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Service Delivery Model

Service Delivery Model. Subcommittee Final Report. Proposed Referral Flow Chart. Patient/Family. CCS Special Care Center or CCS-approved physician. request for palliative care. CCS. Spiritual. Community Based Medi-Cal Provider (Home Health Agency or Hospice)

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Service Delivery Model

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  1. Service Delivery Model Subcommittee Final Report

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

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