Care Coordination for
Children, Young Adults,
and Their Families
OBJECTIVES FOR TODAY
Participants will leave with an understanding of:
o FamilyCare Health and OHP
o Care Coordination programs available for children, young adults, and
families who are capitated to FamilyCare Health
o Wraparound planning process
o When to consider making a referral to Wraparound or
Intensive Care Coordination (ICC)
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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
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FAMILYCARE HEALTH POINTS OF CONTACT
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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
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INTENSIVE CARE COORDINATION
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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
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Family and youth driven, strengths based, and culturally and linguistically
appropriate
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Ratio of 1:30 Coordinator to Family
Meetings held as needed for a period of 1 to 6 months
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WRAPAROUND CARE COORDINATION
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A formalized, research-based model of care coordination
Adheres to 10 guiding principles
Adheres to a structured team planning/facilitation process
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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
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FAMILYCARE HEALTH WRAPAROUND PROGRAM
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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
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WHO TO REFER?
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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 or more systems
• Youth and family interest
*Higher levels of mental health treatment can be accessed without enrollment in ICC or
Wraparound
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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.
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WRAPAROUND CASE EXAMPLE
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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.
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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
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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
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PLAN IMPLEMENTATION
Team meets monthly to review and update plan
• Ten Principles are 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
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TRANSITION
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Team celebrates successes
Care Coordinator and Family Partner prepare the family and team to
progress towards successful achievement of the family vision
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Questions?