1. Care Coordinator Roles and Responsibilities
Sharon Lambton R.N., MSN
Nurse Consultants
Pediatric Palliative Care Waiver – Partners For Children

2. Overview Care Coordinator (CC) qualifications
What is PFC Care Coordination?
Where is Care Coordination done?
CC activities
Communication
Administrative responsibilities

3. Care Coordinator(CC) Qualifications
MSW
Masters degree and certification from accredited program, RN
State of California License,
ELNEC or equivalent – last 5 years,
3 years of pediatric training, experience,
1 year of clinical end of life care experience.

4. What is PFC Care Coordination?
Goals
Holistic Care
Communication, collaboration, and information sharing
Shared decision making
Partnership among child and family, CCS program and providers.

5. Coordination of Services:
Coordinate multiple complex services
Enables the participant to receive all medically necessary care to remain in the community with the
GOAL of decreasing the frequency & length of stay in acute care hospitals
Optimizing care through facilitation of access to community resources
Note: Care Coordination is a service provided by a waiver provider HHA or HA of the child/family choice, and must be an employee of the agency.

6. What is PFC Care Coordination?
Includes the child & family
Development & implementation of F-CAP
Identification of services
Request services from CCS Nurse Liaison (CCSNL)
Community collaboration
Administrative responsibilities
Health & Welfare

7. What is PFC Care Coordination?
The initial responsibility of the CC is meeting with child/family and the development of the F-CAP
Family Centered Action plan (FCAP) is a comprehensive care plan
F-CAP identifies social, emotional, spiritual, physical and environmental issues that affect the child/family health and maximum potential, including but not limited to palliative care
Care Coordinator implements the F-CAP by working directly with the child/family.
Home visits for monitoring of Health & Safety issues
Central coordinator of services.

8. Care Coordination Hours of Care Coordination
Minimum of 4 hours per month
Authorization of Care Coordination
Initial 22 hours (G9001)
Initial visits/contact to develop the Family-Centered Action Plan (F-CAP)
Monthly case management (T2022)
4 – 8 hours per month
Supplemental case management (G9012)
used after the 8 hours of monthly case management (no more than 60 hours in 90 days).

9. F-CAP Process F-CAP identifies:
The F-CAP Process is designed to integrate the child/family’s goals and medical objectives to help the child to successfully and safely live in the community.
F-CAP identifies:
Current medical treatment plans with each participating provider
Duplication or confusion in medical care among various providers.
Qualified local service providers that meet the child and family care needs
Issues that interfere with family functioning.

10. F-CAP Process
The F-CAP process is intended to be flexible and does not have to be completed all in one visit.
Questions may be addressed by observation and clarified by the Care Coordinator.

11. Care Coordinator Activities:
A key function of care coordination is for a Care Coordinator to assist with parent(s) in condensing, organizing, and making accessible to providers critical information that is related to care and necessary for effective medical management.

12. Activities for Care Coordination in the Home Setting
Care Coordinator services will range from 4-8 hours or more per month depending on the individual child/family need.
Initial face-to-face meeting in the home to assess the needs of the child/family.
This assessment will include information gathering and development of the F-CAP.

13. Activities for Care Coordination in the Home Setting (cont.)
Visit the home for regular monitoring of health, safety and welfare including home safety assessment.
Provide ongoing education and training to child/family regarding medical treatment.
Accompany child/family to appointments, i.e., physician, school, or hospital if necessary.

14. Communication Collaboration with between CC and CCSNL
CCS Nurse Liaison (CCSNL) is a nurse at the CCS office designated to work with PFC clients
Work with CCSNL on F-CAP development
Medications
Current State Plan services
Submit F-CAP to CCSNL to receive authorization for implementation.

15. Communication Collaboration between CC and CCSNL
Connect regularly and share information with the CCSNL
Maintain a partnership with the CCSNL to ensure a seamless process of care which will include sharing results of the monthly evaluation, any observations of health and safety issues as well as the effectiveness of the F-CAP.

16. Communication Example of Collaboration CC, CCSNL, School,
Child & family

17. Communication Collaboration between CC and CCSNL
Discussion of all issues related to the care of the child/family,
including services available through other sources such
as state plan benefits,
private insurance,
or available community resources.
Sends copies of reports (F-CAP, expressive therapy reports, incident reports) to the CCSNL.

18. Communication Outside Agencies
Report all health & welfare incidents to;
CCSNL,
California Department of Public Health/ Licensing and Certification Division as indicated
Appropriate reporting agency,
CPS
APS, and
Other

19. Communication
SCC: Connect as needed with multidisciplinary teams within Special Care Centers to assist the family with coordination issues.
School: Connect as needed with school staff, attend Individual Education Plan.
PCP: Accompany child/family to physician visits as needed.
DME/pharmacy provider: work with CCS to obtain necessary equipment/ supplies /medications.

20. Administration
CC will provide at minimum 4 hours of Care coordination services per child each month.
Ensure that documentation of activities performed by CC on behalf of the child/family is maintained in the child’s record.
Receive initial authorization for care coordination from CCSNL prior to first visit to child/family.
Ensure all other PFC services are authorized as identified on F-CAP.

21. Administration CC Responsibilities:
Central coordination of medical/psychosocial services.
Knowledge of CCS, community, and provider resources and limitations.
Arrange for services needed to meet the goals of the child identified in the F-CAP and to resolve problems related to meeting those goals.
Establish contact and coordinate care needs with local agencies, such as schools, religious institutions, or other service agencies such as scouting, Making a Wish Foundation, etc., to meet the child/family identified needs.

22. Administration
Conduct family centered team meetings, every 60 days for each enrolled child:
The team must include at least one nurse, one social worker (who meet waiver qualifications), the CCSNL (either in person or by telephone), and other service providers involved in the waiver-related care of the child.

23. Summary Care coordinator qualifications What is PFC Care Coordination?
Where is Care Coordination done?
Care Coordinator activities
Communication
Administrative Responsibilities

24. Questions?