Care Plans in CERNER

Care Plans for CSHCN in Foster Care

Timeline

-A child is placed in a new foster home

-Foster parent requests OCS Physical

-CMS notifies RN CM of appointment

-RN initiates plan of care

-An individualized care plan is composed with input from the child, their PCP, foster parents, OCS case worker, and if appropriate biological parents.

-RN sets a reminder for 5 months from the date of the appointment to update care plan before their scheduled appointment with PCP

-The RN case manager updates the care plan as needed

-A “sticky note” at the top of the child’s chart alerts staff that the child has a care plan scanned to their chart which can be accessed to provide more comprehensive care.

Goal:

Transition to Level 3 Care

Megan K.

The Medical Home Index

Appendix

Center for Medical Home Improvement

"The child with special needs,

family, and PCP review current

child health status and anticipated

problems or needs; they create/

revise action plans and allocate

responsibilities at least 2 times per year or at individualized intervals."

Theme #3.4: Assessment of Needs/ Plans of Care

The Southcentral Foundation Pediatric Clinic

is operating at Level 2:

"PCPs identify specific needs of

CSHCN; follow-up tasks are

arranged for, or are assigned to

families &/or available staff."

Center for Medical Home Improvement 2001; Transition to adulthood indicator #2.5.1 revised 2006

Health Care Needs of Children in the Foster Care System Mark D. Simms, Howard Dubowitz and Moira A. Szilagyi Pediatrics 2000;106;909

Trends In Age Gender And Ethnicity Among Foster Children In Alaska Diwakar Vadapalli, Virgene Hanna, and Jessica Passini, 2014.

http://www.iser.uaa.alaska.edu/Publications/2014_12-TrendsInAgeGenderAndEthnicityAmongFosterChildrenInAlaska.pdf

Principles of Pediatric

Care Coordination

Spring 2016

Who falls through the gap?

Measuring Success

In our state, Alaska Native children are 7 times more likely to be in foster care than white children (Vadapalli, Hanna, and Passini).

How is Care Impacted?

Foster Children

"Many children enter foster care with chronic health, developmental, and psychiatric disorders, reflecting the neglect and abuse experienced before placement in addition to the trauma from being separated from their parents. More disturbing, however, is evidence that their health care is often neglected while in foster care."

-Chart reviews would demonstrate that each CSHCN in foster care has a clear, concise care plan accessible to the primary care team and that foster parents and, if appropriate, biological parents are given a copy to share with other individuals and agencies involved in the child's care.

-Chart reviews would also demonstrate that the primary care provider reviews the care plan with the foster parents in person twice a year. Every six months a new plan of care is scanned to the chart.

-The nurse case manager updates the plan with input from other members of the team (CMA, CMS, PCP, RD, BHC) and review this with foster parents over the phone as needed.

Special Considerations for our Population

Children who are placed foster care are required by the State of Alaska Office of Children's Services (OCS) to have a physical exam after placement with a foster family. Despite this requirement, communication between OCS, foster parents, specialists, and medical providers is severely lacking.

A care plan that summarizes a child's health care needs and relevant social information would bridge the communication gap.

Room for Improvement

In addition to a basic care plan, the following would be included

-Simms, Dubowitz & Szilagyi

Electronic Medical Records have facilitated communication between health professionals, but there are still gaps.

Alaska Native Children with Special Health Care Needs (CSHCN) who are in foster care are a high risk population and members of the health care team, foster parents, biological parents, and OCS workers need to communicate effectively to ensure adequate healthcare for this population.

-Does the child have a nickname?

-When did they go into foster care?

-Foster parents' contact information

-Any siblings? (separated due to foster placement)

-Biological parents (extent to which they are involved)

-OCS caseworker

-Tentative plan (reunification with family? adoption?)