1. Family-Centered Action Plan Partners For Children Provider Training 2013 Jill Abramson, M.D., MPH Sharon Lambton, RN, MSN Galynn Thomas, RN, MSN

2. PFC Provider Training  Overview  Care Coordination/CCSNL/Communication  Family-Centered Action Plan  Services/Billing  Federal Assurances/ Health & Welfare  Agency Responsibilities/Summary

3. What happens before the F-CAP begins?

4. Pre F-CAP  Child referred to CCSNL – signed referral  Medical eligibility - Level of Care determination completed  Child/family meets with CCSNL  PFC Family /Child Agreement - signed

5. Pre F-CAP  Freedom of Choice - signed  PFC Provider chosen  Child enrolled in the PFC by CCSNL  Agency notified by CCSNL.

6. COMPREHENSIVE CARE PLAN Family-Centered Action Plan (F-CAP) (F-CAP)

7. Comprehensive Care Plan  Communication

8. Comprehensive Care Plan  F-CAP  Purpose  History  Development  Sections  Frequency

9. F-CAP Purpose  Purpose: comprehensive family-centered care plan identifying needs, describing goals and desired services –Child –Family –Circle of Support –Care Coordinator

10. F-CAP Purpose  Integration of child/family/care providers: –Goals –Medical objectives  Help the child successfully and safely, live in the community.

11. Comprehensive Care Plan  Family-Centered  Parent/family present at all stages –Initial Development –Interim –60 Day Assessments –6 Month Full F-CAP Revision

12. Comprehensive Care Plan  Serves the child across many settings –Home –School –Hospital –Outpatient –Community –Other

13. Comprehensive Care Plan  The Care Plan identifies –The Issues –The Goals –The Resources –The Services that support the goals.

14. F-CAP History  History  Key document

15. F-CAP Development Who participates: –Child Family –Circle of Support Care Coordinator – CCSNL

16. F-CAP Development continued  Who participates continued –Special Care Center –Physician –Counselor –Expressive Therapist(s)

17. F-CAP Development continued  Who is responsible for completion? –Care Coordinator –CCSNL

18. F-CAP Development continued  Collaborative, Coordinated effort  Care Coordinator

20. F-CAP Sections –Patient Information –Health & Symptom Management –Health & Safety (Federal Assurance) –Family Social Information –Home Environment Evaluation –Goals and Plans –Services –Family Tools

21. F-CAP Sections  Patient Information –Demographic –Diagnosis –Health care providers –Other agencies

22. F-CAP Sections  Health & Symptom Management –Medical history –Physical assessment  Review of systems –Rehabilitation potential –Education medical treatment  Medical treatment goals –Goals specific to medical treatment

23. F-CAP Sections  Health & Safety – Federal Assurance –Risk factors  Intervention  Plan –Education –Risk of abuse, neglect, or exploitation –Discussion and reminder to child & family

24. Health & Welfare  Examples –Reports to agencies –Education begins with the CCSNL  Sets the tone – non threatening –Every F-CAP review

25. F-CAP Sections  Family / Social Information –Caregiver –Children –Adults –Circle of Support

26. F-CAP Sections  Family / Social Information –Spiritual beliefs/ religious beliefs –Traditional health care beliefs –Contextual and cultural issues

27.  Family / Social Information –Psychosocial ChildFamilySiblings –Observations/ impressions/ concerns –Plan and specific goals F-CAP Sections

28.  Home Environment Evaluation –Home & neighborhood –Local notifications –DME –Pets/ Pests –Back-up emergency plan –Plan to address any needs

29. F-CAP Sections  Goals and Plan –Child’s goals –Family & Circle of Support goals –Care Coordinator goals –Services to meet goals –Identification - safety measures

30. F-CAP Sections Goals and Plan-  Family- Centered Team Meeting (FCT) –Different from the Agency Interdisciplinary meeting –In the home or parent choice –Who attends? –Reports/ Expressive Therapist /Physician

31. F-CAP Sections  Goals and Plan – FCT Meeting –Reflects the child & family goals –Identifies differences in goals & resolution of differences –Facilitates integration of goals –Identifies & documents all who participated

33. F-CAP  Determine if Care Coordination is anticipated to be : –High Complexity –High Risk –Mainly for Support & Management

34. F-CAP Sections  Services –Partners for Children –State Plan –EPSDT Supplemental Services –Community

35. F-CAP Sections  Family Tools  Physician, Care Coordinator & CCSNL Signatures  Physician sign off section

36. Comprehensive Care Plan Who besides Care Coordinator may review the F-CAP? may review the F-CAP?  Other agency staff  CCSNL  CCS Medical Consultant  Referring physician or PCP  State PFC staff  Any who have integral part in health care of child

37. F-CAP Frequency  Initial F-CAP within 14 days of referral from CCSNL  Full F-CAP every 6 months  Every 60 days F-CAP addressing at minimum, sections: –2-A, 4, 7, 8 and 9-B

38. F-CAP Frequency cont.  Interim F-CAP needed –When F-CAP no longer meets the needs –When there are changes in condition or goals  Note: All subsequent reviews are based on the date the initial F-CAP was started.

39. F-CAP Submission  Review Summary Sheet Document –Purpose of document  Initial  6-Month  60-Assessment  Interim Assessment  Time Frame – within 14 days of meeting with family.

40. F-CAP Submission cont.  Physician signature  Physician review - future

42. F-CAP Summary  Care plan developed by child/family, care coordinator, with input from CCSNL, other providers  Future changes –F-CAP Revision

43. Summary  F-CAP  Purpose  History  Development  Sections  Frequency

44. PFC Provider Training  Overview  Care Coordination/CCSNL/Communication  Family-Centered Action Plan  Services/Billing  Federal Assurances/ Health & Welfare  Agency Responsibilities/Summary

45. CCSNL Contact Information  Alameda –Joanna King (510) 267-3248  Fresno  Elizabeth Manfredi ( 559) 600-6552  Los Angeles –May Randolph - (626) 569-3997  Marin –Victoria Harter – (415) 473-6824

46. CCSNL Contact Information cont.  Monterey –Kathie Yoshiyama (831)  Orange County –Vicki Munzing - (714) 347-0346  San Diego –Cynthia Fera (858) 966-7829  San Francisco –Victoria Young – (415) 575-5758

47. CCSNL Contact Information cont.  Santa Clara –Vickie Dunn (408) 793-6248  Santa Cruz –Heather Allen (831) 763-8918  Sonoma –Anna Evenson (707) 565-4503

48. Family Centered Action Plan  Questions