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					                                                                              DRAFT, rev 29 April 2010


                                       Cabarrus County
                                         Action Plan
             List of Potential Community and Systems Change Objectives

The five Goals of Innovated Approaches
   Goal 1.     Families of children and youth with special health care needs will partner in
       decision making at all levels and will be satisfied with the services they receive. (NC now
       at 58.2%)
   Goal 2.     All children and youth with special health care needs will receive coordinated
       ongoing comprehensive care within a medical home. (NC now at 46.5%)
   Goal 3.     All children will be screened early and continuously for special health care needs.
       (NC now at 65%)
   Goal 4.     Services for children and youth with special health care needs (CYSHCN) and
       their families will be organized in ways that families can use them easily. (NC now at
       89.3%)
   Goal 5.     All children and youth with special health care needs (CYSHCN) will receive the
       services necessary to make appropriate transitions. (NC now at 39.9%)

Systems Change Objectives
Systems change objectives are new or modified programs, policies or practices of community
organizations that relate to accomplishing the mission of Innovative Approaches. Systems change
objective are organized below by Behavior Change Strategy within Sectors relevant to your county.

General format for systems change objectives:
    By (date), xxxx

*Proposal
**Meetings
Families
   Providing Information and enhancing skills
    Be involved in all decision making to assure satisfaction with services * (Goal 1)
    Become familiar with available services and resources ** (Goal 4)
    Provide education to parents about the systems and how it operates**(Goal 4)
    Parent involvement subcommittee evaluate information collected from surveys and focus
       groups to assess need to design educational materials, forums, and training sessions to
       supplement existing resources * (Goal 1)
      Collaborate with project coordinator to identify additional needs, organize parent resources,
       and communicate to medical home practices to assure up-to-date information is consistently
       being shared * (Goals 1,2)
      Participate in focus groups to express needs, barriers, and offer suggestions for improvements *
       (Goal 1)
      Reach out to diverse families * (Goals 4,5)
   Modifying Access, Barriers and Opportunities


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   Peer to peer technical assistance to expand capacity to respond to requests * (Goal 4)
   Identify women and families that may need care coordination
  Enhancing Services and Support
   Adolescents and families guide their own care planning * (Goals 1,5)
   Become primary care manager * (Goals 1,5)
   Use “All About My Child” notebook to organize child’s information and share with providers **
      (Goals 2,4)
     Use phone apps to organize child’s information and share with providers**(Goals 2,4)
     Provide advocates for families** (Goal 4)
     Use medical home providers as “the gate keeper” between families, specialist and during the
      transition from child to adulthood**
     Assist children at an early age* (Goal 3)
     Medical home for every child
  Altering Incentives and Disincentives
  
  Modifying Policies and Broader Systems
  

Medical Home
  Providing Information and enhancing skills
     Peer to peer technical assistance to expand capacity to respond to requests * (Goals 2,3,4,5)
     Partner with insurance companies to improve funding avenues and billing practices * (Goal 2)
     Share information by using “All About My Child” notebooks * (Goals 1,2,5)
     Become familiar with local resources to make appropriate referrals * (Goals 2,5)
     Provide well child care schedule to families so they understand the importance of preventative
      services * (Goals 1,3)
     Educate families on value of medical home ** (Goal 2)
     Improve communication between medical home and specialists ** (Goals 2,4,5)
  Modifying Access, Barriers and Opportunities
     Build capacity in adult medical homes to manage this complex population * (Goal 5)
     Create a way to ID existing assessments in order to start with accurate information **(Goal 2 )
     Implement effective agreements that assure sharing of child health service information* (Goal
      2)
     Establish a system of communication for health and human services professionals and parents*
      (Goal 2)
     Timely referrals – educating medical home providers on timely referrals
  Enhancing Services and Support
   Create registry to identify CYSHCN within a practice that may need a pre-visit contact to
      schedule adequate time for appointments, alert staff and providers, and facilitate special needs
      grouping * (Goal 2)
     Assure Medicaid and State Children’s Health Insurance Program enrollment to alleviate some
      access disparities * (Goal )
     Provide well child care schedule to care coordinators and case managers so they can prioritize
      this care * (Goal )



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                                                                              DRAFT, rev 29 April 2010


     Include social workers or family navigators in the medical arena ** (Goal )
     Improve the identification, tracking, and quality of services provided to CYSHCN* (Goal 2)
     Avoid duplication of effort by multiple agencies to decrease cost of care provided by the
      system* (Goal 2)
     To increase the ease of service access for children and their families* (Goal 2)
  Altering Incentives and Disincentives
     Offer and making referrals to low/no cost options** (Goal 2)
     Referrals to free clinics** (Goal 2)
  Modifying Policies and Broader Systems
  

Schools
  Providing Information and enhancing skills
   Send health service information home**
   Understand and implement current policies and simplify identification process**
   Provide health education**
   Enhance communication between school systems**
  Modifying Access, Barriers and Opportunities
   Cabarrus school system adds one extra year to elementary, middle and high school to ensure
      the child remain in the school system until the age of 21. In turn, the child transition into
      independent living**
     Kannapolis school system offers the student the chance to remain in the school system a
      year or two after his senior year to help with the transitioning plans to independent
      living**
     Investigate capacity to include lead case/care manager in student transitioning plans including
      independent living and potential vocational rehab * (Goal 5 )
     Modify meeting times with families** (Goal 1)
     Depending on the need of children to have additional access “one-on-one”
  Enhancing Services and Support
   Coordinating with adult compensatory education to help with academic transition
  Altering Incentives and Disincentives
   Cultural competency and sensitivity* (Goal 1)
  Modifying Policies and Broader Systems
  

Advocacy Organizations
  Providing Information and enhancing skills
   Utilize Family Support Network to coordinate efforts * (Goal 2)
   Teach parents on how to advocate for their own children and families (Goal 1)
   Educate families, providers and agencies on current policies, organizations, and resources (Goal
      1)
  Modifying Access, Barriers and Opportunities
   Extend reach of Family Support Network into areas where families are already present * (Goal 1)


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    Help find children a medical home* (Goal 2)
   Enhancing Services and Support
   
   Altering Incentives and Disincentives
   
   Modifying Policies and Broader Systems
    Work to implement policies that support CYSHCN* (Goal 1)

Public Health Serving Agencies
   Providing Information and enhancing skills
    Steering Committee will bring key players together, review child outcomes, address system
       issues and review evidence based protocols * (Goal 1)
      Outline similarities and differences between medical home care coordinators and community
       based case managers * (Goal 2)
      Once differences in the two models are understood then define care coordination practices, set
       goals, identify how each is staffed and define who is eligible and how the services will be
       financed * (Goals 1,2)
      Define key partnerships * (Goal 1)
      Survey families to gather pertinent data * (Goal 1)
      Provide “All About My Child” notebooks to all case/care managers * (Goal 2)
      Become familiar with local resources to make appropriate referrals * (Goal 2)
   Modifying Access, Barriers and Opportunities
    Advocate for continued funding to ensure CSHCN continue to receive needed coordination of
       care * (Goal 2)
    Peer to peer technical assistance to expand capacity to respond to requests * (Goal 2)
    Provide case workers to Hispanic population ** (Goal 2)
   Enhancing Services and Support
    Bring care coordinators and case managers together to identify gaps available services * (Goal )
         o For all ages 0 to 21 ** (Goal 2)
    Bring care coordinators and case managers together to develop a clear flow chart for accessing
       care coordination or case management services * (Goal 2)
      Bring care coordinators and case managers together to develop key indicators to measure
       success * (Goals 2,3)
      Work on process to manage and collect information to focus on areas of concern to improve
       primary health care utilization * (Goal 4)
   Altering Incentives and Disincentives
   
   Modifying Policies and Broader Systems
   

Faith and Spiritual Groups
   Providing Information and enhancing skills
    Stimulus reduce classroom


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   Training sessions for special needs children
  Modifying Access, Barriers and Opportunities
  
  Enhancing Services and Support
  
  Altering Incentives and Disincentives
  
  Modifying Policies and Broader Systems
  



Additional Systems Change (not otherwise categorized)
     Educate community on acronyms ** (Goal 4)
     Create a comprehensive, electronic place for system knowledge and resources ** (Goal 2)
     Use technological equipments (Hi-tech phones) to inform patients ** (Goal 2)
     “help families learn how to effectively navigate the healthcare system giving them the
      information and the skills to deal with insurance issues and communicate more effectively with
      clinicians” * (Goal 4)
     Educate community on protocols * (Goal 4)
     Linguistic and cultural competency to assure outreach efforts to this population to increase
      utilization of services and satisfaction * (Goal 4)
     Build system that integrates all care/case management services* (Goal 2)
     Build upon the new transition-planning model to coordinate pediatric to adult transition * (Goal
      5)
     Explore options for grievance – “Complaint resolution”

Internal Innovative Approaches Development

     Assure increased family support* (Goal 4)
     Assure effective communication processes among providers and community service agencies *
      (Goal 2)
     Consider hiring parent as staff to act as liaisons to practices, care coordination, case managers
      and evaluators * (Goal 4,5)
     Assure use of evidence based protocols for chronic conditions * (Goal 2)
     Assure best practice models of care coordination * (Goal 2)
     Assure transition planning processes * (Goal 5)
     Create one consistent referral form ** (Goal 4)
     Close service gap to families without Medicaid ** (Goal 4)
     Research and identify medical home providers with extended hours for better access* (Goal 2)
     Review policies and structures that may make coordinated care difficult to access or fund in
      order to ensure families have access to needed services and improve systems of care
      coordination * (Goal 2)




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   Integrate system of care training into pediatric and specialty residency programs, to educate
    residents on care coordination and effective strategies for improved systems of care* (Goal 2)
   Clearly define CYSCHCN population ** (Goal 1)
   Project coordinator assist with development and dissemination of resources * (Goal 2)
   Steering Committee create subcommittees* (Goal 1)




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