A scoping review to inform care coordination strategies for youth with traumatic brain injuries: Care coordination personnel

Introduction & Importance: Effective, patient-centered care coordination has been shown to improve outcomes for children with special healthcare needs (CSHCN), who often have complex, long-term involvement with multiple service providers. Traumatic brain injury (TBI) can result in long-term physical, intellectual, social, and emotional disabilities that persist long after acute treatment. Yet, even though it is a chronic condition, TBI remains an area with scarce standardization and research surrounding the complex, long-term care coordination need in this population. The purpose of this scoping review is to summarize current research on outcomes in CSHCN after implementation of care coordinators, whether individual or teams, to inform future research for youth with TBI. Methods: OVID/Medline, CINAHL, PsycINFO, EMBASE, and ERIC databases were searched for articles relevant to care coordination and CSHCN. Results: 31 articles met inclusion criteria. Outcomes for children and families were grouped into 5 major categories: healthcare utilization, cost of care, disease status, parent and child quality of life, and healthcare satisfaction and perception of care. Discussion: Implementation of care coordinators, whether in the form of individuals, dyads, or teams, resulted in overall positive outcomes for CSHCN and their families across all 5 major outcome domains. Future research should be focused on the efficacy of care coordinators differing in profession, qualifications, and educational attainment specifically for the unique needs of children with TBI. Additionally, the application of care coordination within medical homes should be further investigated to increase proactive, preventative care of children with TBI and further reduce reactive, need-based treatment only.

Expanding Arizona’s Dementia Capable System

Currently, 5.8 million US adults live with Alzheimer’s disease (ADRD); the number is expected to double by 2050. Arizona will experience the greatest percent increase in ADRD by 2025. This project targeted three underserved groups in order to expand Arizona’s dementia capable system: people living alone with ADRD; people with Down Syndrome or another intellectual/developmental disability (DS/IDD) aging with ADRD and their family caregivers; and people with ADRD and their caregivers in the Latino community. This presentation describes the development and delivery of the project’s educational workshops, case management services, and evidence-based programs. Over 2,220 participants have participated in workshops to date with the largest percentage being case managers, care coordinators, and discharge planners. Evaluations have been extremely positive with 86.1% being “very likely” to recommend the project to others. The presentation concludes with findings and lessons learned regarding the delivery of the project’s evidence-based programs and case management services.

What Matters Most: ACP Evolving in Practice

The University of Southern Indiana (USI) GWEP uniquely embeds Area Agencies on Aging (AAA) care coordinators within primary care settings to invite the participation of aging patients in advance care planning (ACP), among other health interventions. Two subsequently developed features of the USI GWEP’s ACP initiative emerged to address the What Matters metric of the 4Ms: 1) Patients are invited to engage in What Matters Most conversations through multiple touchpoints that frame Medicare Wellness Visits with a Deaconess provider and introduce a free, online ACP platform, Prepare for Your Care. 2) Provider, patients and families are supported in having ACP conversations with the dedication of a new Advance Care Planning facilitator position. Certified in Respecting Choices and jointly funded by the GWEP and Deaconess, the ACP facilitator supports individuals in navigating these essential healthcare conversations about balancing quality care with quality of life.

The Myth of Care Coordination: Whether Professional Care Coordination Improved Older Adults’ Health Outcomes?

Background Current evidence on the effects of Care Coordination (CC) on older adults’ well-being and health service utilization is inconsistent. Previous studies are mostly limited to regional data and focus mostly on nurse-led CC instead of layperson Care Coordinators like family caregivers. This study explores the effects of having CC in a national sample of U.S. older adults and whether the coordinators’ professionalism impacts the effect of having CC on multidimensional health outcomes (Health outcomes were conceptualized as physical health, healthcare utilization, and care encounters). Methods Data were from the 2016 and 2018 waves of the Health and Retirement Study (HRS) (n=1,372). Multivariate regression models were used to examine the effects of CC on multidimensional health outcomes in 2016 and the longitudinal effects of having CC. We also tested the effect of Care Coordinators’ professionalism on the multidimensional health outcomes. All models controlled for sociodemographic characteristics and health status. Results Findings suggest that having CC doesn’t have a positive effect on older adults’ health outcomes. Having CC was associated with an increased number of acute diseases (β = 0.16, p < .001) and nonacute diseases (β = 0.21, p < .01) in longterm. The results regarding cross-sectional effects show that receiving care from a Coordinator was related to increased health service utilization. Participants with professional Care Coordinators were more likely to report receiving person-centered care (OR=1.60, p<.05). Conclusion This study demonstrates the limited effects of CCs on older adults’ physical health outcomes, and emphasized the importance of care coordinators’ qualifications.

An Analysis of the Effects of Psychosocial Work Environment on the Retention Intentions of Primary Care Coordinators Nursing Patients with Chronic Illness

This study aimed to investigate the effects of psychosocial work environment on the retention intentions of care coordinators taking care of patients with chronic illness. A descriptive survey study was conducted with a convenience sample of care coordinators who organized patients and treatment teams that offered professional and persistent treatment. A total of 132 participants were recruited from 19 October to 19 November 2020. The data were analyzed through descriptive statistics, t-tests, ANOVA, Scheffé post hoc, and hierarchical multiple regression using SPSS 26.0. The results showed that work organization and job content (β = 0.254, p = 0.014) and value at the workplace (β = 0.245, p = 0.034) had significant effects on the retention intentions of participants. The final model of the study explained 40.1% of participants’ retention intentions (F = 11.830, p < 0.001). The development of educational programs and implementation of policies for improving the psychosocial work environment were found to be essential for increasing the retention intentions of professional care coordinators.

Audit on the documentation of ethnicity within CAMHS

AimsEvidence suggests children from minority ethnic groups have lower rates of referrals from primary care to CAMHS, are more likely to be referred via involuntary or compulsory routes and less likely to have access to therapies than children from white backgrounds. In order to understand how ethnicity influences individuals and ensure service innovation meet these needs data collected have to be accurate. The Mental Health Services Data Set outlines all children and families receiving NHS care should have ethnicity included as a mandatory data submission and services are performance managed on this.The aim of this audit to review the documentation of ethnicity for service users in CAMHS. We agreed that 100% of patients within York and North Yorkshire (Y&NY) CAMHS should have their ethnicity documented.MethodIntegrated Information Centre (IIC) was used to collect data on the documentation of ethnicity for patients under Y&NY CAMHS on 27th August 2020.ResultThe total caseload was 4109 patients.823 (20%) had their ethnicity documented as ‘unknown’ (the clinician had entered ‘unknown’ or the patient has ‘declined to disclose’).49 (1.2%) patients had no entry regarding ethnicity (missing).ConclusionWe recommend further exploration to consider why 1 in 5 patients have ‘unknown ethnicity’ documented. We recommend: conducting a refined search considering the percentage of ‘declined to disclose’ and ‘not stated’ within the ‘unknown ethnicity’ section emailing care coordinators for patients with ‘unknown ethnicity’ or ‘missing ethnicity’ conducting a questionnaire to gather the opinions and experiences of clinicians, patients and families when talking about ethnicityreviewing the process for documenting ethnicity to improve accuracy developing staff training, to promote a culture of confidence and curiosity when discussing ethnicity Following this intervention we will aim to re-audit and consider if this has improved the rates of documentation of ethnicity.

Survey to evaluate care of complex clients in residential setting

AimsDelivering a new efficient assessment and shorter term secondary mental Health intervention service for individual sectorsBackgroundIn November 2015, there was a transition to services with the focus on delivering more efficient service to clientsPreviously we had been a combined sector Service. This transition, a reduction in resources and a move away from delivering care Through specialist mental health teams created from the national service framework - such as Assertive outreach, early intervention in psychosis and community rehabilitation - to a more Streamlined generic service, catering for these differing groups of people using a “Pathways Model” approachResultAcross the two sectors we had 47 clients on CPA Pathway living in 24 hour residential Settings who all had a current care coordinator.These 47 clients represented the workload currently of 2.8 FTE Band 6 care coordinators.There were at Origin, 13 Residential/Nursing/Secure 24 Hour care providers, where clients were residing.However of these 90% of residents lived in one of 5 settings, 3 settings in Ashfield and 2 in Mansfield.Over 50% of individuals residing did not have existing connections with Mansfield or Ashfield before being placed into the area.18 Clients (%38) were under section of the mental health act and 1client (%2) was on a life-Licence from criminal justice.ConclusionTransfer of CPA Care Coordination ProtocolTo send paper referral to our Single Point of Access Meeting at the listed address at the earliest point relocation/placement is confirmed.Formal handover meeting for care will be coordinated, not sooner than 3 months after the placement commences. It will be expected that services currently involved in provision of service continue to hold care responsibility in the interim period.As we move to a paperless environment, provision of electronic documentation such has previous CPA documents, Risk assessments, social circumstance reports & Discharge summaries, would be greatly appreciated

Assessment, Allocation, And Management Of Home And Community Care Services For Medically Complex Children : A Case Study

This study examines the experiences of CCAC Care Coordinators when assessing, allocating, and managing medically complex children who require home and community care services. A case-study design was implemented, employing a focus group with seven Care Coordinators and an analysis of the 14 Local Health Integration Networks (LHINs) Integrated Health Service Plans (IHSPs) across Ontario. Three major findings arose from the study. First, families are experiencing increased levels of burden related to the child's care responsibilities. Second, there remains a health human resource shortage of individuals with a specialization in paediatrics in the home and community sector. Third, Care Coordinators function as street-level bureaucrats when allocating publicly funded services without the use of a standardized assessment tool. Ultimately, a model of care needs to be implemented supporting a balanced approach to assessment, utilizing standard assessment tools while providing a means for Care Coordinators to utilize their expertise in allocating services.