to promote the use of technology, data collection, and sharing and to promote improved care coordination.

Main Objectives:

Create, develop and convene a community-wide coalition to plan and provide oversight for the project development and implementation to support medical homes and family-centered care.
Parents and families (with a focus on California Children’s Services children and families) will increase their knowledge and effective utilization of health care systems and resources and build more effective partnerships with their primary health care provider.
Improve the coordination of care for children with special health care needs and their families by establishing an integrated training, technical assistance, and consultation program for public and private pediatricians, specialist physicians and their staffs, other health care providers, care coordinators, and along with Objective #2, parents and families.

Major Activities:

Review literature on best practices for medical home model and family-centered care.
Implement medical home model using data from literature and existing publications and established projects.
Develop evaluation and outcome assessment plan and ongoing quality assurance activities.
Provide parent/family integrated training on the systems of care for children with special needs.
Create Medical Home “Passport” binder for families to organize children’s records for the service systems with which their children are involved.
Provide mentoring/leadership training for parents of children with special needs.
Train providers on medical home model of care and provide technical assistance.
Outreach to providers on promoting the medical home and family-centered care.
Survey families and parents on what they need/want from health care providers and utilize information for development, implementation and evaluation of the training.
Pilot medical home model in ten practices.
Advocate and support reimbursement for physicians who provide medical homes to children with special needs.

Far Northern Regional Center Shasta County

Contact:Linda Kilzer

Far Northern Regional Center, Early Intervention Services

1900 Churn Creek Road #112 Redding, CA 96002

Phone: 530-222-8795 ext. 3174 Email:

Goal 1: Increase coordination of care for children with special health care needs (CSHCN) who receive services from both California Children’s Services (CCS) and Far Northern Regional Center (FNRC).

Objectives:

Develop a medical passport to provide accurate medical information between the child’s medical home and other medical providers involved with patient care, both local and out of the area.
Create a resource team that includes a parent support specialist and a medical care coordinator to work with families and medical providers to improve continuity of care.
Initiate dialogue between primary and tertiary care providers.

Goal 2: Develop fully functionally medical homes for CSHCN.

Objectives:

Enhance medical home characteristics that already exist at Shasta Community Health Center to encompass all the requirements for being a fully operational medical home.
Outreach to private providers to encourage them to become medical homes to CSHCN.
Reduce financial and policy barriers to the provision of coordinated care for CSHCN.

Goal 3: Assure that families receive appropriate support, understand the medical system, and fully partner in their child’s medical care.

Objectives:

Establish a system of peer-to-peer support for families.
Train families on the use of a medical passport.
Develop resource teams that include parents in the planning and implementation of medical care for their children.

Major activities

Conduct chart reviews of all FNRC consumers who are CCS clients to identify their primary physicians.

Contact primary physicians to determine barriers to providing coordinated care.
Survey paneled physicians to assess which aspects of the CCS program are counterproductive to a coordinated approach to care for complex patients.
Conduct family interviews to determine what is and is not working well to meet their children’s needs.
Convene bimonthly meeting of medical home consortium.
Hold quarterly meetings of stakeholders (primarily physicians interested in the medical home concept) to receive ongoing feedback on barriers to medical home care and problem solution.
Conduct introductory session to pediatricians on medical home project given to Mercy Medical Center as part of pediatric division meeting.
Train community physicians on the medical home model.
Develop a medical passport for families to organize information on their children.
Establish a parent-to-parent network with parent mentoring program; parents will eventually serve project staff as resource team members.
Pilot fully functional medical homes with at least two pediatricians.
Train parents on medical homes, family-centered care, and care coordination.
Recruit and train parents to participate in Resource Teams to provide parent support for medical homes.

The Los Angeles Medical Home Coalition Los Angeles County

Contact: Thomas Klitzner, MD, PhD, Executive Committee Chair

The Los Angeles Partnership for Special Needs Children

5000 West Sunset Blvd, Suite 510 Los Angeles, CA 90027

Phone: 310-825-7148 Email:

Goal: To improve services for children enrolled in the Los Angeles County California Children’s Services (LAC/CCS) program through the promotion of the medical home model of care delivery.

Objectives:

Increase the number of children enrolled in LAC/CCS who have an identified medical home.
Improve the quality of the services provided in participating medical homes by establishing provider training sessions and using the rapid cycle improvement process to effect change.
Increase support for providers serving as a medical home for children enrolled in LAC/CCS.

Major Activities:

Identify a pool of providers willing to serve as a medical home for children enrolled LAC/CCS
Identify families without medical homes by having CCS case managers make introductory phone calls to new or established families.
Develop and maintain a database to track project activities and evaluate progress toward achievement of the project goal and objectives.
Plan and convene three provider training sessions, utilizing rapid cycle improvement strategies, to identify and test practice enhancements.
Identify tools to measure the quality of medical home services.
Maintain communication with participating providers by email, list-serves, conference calls and reports, to facilitate sharing among the group.
Collect and summarize information about challenges, practice innovations and lessons learned, to disseminate among larger groups of providers.
Increase care coordination support to medical home providers by utilizing resources from Medi-Cal managed care plans, CCS, special care centers, office staff, Regional Center and parents.
Increase the use of existing CCS reimbursement mechanisms in place for primary care providers serving children in the CCS program through training and consultation with providers.
Disseminate innovations and lessons learned via existing relationships with Medi-Cal managed care and CCS Workgroups through developing a report on successes and lessons learned from provider training sessions.

Parents Helping Parents, Inc. Santa Clara County

Contact:Nancy Eddy, Director of Health Related Services

Parents Helping Parents, Inc.

3041 Olcott Street Santa Clara, CA 95054

Phone: 408-727-5775 Email:

Goal: To create a local coalition in Santa Clara County consisting of providers and parents that is responsive to the needs and strengths for our community in order to increase the number of Santa Clara County children with special health care needs who have medical home to help ensure family-centered care for these children.

Objectives:

Establish an active coalition that meets regularly to identify needs and develop strategies to establish and support medical homes for children with special health care need in Santa Clara County.
Make recommendations for Santa Clara County on access/barriers to medical homes, reimbursement mechanisms, and models of service delivery.
Promote family-centered care for Santa Clara County children with special health care needs, specifically for those children served by California Children’s Services (CCS).
Increase the number of available medical homes for children with special health care needs by supporting providers as medical homes and training families on the concepts of family-centered care and medical home.
Provide a model for the state on ways to increase access to and support for family-centered medical homes for children with special health care needs.
Participate in the development and support of a statewide network of medical homes.

Major Activities:

Collect data related to the number of medical homes in Santa Clara County and the numbers of children who have and/or need an identified medical home by adapting existing surveys and conducting focus groups.
Develop and distribute tools/resources to support providers and families.
Conduct training for families and health plans.
Review and make recommendations to promote a seamless system of care for children with special health care needs.
Identify and recommend strategies for conducting outreach on medical homes for pediatricians and family practice doctors.
Survey Santa Clara County pediatricians/medical providers to assess their needs in implementing/maintaining a family-centered medical home.
Develop and pilot one or more tools to support medical providers as medical homes and link them with each other and to community-based services for families.
Survey CCS families to identify the number of children served by CCS who have a medical home, what services they receive and what services they need.
Train parents regarding medical homes, family-centered care, care coordination, and parent/professional collaboration.
Provide medical home notebook for families of children with special health care needs.
Collaborate with health plans to enable them to incorporate the medical home concept into their programs and services.
Develop an infrastructure for providing medical home information and other data among providers for the same child in order to support family-centered medical homes for children with special health care needs.

Partnership Health Plan of California Solano, Napa, Yolo Counties

Contact:Chris Cammisa, MD, Medical Director

Partnership HealthPlan of California

360 Campus Lane #100 Suisun, CA 94585

Phone: 707-863-4448 Email:

Goals:

1.To identify and address barriers to quality of care and life for the children with special health care needs (CSHCN) population.

2.To create innovative solutions to assist members in selecting a medical home.

3.To assist medical homes in providing a comprehensive service delivery system.

Objective:

To collaboratively develop interventions to address selected opportunities for improvement identified by providers and members.

Major Activities:

Create registry of children ages 0-21 who meet the Balanced Budget Act definition of children with special health care needs.
Stratify severity of illness of children with special health care needs in order to prioritize target group members for outreach activities.
Survey contracted physicians caring for children with special health care needs to assess issues such as access to care, comprehensiveness of care and cultural competence.
Survey families of children with special health care needs to evaluate members needs e.g., need for prescription medication, utilization of mental health or educational services, etc.
Train members on medical home concept and related topics.
Train providers on the medical home concept and related topics.
Survey medical home providers to assess satisfaction with continuity and coordination of care.
Distribute a binder to caregivers of children with special health care needs which will contain critical medical, behavioral, and social information to optimize care coordination between providers.

San Benito County Public Health Services San Benito County

Contact:Patricia Cincone, CCS Administrator

San Benito County Health & Human Services Agency/Public Health Services

439 Fourth Street Hollister, CA95023

Phone: 831-637-5367 Email:

Goals:

1.To increase the number of physicians who understand the concept of a medical home and are willing to provide medical homes for children in San Benito County.

2.To increase the number of children who have medical homes which they access for primary, preventive and episodic care, to support and empower parents of children with special needs in obtaining family-centered care.

3.To improve care coordination between primary care providers, specialty providers and community services.

Objectives:

To clearly define the scope of the problem experienced by families of special needs children in San Benito County.
To support families of children with special needs.
To conduct outreach to local pediatricians.
To promote a seamless system of care.

Major Activities:

Identify data collection and assessment instruments.
Conduct a family focus group to identify the number who have medical homes, access problems, perceptions about preventive care, access to specialty care, service coordination needs, and needs for support groups.
Utilize a children with special health care needs survey tool to obtain data from high-risk infant population.
Design and set-up parent-to-parent support groups.
Conduct parent training on parent leadership in creating systems change.
Train parents on medical homes, family-centered care and tools for helping families keep track of medical reports.
Meet with community pediatricians to ask questions regarding experiences in serving children with special health care needs and the barriers and successes in doing so.
Recruit managed care California Children’s Services paneled providers and train them on billing procedure for fee-for-service Medi-Cal.
Develop forms for medical information exchange between primary care providers and specialty care providers.
Convene bimonthly coalition meetings.