1. Service Delivery Model Subcommittee Final Report

2. Proposed Referral Flow Chart CCS Special Care Center or CCS-approved physician Non-waiver services -meds -shift nursing -DME -therapies (psychosocial, physical, occupational) Community Based Medi-Cal Provider (Home Health Agency or Hospice) Assessment/Plan of Treatment (POT) /Care Coordination Respite * Child Life* Bereavement * Activity Therapies* Patient/Family CCS request for palliative care Spiritu al *Services provided by licensed or credentialed staff.

3. Considerations Waiver providers must be Medi-Cal providers AB 1745: Waiver providers to include home health agencies and hospice agencies Palliative care coordination to be built into the role of community provider (HHA or Hospice) “Fee-for-service” billing required to evaluate cost neutrality Cost Neutrality will be measured against a similar group receiving care in an institution

4. Role of Palliative Care Coordinator Arrange for initial and follow-up home health assessment Develop Plan of Care (POC) Coordinate the community-based POC, integrating family goals with medical goals Keep team and family informed of changes/updates Attend appointments at family request

5. Role of Palliative Care Coordinator Arrange transportation to and from appts. Utilize knowledge about local resources and state plan services Assist family in identifying and accessing community-based resources Request authorization as appropriate for POC

6. Recommendations for Palliative Care Coordinator Adopt as discussed: Palliative Care Coordinator (new position) should be based at community based agency (qualifying hospice and/or home health agency) Palliative Care Coordinator should have a liaison within the Specialty Care Center to coordinate care from tertiary care center. It is the Palliative Care Coordinator’s responsibility to communicate fully with County CCS Case Manager

7. Recommendations for Palliative Care Coordinator To adopt tasks of Palliative Care Coordinator discussion (minutes) Adopt a case load ratio that would reflect levels of care and the eligibility criteria to be adopted A 1/20 ratio is currently in use for experienced coordinators with high needs patients Service Delivery Subcommittee will research other ratios and patient levels and make further recommendations

8. Community Based Palliative Care Team Palliative Care Coordinator: may be either RN or Social Worker Registered Nurse Medical Doctor (staff M.D., PCP, or Specialty Provider) Social Worker Chaplain

9. Community Based Palliative Care Team *Child Life Specialist *Dietician *Activity Therapist *Other therapies (including but not limited to art, music, dance) *Note: as indicated on the community-based POC. May not be agency employees, but should be available if indicated on POC

10. Recommendations for Community Based Palliative Care Team Licensed or Certified personnel Some team members are already eligible to provide state plan services and are eligible to bill Medi-Cal if identified on plan of care. They will not be listed in services under the waiver. These state plan services will be available to patients and coordinated by Palliative Care Coordinator.

11. Services Community Based Palliative Care Coordination Pain and symptom management 24/7 RN callback service with ability for call back within 15 minutes and appropriate professional home visit, if necessary Family support to include all critical members: parents, siblings, grandparents, and caregivers when appropriate

12. Services Respite: RN, LVN, or volunteer (as appropriate to meet child’s needs Activity therapy Child Life specialist Spiritual care Note: All professional services to be provided by appropriately licensed or credentialed personnel.

13. Recommendations for Services Adopt as discussed: –24/7 callback service timeline for home visit to correlate with geographic obstacles but recommend within 2 hours continuous access to callback personnel until home visit is complete or transportation is deemed necessary

14. Essential Qualities of Participating HHAs or Hospice Agencies Community-based agency Palliative Care expertise as evidenced by: –ELNEC, IPPC, or EPIC training for appropriate professional staff or –Other similar coursework such as Harvard Program in Palliative Care Education and Practice, etc.

15. Continuing Education Ongoing training in both pediatrics and palliative care Include incentive to participating agencies to develop expertise in infant care Core competencies: Technical/professional skills must meet basic skills standards

16. Recommendation Adopt as discussed Core team members (RN, MD, MSW/MFCC, PCC) must meet core competency standards as described by State DHS and Standards of Quality Hospice Care published by California Hospice and Palliative Care Association (CHAPCA)