How FidelityEHR Supports Care Coordination

Delivering Care To Children and Youth In NeedOne in 10 youth will experience mental health challenges that are severe enough to impair their ability to function at home, at school and in the community. Of these children, 10 percent will drop out of high school as a result of their disorder.1 Many of the children and youth who are afflicted by severe emotional disturbances lack access to care. In fact, based on a recent NIH national survey, only half of all children and youth in need of behavioral and emotional health care services end up receiving them. Those who are able to access care may not receive an appropriate treatment plan due to gaps in the child welfare system and a lack of information sharing between health care providers, family members, and community supports who work with the child or youth.

The Case for Good Care Coordination: Better Outcomes, Reduced CostsCoordinated care is difficult to standardize, because each child or youth requires a customized care plan. That said, all care coordination models have two things in common: the strategies are team-based, involving more than two participants, and family-driven. Care coordination, when implemented well, has been shown to provide many benefits for children and youth who experience significant behavioral and mental health challenges, and their families. Some of these benefits include:

• Improved care outcomes and overall health• Greater satisfaction for the youth, family and providers• Reduced costs associated with care fragmentation and over-utilization of care

Coordinated care models ultimately function to reduce gaps in the child welfare system. This helps deliver better access to care, while offering a more effective and less expensive alternative to emergency department visits, residential treatment and hospitalizations, or juvenile justice programs.2

Why Integrated Care is Federally RecommendedIn 2013, the Center for Medicaid and Medicare Services and SAMHSA released a statement that encouraged States to use the Medicaid program to cover a range of behavioral and mental health services, including: care coordination, intensive home-based services, family support, respite care, and Wraparound care.

Good care coordination has been proven to improve outcomes for children and youth who suffer from significant behavioral and mental health challenges.

1 National Center for Children in Poverty, Children’s Mental Health: What Every Policymaker Should Know2 Banghart, P.; Cooper, J.L. 2010. Unclaimed Children Revisited: Focusing on Outcomes – A Case Study of the Michigan Level of Functioning Project. New York, NY: National Center for Children in Poverty, Columbia University Mailman School of Public Health.

WHO IS ELIGIBLE FOR COORDINATED CARE? Five core considerations are used to determine a child or youth’s eligibility3

1. Condition or DiagnosisThe child or youth needs to have a specific condition or diagnosis. This criteria varies based

on a wide range of factors, including state and federal requirements, clinical judgment,

payer preferences, and advocacy initiatives.

2. Medicaid EligibilityThe child or youth must be currently enrolled in Medicaid, and these programs are often

limited and varied by state.

3. AgeSome children and young adults may be excluded based on their age due to transition

issues when a child ages out of their eligibility.

4. Payer Cost SavingsCare coordination may be prioritized when the payer identifies that it provides a return

on investment by replacing “unnecessary” or “avoidable” services, such as emergency

department visits or hospitalization.

5. Risk Analysis

Will the child or youth’s care be expensive to payers? Is the individual involved in foster care

or child welfare programs? Does the individual experience complicated medical, social or

support-based challenges? Based on the organization and family’s needs, risk will be taken

into consideration when determining care coordination eligibility.

What Does High Fidelity Care Coordination Look Like?

Successful care coordination models take into consideration many aspects of each child or youth’s lives, which includes: their community, culture and beliefs, language skills, academic background, the youth’s core competencies and strengths, family and life at home, medical history, nutrition, community partnerships and supports, social services and mental, behavioral, and emotional health.

Care coordination is separate from disease management or even case management. Although both case management and care coordination produce individualized care plans, coordinated care requires a team and network of providers as opposed to a singular agency. Studies show that outcome-based systems are able to track youth outcomes, improve provider capacity and tailor services.2

3 Bachman, S; Comeau, M; Jankovsky, K. 2015. The Care Coordination Conundrum and Children and Youth with Special Health Care Needs.

Providing Care Coordination through Systems of CareThe system of care is a framework and philosophy for delivering effective care coordination. It involves coordinated collaboration across a network of provider agencies, youths, and families. The goal is to provide children and youth who experience seious emotional disturbances (SED) with enhanced accessibility to the treatment they need. Systems of care also aim to improve outcomes through coordinated care that reflects each individual’s strengths, needs, background and social supports.

Improving Outcomes through Care CoordinationA recent SAMHSA report shows that the rate of suicidal thoughts among children and youth with SED who received system of care services dropped by 26% in six months and 43% in one year.5 Systems of care are encouraged to abide by guiding values and principles to ensure better care coordination outcomes. In addition, accountability has been shown to render better fidelity to the system of care practice model. In particular, 10 core factors, defined as the Getting To Outcomes® (GTO) guidelines, should be considered when deploying a system of care strategy to improve accountability: Needs and resources, Goals, Best Practices, Fit, Capacities, Plan, Process Evaluation, Outcome Evaluation, Quality Insurance, and Sustainability.6

4 McKay, M. M.; Hibbert, R.; Hoagwood, K.; Rodriguez, J.; Murray, L.; Legerski, J.; et al. 2004. Integrating Evidence-based Engagement Interventions into “Real World” Child Mental Health Settings. Brief Treatment and Crisis Intervention 4(2): 177-186. 5SAMHSA Children website. Applicable URL accessed on May 5, 2016. 6Getting to Outcomes In Systems of Care. July 2009. Icons provided by Freepik at www.flaticon.com

The system of care should be heavily informed by the

needs of the youth and their family. Understanding the

youth’s needs and strengths will help determine the

right mix of services and supports needed.

Supports in the community are a fundamental facet

of the system of care philosophy. They help

contribute to youth and family engagement. In turn, this engagement has been

shown to improve treatment efficacy.4

Agencies, services and treatment programs

should reflect the cultural, ethnic, linguistic and racial

differences of the youth and their family. This helps deliver

better access to treatment and helps to eliminate

disparities in care.

SYSTEM OF CARE VALUES

Culturally & Linguistically Informed

Family Driven & Youth Guided

Community Based

HOW FIDELITYEHR ALIGNS WITH SYSTEM OF CARE GUIDING VALUES

FidelityEHR was designed to support family-driven and team-based coordinated care models to produce better emotional health outcomes for children and youth. These values are:

1. Family Driven

2. Youth Guided

3. Evidence Based

4. Cultural & Linguistic Competence

5. Individualized and Community Based

1. FAMILY DRIVEN

Families have a primary decision-making role when it comes to the care of their children, and they should be involved in:

• Choosing supports, services and providers• Setting goals• Designing and implementing programs• Monitoring outcomes• Determining the effectiveness of all efforts

How FidelityEHR supports Family Driven care coordination:

• FidelityEHR captures family-centered interviews, insights, family timelines, and family systems assessments that inform the treatment plan

• Care plans embed signatures from family and youth to ensure their consent and that their views and needs have been acknowledged

• Team meeting worksheets incorporate ongoing assessment of family support, connections, and satisfaction

• Youth and family can log in to the health record portal to access messages, reminders, educational resources for diagnoses and medications, a copy of the treatment plan, and other features that display shared data regarding goal tracking and interests

2. YOUTH GUIDED

Youth guided systems of care engage the youth as an equal partner in creating change to produce better outcomes.

Feedback from youth will help to inform policies and procedures at the individual, community, state and national levels.

FidelityEHR emphasizes youth and family preferences, visions and strengths to promote self-efficacy

• The EHR tracks both initial and ongoing assessments of needs and strengths identified by the youth. These insights help to shape strategies that reflect care plan’s goals and anticipated outcomes

• FidelityEHR captures youth-centered interview, insights, timelines, and family systems assessments that inform the treatment care plan

• Care plans embed signatures from youth to ensure their consent and that their views and needs have been acknowledged

• Team meeting worksheets incorporate ongoing assessment of youth support, connections, and satisfaction

• The youth has access to their FidelityEHR health record portal where they can find messages, reminders, educational resources for diagnoses and medications, a copy of the treatment plan, and other features that display shared data regarding goal tracking and interests

• Youth can complete standardized assessments, such as the CANS, CAFAS and WFI-EZ

3. EVIDENCE

BASED

Evidence-based practices are important facets of an effective coordinated care service delivery system.

Feedback from youth will help to inform policies and procedures at the individual, community, state and national levels.

FidelityEHR is the only electronic health record provider that continues to conduct ongoing evidence-based research to demonstrate improved care coordination efficacy in systems of care.

• Better fidelity is rendered to care coordination models due to its outcome-based configuration and ongoing real-time data analysis

• Based on the team’s goals and strategies, FidelityEHR’s team meeting worksheet includes all core assessments and case notes to track both baseline and ongoing progress made toward the treatment plan’s goals

• Core Assessment outcomes are graphically monitored in the Youth Record dashboard, making it easy to share outcomes with all team members:

• Youth Needs Progress • Residential Outcomes • Family Satisfaction • Youth Connections • School Outcomes • Family Connections • Community Outcomes

• Customizable assessments and licensed assessments, such as the CANS or CAFAS, can be integrated to support outcome-based and data-driven decision-making

4. CULTURAL

& LINGUISTICCOMPETENCE

Agencies, programs and services should reflect the cultural, racial and ethnic diversity of the system of care’s populations.

Cultural competence evolves over time and helps stakeholders to work effectively in cross-cultural situations.

How FidelityEHR supports cultural competence:

• The care plan and Team Meeting Worksheet emphasize the team’s understanding of the youth and family’s values and beliefs regarding challenges, as well as their preferences for next steps

• Gender, race, ethnicity, language, cultural and spiritual domains are assessed and tracked in FidelityEHR

• Primary caregiver, legal guardian and multiple family members are included and can be given access to the EHR

• Community-based outcomes are assessed continuously in FidelityEHR

5. INDIVIDUALIZED& COMMUNITY

BASED

Each child or youth that is provided care through a system of care should have a customized care plan that is developed by the family team.

Community-based services have been shown to be enhanced through building partnerships with service systems and resources throughout the child or youth’s community. Management and decision-making responsibility are also provided to community stakeholders, such as teachers, mentors, coaches, community group leaders and more.

Quickly update the Treatment Plan information and collaborate with family team and community team members in FidelityEHR.

• Youth and family vision building for both home and community integration into the treatment plan is a critical piece in the puzzle.

• FidelityEHR offers ongoing assessment in these domains.

• Service and billing options are customizable and highly flexible to reflect any care coordination practice environment.

• Team meeting reminders, invites and messaging between meetings are delivered through FidelityEHR

FidelityEHR is designed to make every day more efficientInstead of forcing users to fit their unique practice into a rigid health record, FidelityEHR generates data that directly applies to the way each user prefers to manage their cases and track outcomes. Since the beginning, FidelityEHR software development has involved significant field testing and purposeful development to make it user-friendly, practical and, most importantly, helpful to care managers.

What can FidelityEHR do?FidelityEHR's blueprint reflects evidence-based practice models from: System of Care, Wraparound, Integrated Behavioral Healthcare and Person-Centered Planning.

How it was designed:FidelityEHR received financial support from the National Institutes for Health to develop and field test the software through a partnership with Eric J. Bruns, Ph.D. at the University of Washington. Over 70 behavioral health organizations are currently active field test members, and the EHR combines feedback and user testing insights from over 100 different organizations. By conducting continuous user field-testing research, FidelityEHR stays current and directly reflects what users want most out of their results-based health record software.

Customized to align with a wide range of coordinated care models, FidelityEHR uses cutting-edge technical features to provide a flexible repository of information. The important aspects of the EHR are that it:

1. SUPPORTS TEAM-BASED COLLABORATION: The platform facilities easy and secure communication and information sharing between team members.

2. PROVIDES A HOLISTIC VIEW: FidelityEHR integrates with medical electronic health records, to provide a holistic depiction of the youth’s overall mental, behavioral and physical well-being.

3. RECORDS RESULTS: It aids supervision by helping track staff performance evaluation, while analyzing services, implementation, and costs associated with meaningful outcomes.

STREAMLINED DATA ENTRY,BETTER OUTCOMES.Let one of our solutions architects show you how FidelityEHR has helped system of care organizations cut costs, maintain fidelity to their care model and improve outcomes.

www.fidelityehr.com/demo

1.888.978.8305 | 2100 Calle de la Vuelta, C-202, Santa Fe, NM 87505 | www.fidelityehr.com