Embedded Files
Why Care Coordination?
Why Care Coordination?
Care coordination in behavioral health organizes client care activities among various healthcare participants and community resources, ensuring comprehensive, continuous, and person-centered care, for children, youth, and their families in specialty mental health services. It integrates services across healthcare, education, and vital community supports, crucial for addressing the multifaceted needs of clients and their families. This approach emphasizes family involvement and the broader community's role in supporting behavioral health. Tailored care plans are developed, considering each child's and family's unique cultural, social, and personal factors. It also aims to improve access to services and promote health equity by actively addressing social determinants of health. Efficient utilization of resources ensures that healthcare and community supports are effectively aligned to deliver necessary care. Ultimately, care coordination extends beyond traditional healthcare boundaries to include community-based support, preventing the escalation of mental health issues and fostering sustainable health and well-being.
Understanding Care Coordination Needs
Understanding Care Coordination Needs
The Child and Adolescent Needs and Strengths (CANS) assessment is one tool that can inform care coordination by integrating behavioral health needs with social determinants of health (SDoH). This tool captures a comprehensive profile of a child or adolescent’s needs and strengths across multiple life domains, ensuring that both clinical and non-clinical factors are considered in their care. By assessing areas such as family environment, the CANS helps identify the most pressing needs that might require immediate intervention and those that could benefit from ongoing monitoring or preventive measures. Importantly, CANS includes a detailed consideration of SDoH—factors like educational barriers, homelessness, and cultural stress—which significantly impact health outcomes. This broad focus facilitates the development of tailored interventions that address both the immediate health concerns and the environmental factors that contribute to them.
Responding to Care Coordination Needs
Responding to Care Coordination Needs
In addressing care coordination needs, understanding the "how" of effectively implementing care coordination is crucial. This involves a systematic approach where behavioral health providers can integrate both clinical insights and community resources to optimize client care. Effective care coordination extends beyond the clinic, involving a network of community partners and resources that address the broader social determinants of health impacting clients and their families. Models and frameworks discussed below will provide some guidelines on how to provide care coordination services.
Using the Integrated Core Practice Model (ICPM)
Using the Integrated Core Practice Model (ICPM)
The California Integrated Core Practice Model (ICPM) serves as a comprehensive guide for coordinating care within the trauma-informed Children and Youth System of Care. It underscores the importance of multi-agency collaboration, emphasizing that successful outcomes are achieved through shared practices and principles across various service domains. The model is built on the foundations of racial equity, prevention, community-based solutions, and an emphasis on leveraging lived experiences and cultural competencies to foster meaningful and effective interventions.
Steps in Applying ICPM for Care Coordination:
Engagement and Teaming: Initiate care by building a cohesive team that includes service providers, family members, and other key stakeholders. This creates a supportive network that is essential for successful outcomes.
Assessment: Conduct comprehensive evaluations that integrate both the medical and social needs of the child/youth or family, ensuring all aspects of their well-being are considered.
Planning and Implementation: Develop and implement care plans that are informed by the assessment findings, tailored to the specific needs and strengths of the child/youth or family.
Monitoring and Adapting: Regularly review the effectiveness of the care plan, making adjustments as needed to address evolving needs and to optimize outcomes.
Transition: Manage transitions carefully to ensure the child/youth or family continues to receive necessary support, moving towards independence from formal care systems when appropriate.
1. ICPM Model (2024).pdf
Using Targeted Case Management (TCM)
Using Targeted Case Management (TCM)
Targeted Case Management (TCM) is a pivotal service designed to enhance equity and reduce disparities in healthcare access for individuals with complex needs. By providing specialized, coordinated care, TCM effectively addresses the systemic barriers that often prevent marginalized communities from obtaining necessary health and social services. This management approach ensures that individuals receive the comprehensive support needed to navigate the healthcare system, improve their health outcomes, and achieve greater social and functional stability, regardless of socioeconomic, racial, or other potential barriers.
Steps in Applying TCM for Care Coordination:
Assessment of Needs: Initiate the care coordination process with a thorough assessment to identify all medical, social, educational, and other service needs that support the client’s overall well-being.
Plan Development: Develop a detailed care plan that outlines the goals, treatment strategies, and services required to address the identified needs, ensuring active participation from the client.
Referral and Linkage: Facilitate connections to necessary services by coordinating with healthcare providers, social services, educational institutions, and other community resources.
Monitoring and Follow-Up: Continuously monitor the client’s progress and the effectiveness of the care plan, making necessary adjustments to ensure that the services provided adequately meet the client’s evolving needs.
Transition Planning: Prepare for the client’s transition from intensive case management to a more self-sufficient status by ensuring they have achieved the goals of the care plan and are linked to ongoing support if needed.
Using the Wraparound Model
Using the Wraparound Model
The Wraparound model is an intensive, individualized care coordination process tailored to children, youth, and their families, particularly those who face serious mental health or behavioral challenges. This process integrates various community-based services and natural supports into a cohesive plan aimed at keeping children in their homes and communities. Overview of the Wraparound Model:
Holistic Approach: Wraparound places the child and family at the center, prioritizing their needs, strengths, and preferences in the planning and execution of services.
Family and Youth-Driven: The model is highly collaborative, involving the family and youth actively in every step to ensure the services provided align with their visions and goals.
Team-Based: Services are coordinated by a dedicated team comprising family members, professionals, and community members who collectively devise and implement a plan that addresses the child’s needs across various life domains.
Implementing the Wraparound Model for Care Coordination:
Engagement and Team Preparation: Establish trust and build a collaborative team including the family, relevant service providers, and community members who support the youth and family’s needs.
Initial Plan Development: Together with the team, the family helps identify their needs and strengths, setting measurable goals that are reflective of their values and culture.
Implementation: The team works on executing the plan, employing strategies that are flexible and can be adjusted based on ongoing assessments of the family’s progress and feedback.
Transition: As goals are achieved, the team develops a strategy for reducing or modifying their involvement, ensuring the family can maintain progress independently, leveraging natural supports within their community.
5. Wraparound Process Guide (2024, English).pdf
8. PRAPARE Toolkit (English, 2022).pdf8. Oregon Model in Addressing SDoH.pdfPRAPARE Model for Addressing SDoH
PRAPARE Model for Addressing SDoH
The PRAPARE model, an acronym for Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences, serves as a comprehensive framework designed to help health centers and other providers assess and address the social determinants of health (SDoH) of their clients. It emphasizes a systematic approach to understand and act on the factors outside of traditional clinical care that affect client health outcomes.
Overview of the PRAPARE Model:
Holistic Assessment: PRAPARE enables providers to gather detailed information on a wide array of social determinants, such as housing stability, food security, education, employment, and social integration, through a standardized set of questions.
Data-Driven Interventions: By identifying the specific social needs of patients, providers can tailor interventions and connect individuals with appropriate community resources.
Improving Health Outcomes: The model supports providers in addressing the root causes of health disparities, thereby improving overall health outcomes and reducing healthcare costs.
Steps in Implementing the PRAPARE Model for Care Coordination:
Staff Training and Engagement: Educate and engage healthcare staff on the importance of SDOH and the use of PRAPARE to ensure effective implementation and adherence to the model.
Assessment and Integration: Implement the PRAPARE assessment as part of routine client intake to collect comprehensive social health data.
Actionable Care Planning: Utilize the assessment to develop individualized care plans that address both medical and social needs, coordinating with various healthcare and social service providers. Concrete examples in the document to the left.
Ongoing Monitoring and Adjustment: Regularly review the effectiveness of interventions and the relevance of the care plans, adjusting them as necessary to meet the changing needs of clients.
Community Collaboration: Strengthen partnerships with local community organizations and stakeholders to expand the resource network available to patients and enhance the overall impact of the PRAPARE model on community health.
Page updated
Google Sites
Report abuse