Service Delivery Model

Subcommittee Final Report

Proposed Referral Flow Chart

CCS Special Care Center or CCS-approved physician

Non-waiver services-meds-shift nursing-DME-therapies(psychosocial, physical, occupational)

Community Based Medi-Cal Provider(Home Health Agency or Hospice)

Assessment/Plan of Treatment (POT)/Care Coordination

Respite*

Child Life*

Bereavement*

Activity Therapies*

Patient/Family

CCS

request for palliative care

Spiritual

*Services provided by licensed or credentialed staff.

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

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

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

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

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

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

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

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.

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

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.

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

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.

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

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)