Presentation on theme: "CaCoon Program Orientation for New PHNs - Part 1"— Presentation transcript:
1 CaCoon Program Orientation for New PHNs - Part 1 October 3, 2013
2 CaCoon Program Orientation – Two Webinars Second Annual CaCoon Program OrientationFor PHNs New To CaCoon#1 WebinarOctober 3rd, 2013, 9am – 11amReview CaCoon and Professional Practice#2 WebinarOctober 22nd, 2013, 9am – 11amReview resources, documentation and evaluation
3 CaCoon Program Orientation Goal …to increase the confidence and competence of newer CaCoon Public Health Nurses related to services for children and youth with special health needs.
4 Objectives for Today’s Webinar: ReviewHistory of federal and state programs for children and youth with special health needs (CYSHN)identify one thing learned about CYSHN Title VHistory and purpose of the CaCoon Programidentify the purpose of the CaCoon programPublic Health Nursingidentify public health nursing populationsCaCoon Program Eligibility and Standardsrecognize how CaCoon clients are eligible for the programknow where to find the standards for CaCoonCaCoon Public Health Nursing PracticeUnderstand two principles of Professional Growth ProgressionRecognize risks in Therapeutic/Helping Relationships in CaCoon
5 History of federal and state programs for children and youth with special health needs (CYSHN)identify one thing learned about CYSHN historyHistory of federal and state programs for children and youth with special health needs (CYSHN)HN Title V
6 History of Services to Children with Special Health Needs 1900’s: Statewide services delivered to a specific subset of CYSHN supported by the University of Oregon, later called OHSU, often free.1935 Title V of the Social Security Act : Enabled each state to extend and improve services for locating crippled children, and provided for medical, surgical, corrective and other services and facilities for diagnosis, hospitalization and aftercare. (purpose)Crippled Children’s Services separate from Maternal Child Health Services.1989 Maternal Child Health Bureau (MCHB) began the block grant to the states.
7 Omnibus Budget and Reconciliation Act of 1989 1987 Federal MCH focus shifted tocommunity-based services80 year time spanOmnibus Budget and Reconciliation Act of 1989Redefined mission & function of State CSHCN programsCare coordination added as a targeted servicePromote and provide family-centered, community-based, coordinated care for CSHCNFacilitate the development of community-based systems of servicesIn 90 years went from direct service at tertiary care centers to community centered care coordination and the emphasis on building capacity to serve sychn at the local level.
8 1989 New Definition of Children with Special Health Care Needs Children with special health care needs (CSHCN) are defined as:"those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally”No longer ‘crippled children”Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB)Changing the definition changed the emphasis of action from child find and treatment to a comprehensive system of care which included children with special needs in their home communities while seeking to build capacity of local, regional and teriary care systems.
9 “Insurance” to assurance… Since 1997 the conceptual framework for the services of the Federal Title V Maternal and Child Health Block Grant is envisioned as a pyramid with four tiers of services and levels of funding that provide comprehensive services for mothers and children, including children with special health care needs. The model displays the uniqueness of the MCH Block Grant, which is the only Federal program that provides services at all levels.DIRECTHEATH CARESERVICES:(GAP FILLING)Examples:Basic Health Services,and Health Services for CSHNENABLING SERVICES:Examples:Transportation, Translation, OutreachRespite Care, Health Education, FamilySupport Services, Purchase of Health Insurance, Care Management, Coordination with Medicaid, WIC, and EducationPOPULATION-BASED SERVICES:Examples:Newborn Screening, Lead Screening, Immunization,Sudden Infant Death Syndrome Counseling, Oral Health,Injury Prevention, NutritionAnd Outreach/Public EducationBefore 1989, Crippled Children’s Services were very different, with the direct service at the bottom, funded by federal dollarsINFRASTRUCTURE BUILDING SERVICES:Examples:Needs Assessment, Evaluation, Planning, Policy Development,Coordination, Quality Assurance, Standards Development, Monitoring,Training, Applied Research, Systems of Care and Information Systems
10 History, funding and purpose of the CaCoon Programidentify the purpose of the CaCoon program
11 CaCoon started as pilot program 1987-25 years ago CaCoon was established under a MCH SPRANS grant in 1987(Special Projects of Regional and National Significance)Public health nursing fit the target activities of the new MCH directivePiloted in Four counties in , went statewide in 1992Promatoras added in 4 counties with a high proportion of Hispanic families 19952010 recognized as a Promising Practice by Association of Maternal Child Health ProgramsIn 2012, CaCoon evaluation demonstrated effectivenessForward thinking people in Oregon Services to Children and Youth with Special Health Needs saw an opportunity to develop a community based system of care which would work with tertiary care for CYSHN and their families to build informed care coordination for CYSHN and their families through home visiting public health nursing./AMCHP defines “best practices” as a continuum of practices, programs and policies that range from emerging to promising to those that have been extensively evaluated and proven effective, i.e. best practice.
12 Oregon Center for Children and Youth with Special Health Needs CaCoon = CAre COordinatiON OCCYSHN contracts with County Health Departments to identify and provide PHN home visiting care coordination to families of CSHN purposeEach county has a designated Public Health Nurse CaCoon Coordinator. Many have several PHNs serving CaCoon families along with Promotora and community health workers since 1991 have gone from 36 to 150 nursesEach County is funded differently based on the projected number of children with special health conditions.CHANGE IS COMING!
13 Funding for CaCoon: Title V Block Grant: At this time Federal Maternal Child Health Bureau (MCHB) provides a block grant to each stateFederal dollars are matched with state dollars in a 4:3 ratio70% of the combined funds are used for general MCH populations30% of funds must serve children with special health needs (CSHN)
14 Funding for CaCoon: Title V Block Grant General MCH dollars go to the Oregon Health Authority (OHA), Center for Prevention and Health Policy, to serve general populations through programs such as Babies First! and Maternity Case Management %Children with Special Needs dollars go to Oregon Center for Children and Youth with Special Health Needs(OCCYSHN), located at OHSU for programs such as CaCoon or Child Development and Rehabilitation Center 30%
15 Funding for CaCoonContracts to local Health Departments (LHDs) from OCCYSHN (state dollars)Targeted case management (Federal dollars w county match. This is changing)County general funds (very limited)Grants, other local sources of fundingCCO partnerships, with fee for services and contracts
16 OHSU/IDD/CDRC/OCCYSHN CaCoon is one program within the Center for CYSHN, which is part of the Institute of Development and Disability at Oregon Health and Sciences UniversityOHSU/IDD/CDRC/OCCYSHN
17 Affordable Care Act and Title V CYSHN 2013 Federal funding for Title V changingHow: we don’t knowState of Oregon Health TransitionMany changes, not all knownPOPULATION-BASED SERVICESExamples:Newborn Screening, Lead Screening, Immunization,Sudden Infant Death Syndrome Counseling, Oral Health,Injury Prevention, NutritionAnd Outreach/Public EducationMandates to Title V agencies from MCH remain the same at this time with great emphasis on Care Coordination that ever!INFRASTRUCTURE BUILDING SERVICES:Examples:Needs Assessment, Evaluation, Planning, Policy Development,Coordination, Quality Assurance, Standards Development, Monitoring,Training, Applied Research, Systems of Care and Information Systems
18 Practice, Standards and Eligibility CaCoon ProgramPractice, Standards and EligibilityIdentify one element of CaCoon PHN practiceRecognize how CaCoon clients are eligible for the programKnow where to find the standards for CaCoonIdentify a risk of boundary crossing in home visiting
19 Public Health Nursing An Element of CaCoon Public Health Nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social and public health sciences(APHA, Public Health Nursing Section, 1996.)
20 Public Health NursingPublic health nurses integrate community involvement and knowledge about the entire population with personal, clinical understandings of the health and illness experiences of individuals and families within the population.
21 Cornerstones of Public Health Nursing Population basedGrounded in social justiceFocus on greater goodFocus on health promotion and preventionDoes what others cannot or will notDriven by the science of epidemiologyOrganizes community resourcesLong-term commitment to the communityRelationship basedGrounded in an ethic of caringSensitivity to diversityHolistic focusRespect for the worth of allIndependent actionStandard of practice defined by nurse practice lawCornerstones of PH Nursing, Minnesota Department of Health, revised 2007
22 Public Health Nurses serve Vulnerable Populations* Economic: poverty and link to hazardous environments and inadequate nutritionEducational: ability to understand health information and make informed choicesSocial: support systemHealth status: physical, biological, psychologicalHealth risk: lifestyle, environmentalFrom the North Carolina Institute for Public Health* Power differentials in systems of care increase vulnerability*
23 Children with special health needs a vulnerable population Complex physical and developmental needs73% of CaCoon clients have more than one risk factor (ORCHIDS data FY2010)Difficulty accessing care because of finances, transportation, geography, health complexityFamilies often living in poverty; Child’s condition requires difficult choices
24 From the North Carolina Institute for Public Health CaCoon PHNsIdentify (outreach and case finding)Link to health services (case manager)Develop or revise programs to meet client needsEducate on health promotionProvide direct careAdvocate for programs and services to meet client needsFrom the North Carolina Institute for Public Health
25 These interventions are not unique to public health nurses but are used by public health interventionists universally…From University of Minnesota Public Health Intervention Wheel
26 CaCoon Care Coordination… our unique contribution CYSHN care coordination within the context ofcomprehensive nursing processData Collection-systematic, objective and subjectiveNursing Assessment-standardizedPlans of Care-focused on measurable outcomesMonitoring/evaluating POC, effectiveness of interventionsModifying plan of care as neededSpecific outcomes orientedInterventions delivered within therapeutic nurse relationshipStandard PracticeYou will hear this over and over: You must demonstrate the value of your worth through accurate billing and data collection, accurate and clear documentation and positive outcomes including health and welfare outcomes with client satisfaction for your service!
27 What is Care Coordination? Care coordination is a process that links children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care.Committee on Children With Disabilities. “Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs.” Pediatrics (1999). Pediatrics Web. 11 January 2013 Accessed
28 Care Coordination…provides timely access to services, continuity of care, family support, strengths-based rather than deficit-based thinkingis accomplished everyday by families with and for their children and youth, but support is beneficialis in partnership with the familyrequires critical funding and protected timerequires tested tools, strategies and advocacyCare coordination is very time consuming!
29 CaCoon: More than Case Management “Case Management” is a common role throughout communities and systems of careFamilies with CYSHN often have multiple case managersEach case manager provides services within the context of their employee goals, experience, knowledge and educationCase management might be viewed as gate keeping or restricting servicesFamilies and CaCoon nurses must navigate the system without marginalizing rolesCase management can have negative connotations for families.
30 Skills needed for CaCoon: Technical skillsscreeners/assessments, documentation,resource collection, travel, safetyPersonal-Social Skillsfamily engagement, self awareness, cultural competence, personal/professional skills,ability to ask for helpCritical Thinking Skillsdeveloping plan, monitoring and adjusting the plan, anticipatory planning, practice management, self-managementWe believe that children and youth with special health needs are best served with comprehensive nurse assessments to accurately inform the family, child and system of care related to the health and well-being of the CYSHN and that home visiting PHNs are uniquely qualified to identify strengths/resiliancy factors which support effective, efficient care coordination.
33 CaCoon is partnership to support coping and growth in difficult times Acknowledge difficultiesChange brings resistance from many avenuesChange begins with planning and moves to actionPositive change happens when there is hope and optimismabout the future5. Positive tone and persistent commitment to facilitating growthsupports changeAbility to recognize any movement toward changemotivates more changeAcknowledge early when supports are no longer neededRecognize many people value the shared experience so much they will want to “stay in touch’ to share on-going success orchallenges they have over comeThe interpersonal process of change the home visiting nurses support is unique. We are witnesses to the intimate struggle going on in a home. That is not a small thing. We enter the lives of families who are often in crisis, in normal and natural grief. We bring with us the respectful belief that they can survive, and perhaps thrive someday. Wherever our clients are, we honor their journey.
34 Interpersonal skills = the helping relationshipFirst Competency: Self-knowledgeSecond Competency: Strategic VisionThird Competency: Risk-taking and creativityFour competency: Interpersonal and communication effectivenessCaCoon provides a therapeutic relationshipFirst Competency: Self-knowledgeSecond Competency: Strategic VisionThird Competency: Risk-taking and creativityFour competency: Interpersonal and communication effectivenessFifth competency: The ability to inspireCaCoon nurses must be people with excellent interpersonal skills. Often those without interpersonal skills have little self-awareness or knowledge of their limitations. The clue is their visits fail, people will not engage with them and there are often conflicts with co-workers and community partners who would be supports for their professional growth.
35 Two common circumstances can produce blurring of boundaries: Over helping—doing for clients what they are ableto do themselves or going beyond the wishes/needs of clientsControlling—asserting authority and assumingcontrol of clients “for their own good”Narcissism—having to find weakness, helplessness,and/or disease in clients to feel helpful, at the expense of recognizing andsupporting clients’ healthier, stronger, and more competent features(Pilette et al., 1995)
36 CaCoon Eligibility BabiesFirst! / CaCoon Eligibility List aka the “A/B” listUse of the B90 codeNo financial or health insurance eligibility limitationsCaCoon serves children birth through 20 years of ageCounties determining age prioritiesThe changing health care system in counties means you and your supervisors must stay current with your county system of care! Until told otherwise, CARRY ON!
37 Eligibility Criteria – CaCoon B Codes DiagnosisB1. Heart DiseaseB2. Chronic Orthopedic DisordersB3. Neuromotor disorders including cerebral palsy and brachial palsyB4. Cleft lip and palate and other congenital defects of the head, faceB5. Genetic disorders, e.g. cystic fibrosis, neurofibromatosisB6. Multiple minor anomaliesB7. Metabolic disorders, e.g. PKUB8. Spina BifidaB9. Hydrocephalus or persistent ventriculomegalyB10. Microcephaly and other congenital or acquired defects of the CNSB12. Organic speech disorders, e.g. dysarthia/dyspraxiaB13. Hearing LossB23. Traumatic Brain InjuryB24. Fetal Alcohol Spectrum DisorderB25. Autism, autism spectrum disorder, e.g. PDD,Asperger’sB26. Behavioral or mental health disorder with developmental delayB28. Chromosomal disorders, e.g. Down syndromeB29. Positive Newborn Blood ScreenB30. HIV, seropositive conversionB31. Visual ImpairmentVery High Risk Medical FactorsB16. Intraventricular hemorrhage (grade III or IV) or periventricular leukomalacia (PVL) Or chronic subduralsB17. Perinatal asphyxia accompanied by seizuresB18. Seizure disorderB19. Oral-motor dysfunction requiring specialized feeding program e.g. Failure to Grow, Organic-Non-organic (medical diagnosis), gastrostomy, nasogastricB20. Chronic lung disorder, e.g. tracheostomies, ventilatorB21. Suspect neuromuscular disorder, e.g. abnormal Neuromotor exam at NICU DischargeDevelopmental Risk FactorsB22. Developmental DelayOtherB90. Other chronic conditions not listedAlso share information about A codes and Babies First.
38 B Codes in ORCHIDS and charting Our state data system is only as good as the information enteredThere can be multiple B codes with A codesIn BabiesFirst! there cannot be B codes.In CaCoon there can be both A and BThe more codes entered, the more we know about the clients in CaCoon
39 CaCoon Minimum Standards of Program Performance It is the responsibility of each nurse providing CaCoon services,to ensure that program standards are met for each family served.The local health department will assure initial contact with CaCoon referrals within 10business days of receiving. Initial contact may be by telephone or other means.2. If need the local health department establishes and maintains a triage system that acknowledges the most vulnerable children with special health needs. Priority is given to families with:a. A newborn with a disabilityb. A newly diagnosed infant/child with a disabilityc. Children with increased nutrition risk (e.g., children with congenital cardiac defects, cleft lip and palate, or cystic fibrosis)Families having difficulty accessing or coordinating their child’s care and servicesThe LHD CaCoon program meets a minimum number of visits per year.Each LHD will be given the target number of annual visits that are expected.
40 CaCoon Minimum Standards of Program Performance, continued 4. Families considered part of the CaCoon Nurse’s active caseload receive home visits on a frequency related to assessed need, no less than one face to face contact every three months. PHN visiting will correspond to the needs of the client and family assessed and assumes a mixed population of tier.5. All CaCoon Nurses performs or assures that children and their families receive the following minimum assessments (See Assessment Tools in Chapter 6):a. Family assessment.b. Developmental assessment (use of a developmental screen for this population would be selective and for the purpose of monitoring, teaching or documenting progress).Child health assessment to include monitoring of vision and hearing (includes follow-up of hearing results from the newborn screening including hearing and vision screening).Nutrition assessment – using CYSHN screening tool or equivalent.Tier level assessmentSafety assessment appropriate for CSHNAny PHN visiting a CaCoon client is considered a CaCoon nurse!
41 CaCoon Minimum Standards of Program Performance, continued 6 The client data record reflects evidence of care coordination, cultural competency and family partnership, and use of Tier Level data to develop a plan of care which is periodically reevaluated with the family and changed according to objective criteria or demonstrated and documented need. 7 PHNs serving CaCoon clients assure linkage to essential support and care services such as F2F, CCO ICM, PCP/Specialty Care, SSI, DD, MH 8. Encounter data is entered into the ORCHIDS database. 9 The LHD supervisor assures that CaCoon is represented at the county Local Interagency Coordinating Council (LICC) or planning group that assumes the mandate of LICC.
42 CaCoon Minimum Standards of Program Performance, continued 10 A CaCoon Nurse Coordinator is designated by the Nursing Supervisor (refer to CaCoon Subaward Contract Attachment C-1 for role expectations).11 Counties will report child find activities which ensure families and community organizations are aware of services available through the local CaCoon program.Counties not meeting one or more standards will write a plan of correction which they and OCCYSHN will monitor. Inability to reach and/or maintain standards may, at OCCYSHN’s discretion, result in loss of annual subaward contract renewal.Filed at your local health department, refer to you manual
43 CaCoon Practice in action You will manage your own practiceYou will have your own clientsYou will manage your own chartsYou will assure your own capability to appropriately work with CaCoon clients and their familiesYou must ask for what you need to succeed
44 Case Finding: Referral Common Referral SourcesWICPrimary care providerHospital- could be NICU, well baby, other inpatientOther LHD Clinics- immunizationEarly interventionEHDICommon Referral Problems:Not contacting the family within 10 days of referralNot identifying the vulnerability of the clientNot staying in touch with the referral source
45 Pre-visit planning Review referral Secure complete contact informationDetermine if child has a specific and/or new diagnosisDetermine what services the child is already receivingDetermine urgency of referralClarify prioritiesSeek supervisory support!
46 Pre-visit planning, cont. Ensure you understand the child’s diagnosisFind information about conditionsYou do not need to know everythingYou do need to know where to find the informationAnyone can do a simple web search-do a professional search!Contact the family within 10 days, sooner if possible
47 Engaging Families telephone contact The initial contact is critical to the establishment of a trusting relationshipExplain who you are, what you do and your professional boundariesExplain the reason for the referralExplain services and offer home visitAsk if families have immediate concerns or other questionsAre you concerned about anything today or recently?How is feeding working out? Follow the lead given.Example: Thank you for taking my call, Mrs. Jones. I am a public health nurse, an RN. I have a referral from the WIC program which says you may be interested in home visits. Pause, let her speak….. Often I find families doing a great job with their child and frustrated with the complex system of care for the child. Sometimes families have financial concerns and I can find resources to help. Other times moms may want to understand medical language or a written medical report. I can help with that, too!. If you want, I can weight your baby and talk with you to health providers, link you with other families. I would like to bring you information about our Family Support Program and…….. May we set up an appointment today?
48 Engaging FamiliesParent goal is to minimize their perceived vulnerability (Jack et al, 2005)Overcoming fearBuilding trust - mutual trust grows over timeSeeking mutuality - shared power, dropping the ‘expert’ nurse roleAffirming intrinsic abilitiesPartnership in achieving goalsJack, Susan M, DiCenso, Alba & Lohfeld, Lynne. “A Theory of Maternal Engagement with Public Health Nurses and Family Visitors.” Journal of Advanced Nursing (2005): 182–190. Journal of Advanced Nursing Web. 11 January 2013 AccessedAsk you experienced or admired peers how they connect with families. Share about my experience w peer who had not case load because all her calls received refusal for visits.
49 The First Visit in the home Use an interpreter if needed!Welcome other people the parent may have invitedEngage the parent as a partner in helping their childYou are working with the parent, not delivering aservice to the parentExplain what will happen during this and subsequent visitsAffirm the positive you see, search for it diligently!Initial engagement BEGINS at the first contact. Do not expect to accomplish everything at once. Follow the lead of your contact, pace yourself. Often we are in a rush to DO something and families are reassured by our competency if we can satisfy a need immediately. Often weighing and measuring the child is your first chance to admire the baby and set a warm tone of shared power. Not you as the expert but you, the parent and the baby as a unit of compassion with mutual goals for health improvement..
51 Getting to know CaCoon The CaCoon Manual CaCoon Library in LHD Online resourcesPeople in your communityProviders at tertiary centersYour CaCoon Nurse ConsultantsYour MCH Nurse ConsultantsTIME!
52 We are all in the process of learning Know and accept where you as a learnerAsk for what you need to be more effectiveVulnerable clients can be harmed through inappropriate ‘helping’, CaCoon’s goal is empowermentNurses can impede their professional growth and skill by not protecting professional boundaries.Nurse practice law demands patient/client protection.It is YOUR responsibility as the professional home visitor to take the lead in ‘doing no harm’
53 Questions? Next time topics: Care plan development Documentation ResourcesOther needs?
54 Questions?Next webinar October 22nd, 9-11am Send questions, topics of interests for the 22nd Be watching for the survey monkey
55 CaCoon support to local health departments State CaCoon Nurse Consultants for the 36 counties who:monitor program servicesevaluate data for 36 countiesprovide program orientationprovide ongoing supporttrain PHN’swork closely with the OHA/Center for Prevention & Health PromotionWe share a workforce with OHA
56 OCCYSHN Staff OCCYSHN Director CaCoon Nurse Consultant Marilyn Hartzell M.Ed.CaCoon Nurse ConsultantCandace Artemenko RN,BSN/Administrative AssistantMatthew Gonzalez, BA