Got Care Coordination: Tips, Tricks, and Tools of the Trade - Discussion
- Care Coordination
- Supporting the Medical Home
- Promoting Transition to Adult Medicine
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Providing limited direct clinical care services
Thirty percent of their funds must go to help special-care-needs kids. Care coordination is the primary focus and involves several steps including intake and assessment, creating a care plan, connecting families to Medicaid/CHIP and SSI, and providing consistent, regular follow up - this is key.
They also help support the medical home by referring families to a primary care provider for regular care, guiding transition to adult healthcare by supporting families and providers in the community with training and planning services. They focus on the 16-17 year old age group since they have the most acute need for resources.
ISP also has limited direct clinical evaluation and diagnosis services via telehealth. They have providers such as a speech pathologist, psychologist and Peds APRN to help with developmental delays, autism, behavioral modification, and medication support.
ISP's multidisciplinary team can support your practice with care coordination. They partner with families and promote a patient and family-driven care plan that is closely aligned with the primary care provider or Medical Home.
Mindy and Tina also talked about the following resources you are also encouraged to use:
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Utah Family Voices - a grant program under the Utah Parent Center and works on specific health-related issues, such as autism. Utah Family Voices works directly with families to solve problems related to those specific areas. Staff are all parents of children with special health care needs.
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Utah Parent Center - a family-to-family model where parents of children with disabilities can help other parents with school/education-related issues and give a more personal experience. The UPC can provide support for IEPs and getting services.
Zoom polls asked these questions:
- How do you keep track of your kids with special needs?
- How do you know to follow up?
- What are the criteria for following up?
- What barriers or challenges, if any, do you face (working with children and youth with special health care needs)?
- What success are you having?