Washington State
Medical Home Leadership Network &
Great MINDS Summit May 10, 2013
Connecting the Circles:
Effective Referral and Care Coordination for
Families of Children with Developmental Concerns
Kate Orville, MPH and Kathy TeKolste, MD
UDS Partnerships Meeting June 27, 2013
SUMMIT STAKEHOLDERS & PARTICIPANTS
Pend
Oreille
Whatcom
San Juan
Okanogan
Ferry
Skagit
Stevens
Island
Clallam
Snohomish
Chelan
Jefferson
Kitsap
Grays
Harbor
Lincoln
King
Mason
Grant
Kittitas
Madigan
Thurston
Pacific
Spokane
Douglas
Adams
Whitman
Pierce
Franklin
Lewis
Yakima
Garfield
Benton
Columbia
Cowlitz
Asotin
Skamania
Wahkiakum
Walla Walla
Klickitat
Clark-
5/10 /2013
Other County Summit Participants
LHJs w/UDS Performance Measure
MHLN Teams
Community Asset Mapping
Coalitions
Great MINDS Training
Summit Planning Committee
MHLN Teams
• Diane Liebe, MD (Yakima)
• Kathy Avery, FRC (Kitsap)
• Callie Moore, PHN (Adams)
• Pat Shaw, PHN & Melody
Scheer (Clark)
• Sugely Sanchez, Parent, Great
MINDS (Snohomish)
State Partners
• Toni Nunes, WCAAP
• Kathy Blodgett, ESIT
Family Orgs
• Susan Atkins P2P
• Greg Schell Fathers Network
• Jill McCormick, PAVE F2FHIC
UW MHPP/LEND
• Amy Carlsen
• Kate Orville
• Kathy TeKolste, MD
DOH
• Heather Reed
• Susan Ray
• Linda Barnhart, ARNP
Summit Goals
• Energize efforts
implement universal
developmental
screening across
settings, from doctors’
offices to early
childhood
environments.
Summit Goals cont…
• Support care
coordination among
service providers and
families to ensure that
screening results and
referrals connect
children to
appropriate services.
Summit Goals Cont…
• Strengthen
community-based
networks to
improve children’s
health and
development
Have FUN and be INSPIRED!
What Our Audience Liked Best
• Networking and opportunity
to learn from others
• Exposure to new ideasOregon, care panel, hearing
diff perspectives at
breakouts and informal
discussion, Collective
Impact
Developmental Screening, Cross Agency
Alignment and Early Learning System
Transformation in Oregon
• Start with the end in mind
(child and family outcomes)
• Prioritize relationships &
bringing programs together
as a system. Break down
silos.
• Culture of improvement and
outcomes
•Impact of effective leader with vision in ability to
connect health care with early learning
•Advantage of State leadership – Governor, health
policy appointment in pediatrics with connection to
early learning; health care reform – medical home
credentialing, incentives, CCOs
•Local problem solving (Community Cafes) with
blended funding (efficient, accountable, nonduplicative) increases collective impact
Local differences in lay of land and in solutions
•Connecting policy and on-the-ground efforts
between health and kindergarten readiness to high
school graduation is key
Promising Referral & Care
Coordination Models
• Help Me Grow
• Walla Walla
Children’s Center
• New Patient and
Health Advocate
Model
• Ensuring Successful
Referrals from
Medical Home to
Early Intervention
From Developmental Screening to
Accessing EI: What Helps Parents
• Dev concerns ID’d by
health providers,
family or educatorstrusted relationship
helps
• Process is a journey
• Parents value having
provider offer a few
key resources (WR,
FRC, P2P)
Parents continued….
• Parents view PCP as someone who can help
parents’ capacity. Value when provider:
• Speaks to importance of parent’s role in
child’s life
• Engages parents in fully understanding EI
services, how helpful, and that don’t need a
Dx
• Ask parents about their concerns and what
type/amount of info helpful
Developmental Screening in
the Practice
• Practices love DS after
passing the
implementation hurdle
• Doesn’t take extra
time, allows time to
focus on areas of
concern
• Families appreciate,
DS increases family
satisfaction
DS Cont….
• Solving the interface with
health info tech is
important
• There is interest in
statewide systematic
approach to DS
New Care Coordination Roles
Under Managed Care
• Care coordination support is
needed and the MCO-LHJ
collaboration is a unique
model for approaching this
• Helpfulness of local, onground coordinator
• Web-based approach and
telehealth hold promise
• Care coordinators WANT to
help!
• How can we build relationships
and communication?
Connecting EI and Medical
Homes
• Connections made
are built locally
and require local
problem solving
and flexibility
EI/Medical Home and Families
• Need to work on
cultural outreach to
underserved
populations –
children often ID’d
later
• Language and
cultural brokers very
helpful
EI/Medical Home and PCPs
• Care organizers for
families
• Importance of talking
with local PCPs about
how they want info and
to communicate (e.g.
phone call if concerns)
• Some FRCs write
summary document for
PCPs because IFSP is
lengthy for PCPs time
EI/Medical Home Cont…
• Care organizers for
families
• Importance of talking with
local PCPs about how they
want info and to
communicate (e.g. phone
call if concerns)
• Some FRCs write
summary document for
PCPs because IFSP is
lengthy for PCPs time
Summit Outcomes
Referral and Care Coordination:
• Participants more
knowledgeable about issues,
activities and roles of
stakeholders
• Increased prioritization of these
issues
Opportunities
• Focus on increased
communication between
circles (not silos)
• How do we explain DS
and EI in plain English (or
other languages?)
• Help everyone figure out
roles
Activities
• Upcoming Child Health Notes:
• How to do “Wait and See”
• Benefits of EI from family
perspective
• Community Asset Mapping
• UDS in LHJs
• Statewide UDS Partnerships
efforts…..
Connecting the Circles:
Effective Referral and Care Coordination
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