The California Community Care Coordination Collaborative launched its work with an introductory webinar on April 9. The goal of the Collaborative, funded by the Lucile Packard Foundation for Children's Health, is to improve the quality of care coordination for children with special health care needs by providing a structured opportunity for leaders to learn from one another, identify areas of shared need, discuss emerging challenges and connect with others engaged in this work. Each of the six regional coalitions participating in the Collaborative has begun work. In June, these coalitions will come together at the Lucile Packard Foundation for Children’s Health, which is funding the project, for their first all-day meeting. As the work of the Collaborative develops, we will post resources and information about care coordination.

1. California Community Care
Coordination Collaborative
Introductory Call
April 9, 2013

2. • Introduction and Welcome
– Holly Henry, PhD, Research Program Officer
– Ed Schor, MD, Senior Vice President of Programs and Partnerships
– Janis Connallon, Manager of CAAdvocacy Network for Children with Special Health Care Needs
• Project Descriptions and Introductions
– Contra Costa California Community Care Coordination Collaborative
– Orange County Care Coordination Collaborative for Kids
– Rural Children’s Special Health Coalition
– San Mateo County Care Coordination Learning Community
– Central California Care Coordination Project
– Medically Vulnerable Care Coordination Project
• Preparation for In-Person Meeting
• Questions
AGENDA

3. Contra Costa California Community Care
Coordination Collaborative
Barbara Sheehy, MS
Administrator
California Children's Services Contra Costa County

4. C O N T R A C O S T A C A L I F O R N I A C O M M U N I T Y C A R E
C O O R D I N A T I O N C O L L A B O R A T I V E
SEVEN C’S PROJECT

5. SEVEN C’S COALITION MEMBERS
• California Children’s Services
• CARE Parent Network
• Regional Center of the East Bay
• First 5 Contra Costa
• Clinic Services/Public Health Nursing
• Contra Costa Behavioral/Mental Health
• Head Start/Early Head Start
• Children’s Hospital Oakland and Research Center
• Contra Costa Health Plan
• Early Childhood Mental Health
• West Contra Costa SELPA
• Contra Costa Regional Medical Center, Dept. of Pediatrics
• Kern County Medically Vulnerable Care Coordination Project

6. SEVEN C’S PROJECT GOALS
1. To determine the specific needs of CSHCN, birth to 5
years of age, and their families, for the Seven C’s
Project.
2. To align the organizational structure to implement the
Seven C’s Project for CSHCN, birth to 5 years of age,
and their families, providers and communities.
3. To conduct a 3 month pilot program of the Seven C’s
initiative to work through and validate procedures,
tools, costs and processes before full implementation.
4. To create and implement a financial sustainability plan
to secure Care Coordination staff and other resources
to fully implement the Seven C’s P for CSHCN, birth – 5
years of age, their families, providers and communities.

7. SEVEN C’S MAIN ACTIVITIES
• Convene monthly Seven C’s Partner meetings to develop,
pilot, and support a county-wide CSHCN care coordination
system.
• Learn about the Kern County, MVCCP model, history, Acuity
Form and tools.
• Compile and analyze Contra Costa CSHCN data to develop
projected population to be served by care coordination
initiative.
• Develop a county specific resource list of pediatric special
needs services for families and providers.
• Develop and implement a county wide outreach and
education plan for families and providers.
• Create, implement, and monitor role of Care Coordinator to
support county-wide CSHCN care coordination system.

8. SEVEN C’S ANTICIPATED CHALLENGES
• Some Partners have no experience working
together collaboratively
• Assuring family centered care is institutionalized in
care coordination system

9. Orange County Care Coordination Collaborative for Kids
Rebecca Hernandez, MSEd
Program Manager
Help Me Grow Orange County

10. Key Coalition Partners:
• American Academy of Pediatrics, CA Chapter 4
• Children and Families Commission of Orange County
• CHOC Children's Foundation
• Help Me Grow Orange County
• Orangewood Children’s Foundation/Bridges Network
Collaborative Participants:
• California Children Services
• Cal Optima (Orange County Medi-Cal agency)
• Child Health and Disability Prevention Program
• Comfort Connection Family Resource Center
• County of Orange, Social Services Agency
• CHOC Children’s Early Developmental Assessment Center
• Family Support Network
• Orange County Department of Education/Center for Healthy Kids and Schools
• Public Community Health Nursing
• Regional Center of Orange County
• The Center for Autism and Neurodevelopmental Disorders of Southern CA
Orange County Care Coordination
Collaborative for Kids

11. OC C3 For Kids Goals
Overarching goal: To improve overall care for children and families with
special health care needs by creating a collaborative care coordination
system in Orange County.
1. To identify the specific needs of the Orange County care coordination
collaborative starting with children birth to 5 years of age who have special
health care needs (CSHCN) and their families.
2. To determine the organizational structure of the Orange County care
coordination system for children birth to five years with special health care
needs (CSHCN) and their families.
3. To conduct a pilot of the proposed Orange County Care Coordination model
to validate the efficacy and refine team based development of procedures,
tools, costs and processes before full implementation.
4. To create and implement a sustainability plan to secure resources to
implement a care coordination countywide system with scalability and
potential to expand to other age groups.

12. OC C3 For Kids Activities
• Conduct a trend analyses of CSHCN in Orange County
• Implement a monthly gathering of a diverse countywide collaborative
providing CSHCN case reviews, open discussion and resolution of
challenges
• Develop a care coordination protocol to address system wide issues that
affect CSHCN and their families
• Develop and promote common language via a county wide risk assessment
and referral form to enhance provider communication
• Maximize staff time and resources by focusing on the
efficiencies of care coordination
• Create a sustainable care coordination entity in OC
• Conduct final evaluation combining qualitative
and a quantitative assessments to identify strengths
and weaknesses of the project

13. 13
Anticipated Orange County Challenges
As our project was developed, the core planning
team identified several challenges that may be
encountered. These include:
• Time constraints of the current OC C3 for
Kids participants
• Recruitment of additional organizations who
provide services for CSHCN
• Financial constraints as there has been
tremendous cutbacks to organizations
therefore limited staff to participate
Thank you
Rebecca Hernandez, MSEd
Project Director, OC C3 For Kids
Rhernan2@uci.edu

14. Rural Children’s Special Health Coalition
Siskyou, Shasta and Trinity Counties
Gina Grecian
Program Manager
Wendy Longwell
Parent Health Consultant
Rowell Family Empowerment of Northern California

15. Rowell Family Empowerment
of Northern CA. (RFENC)
• The mission of RFENC is to
empower people with diverse
abilities, and their families, to live
as respected and valued members
throughout their communities by
providing support, education and
advocacy services.
• RFENC is a parent founded, parent
run agency that assists families in
navigating systems, understanding
the laws and regulations that
govern these systems, and provides
parent to parent support.
Rural Children’s Special
Health Coalition (RCSHC)
• Key Coalition Members will
include:
 CA. Children Services
 Far Northern Regional Center
 Community Health Centers
 Health and Human Services
 First 5
 Dept. of Health and Human
Services
 3-5 Family Members from Shasta,
Siskiyou, and Trinity counties
• RCSHC is dedicated to bringing
families and health professionals
together to improve health
coordination in Shasta, Siskiyou,
and Trinity counties.

16. Rural Children’s Special Health
Coalition Goals!
• Professionals are more
knowledgeable about community
service systems and the family
perspective.
• Family members are more
knowledgeable about community
service systems and how to navigate
them.
• All participants see increased
collaboration and communication
among agencies to solve problems.
• All participants find the training
provided has quality, is valuable,
relevant, and useful.
• Problem solve any issues we find
around the transition to the new
managed care Medi-Cal.
• Improving and updating the Medical
Home Binder.
• All participants believe relationships
have been strengthened.

17. RCSHC Project Activities
• Schedule 10 phone and/or face to face meetings per year
• Create Methods to track changes in the systems
• Develop a trainings needs plan and hire speakers and trainers to educate
everyone involved on improving care coordination and developing a clearer
understanding of the transition to the new managed MediCal model
• Coordinate regular convening of a broad range of stakeholders in the targeted 3
counties to define issues, identify local unmet needs, explore resources, and
develop action plans to solve problems
• Work on plans and projects the coalition decide are areas we need to work on.

18. RCSHC Anticipated Challenges
• To get all required coalition members to attend meetings from all three counties.
Challenges we may face include:
 Distance to travel in unsafe weather conditions from the pioneer communities
 Time commitment, with travel, for professionals who may have a tight schedule
• To keep coalition members focused on the goals and activities outlined in the
grant, staying true to the specific agenda
• Finding professional guest speakers/trainers who are willing to travel to the
rural and pioneer communities to provide required educational topics that align
with the RCSHC goals and objectives.
• Keeping the training to be disseminated at a level that can be easily understood
by all. Such as keeping it at a 6th grade reading level

19. San Mateo County Care Coordination Learning Community
Cheryl Oku
Program Manager
Watch Me Grow Demonstration Site
Community Gatepath

20. Key Coalition Members
• Community Gatepath
• CBOs: IHSD Head Start/Early Head Start,
Lifesteps Foundation, StarVista
• First 5 San Mateo County
• Golden Gate Regional Center
• Legal Aid Society
• Lucile Packard Children’s Hospital
• San Mateo County Health System
• San Mateo Co. Office of Education
San Mateo Co. Community Care Coordination Collaborative

21. Project Goals
• Strengthen the existing system of care
coordination for CSHCN through a
collaborative learning community
• Increase access to coordinated, effective,
family-centered services for CSHCN within
the medical home
• Develop a model of care coordination for
CSHCN in the medical home that is replicable
and sustainable
San Mateo Co. Community Care Coordination Collaborative

22. Main Project Activities
• Policy Group
– County-wide care coordination resources
– Referral protocol
– Policy recommendations
• Practitioner Group
– Recommend best practices for care coordination
– Care coordinator handbook or tool
San Mateo Co. Community Care Coordination Collaborative

23. Major Challenges Anticipated
• Integrating care coordination models and
information across different systems
• Changing availability of community resources
for provision of care coordination
• Colocation of community care coordinator in
the medical home
San Mateo Co. Community Care Coordination Collaborative

24. Central California Care Coordination Project
Marion Karian
Executive Director
Exceptional Parents Unlimited Children’s Center

25. Central California Care
Coordination Project
EPU Children’s Center
Fresno, California

26.  Fresno County Department of Social Services
 Fresno County Department of Behavioral Health
 Fresno County Department of Public Health—Public Health Nursing,
Children’s Medical Services
 Central Valley Regional Center
 Fresno Unified School District
 First 5 Fresno
 Children’s Hospital Central California
 CASA
 Children’s Services Network
 Exceptional Parents Unlimited
 Cal Viva
 Marjaree Mason Center (Domestic Violence Shelter)
SMART Model of Care Partner
Oversight Committee Members

27.  To establish an active, interdisciplinary multi-agency
team to receive referrals and coordinate the care of
children with special health care needs.
 To provide outreach and information regarding care
coordination to hospital discharge planning/care
coordination staff, NICU discharge staff, private
pediatricians, and Federally Qualified Health Clinics.
Project Goals

28.  Convening the Care Coordination Planning Team including
representatives from:
 California Children’s Services
 Central Valley Regional Center
 Children’s Hospital—specialty primary care clinic
 Children’s Hospital—High Risk Newborn Follow Up
 EPU Children’s Center
 Parents
 Conducting Outreach to various providers
 Attending the SMART—MOCPOC
 Visiting Kern Medically Vulnerable Project
 Studying models of care coordination
Main Project Activities

29.  The complexities of the reimbursement systems
 The vast-ness of the medical systems
 The limitation of the presence of the project in the scope
of issues surrounding care coordination
 Focusing on an initial population that we can work with as
we are creating the care coordination team protocols
 Focusing on the ways in which we can have the greatest
impact.
 Determining how the Care Coordination Project can fit into
the existing SMART Model of Care
Main Challenges Anticipated

30. Kern County Medically Vulnerable
Care Coordination Project
Marc Thibault, MA
Project Director

31. Kern County Medically Vulnerable Care Coordination Project
Mission Use enhanced coordination of existing case management services to
measurably improve long term outcomes for children, birth to 5 years of age, who are
at risk of costly, lifelong medical and developmental issues.
Background Since 2008, the Kern County Medically Vulnerable (MV) Workgroup of
40+ partner organizations has met monthly at First 5 Kern to address the needs of
CSHCN, their families, providers, and communities.
Partners California Children’s Services; Clinics; Family Resource Centers; First 5 Kern;
Foundations; Hospitals; Insurers; Kern County Departments of Human Services,
Mental Health, Public Health Services; Kern Regional Center; School Districts; Special
Care Centers; Local Agencies, Community Organizations and Institutions.

32. MVCCP Objectives
Key Components of the Care Coordination Process
• Use an accepted Acuity Form to quickly identify and treat more
conditions earlier to make a measurable difference in a child’s life.
• Support local services that already exist.
• Focus on individual cases, working together through a Case Review
Committee, to develop best practices of care coordination.
• Streamline access to, and maintenance of, health insurance and a
medical home, to reduce unnecessary ER visits and hospitalizations.
• Build strong, long-term provider partnerships to sustain a
system of care coordination that is practical, affordable, and
responsive to changing conditions.
• Use longitudinal data to document results.
• Conduct Cost Benefit Analyses to demonstrate savings on at-risk
infants and children to better serve all children in the county.

33. The LPFCH grant to MVCCP provides free technical assistance in
2013 and 2014 to help implement care coordination in 3 counties by:
• facilitating a series of face to face and webinar meetings to assist
local care coordination collaboratives
• sharing the MVCCP Acuity Scale Form to quickly help identify and
refer Children with Special Health Care Needs (CSHCN)
• implementing a process for jointly addressing CSHCN cases
• working together, through a locally selected Care Coordinator
• finding local solutions and resolving care coordination barriers
• using evaluation results from the Kern County MVCCP
• developing best practices, learned in all four counties, and
• jointly addressing the overall system of health care for CSHCN in
these counties.

34. MVCCP Replication Process and Potential Challenges
Replication Process
• MVCCP implemented a “first come, first served” approach, to engage with
early adopter counties.
• Two counties – Contra Costa and Orange – have been actively engaged,
learning about MVCCP Replication, and building their local collaboratives.
• A third county is still in the process of being selected, with outreach occurring
with several counties through the MVCCP Advisory Committee.
Challenges
• Counties understand how big an undertaking it is to take on care coordination
for CSHCN. Budgetary constraints and uncertainties due to local, state and
federal policy and funding changes can affect the level of commitment.
• Must always remain aware of, and sensitive to, the political and historical
dynamics that can differentiate each county in the implementation process.
• Previous or ongoing local collaboration efforts can impact the vision and the
commitment to cooperation, especially depending how competitive the
atmosphere is among potential partner organizations.
• A local governance plan must reflect the collaborative nature of the initiative,
provide accountability and transparency to its work, and result in an inclusive
decision-making process to achieve optimum results.

35. • Preparation for In-Person Meeting
– Finalizing Date in mid-May
– Two Additional Slides
• Challenges Faced
• Progress Made
• 5cs-learning-collaborative@googlegroups.com
• Questions?