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Community Activities – SW

Clark Cowlitz Kitsap Lewis Thurston

Team contact list | County CSHCN Data

Current and Upcoming Activities

• A local resource guide for providers serving children was developed collaboratively by the Clark County MHLN team, the Clark County Public Health --- Children with Special Health Care Needs & EOCF.
• Dr. McGuiness and Pat Shaw presented an "Rx for Family Support" poster at the July 2007 Future of Pediatrics AAP conference.
• Team members are active in the Clark Support for Early Learning and Families (SELF), a coalition to provide early learning resources for parents, providers and the public. Team members helped plan the Sept 2006 forum (300+participants) and a January 23, 2007 CME program for health care providers featuring early childhood specialist and WA Docs for Tots Director Dr. Jill Sells. Dr. Sells spoke on the developmental aspects of early childhood learning and motivating physicians and other health care providers to be community advocates.  This was followed by a brief overview on education in Clark County.  Dr. Phil McGuiness, MHLN Team physician gave an update on the county's local efforts to address early learning, community resources (SELF) and opportunities for involvement -- including the Lunch and Learn (L&L) series being launched.  Medical practices were able to sign up for L&L presentations at their practices.  (The L&Ls focus on Medical Home, Care Coordination, Community Resources and Early Learning and will usually be presented by a SELF rep and a pediatrician/health care provider) A general goal was to have attendees see their roles (as providers, as advocates) to identify family needs and connect parents with community resources.
• The team is collaborating with SELF to develop brief community resource guides/materials (i.e. magnet, tear off sheets) for providers to help them link families with services
• The MHLN team began sending quarterly Child Health Notes to county primary care providers in fall 2006.
• The County Lead Family Resources Coordinator joined the team
• The team CSHCN Coordinator has been active in state medical home activities including participation in the state medical home strategic planning group and the WA Catalyst Financing Care Coordination Workgroup looking at care coordination in the medical home.  Ms. Shaw gave a presentation on work group progress at the Nov. Medical Home Strategic planning workgroup meeting.
• Health access for children with open medical coupons is a concern for the team. The children most often affected are:  foster kids, children on
  SSI, babies born to mothers who have an open coupon,  and undocumented kids who are on the new children's health plan. 

Past Activities

• Developed pediatric rotation schedule for families having a difficult time accessing a primary care provider for their special needs child. Local pediatricians on schedule take turns accepting referrals for special needs kids- especially those with open coupons.
• Developed a resource packet for parents with the low birth weight booklet distributed by Mary Bridge hospital and information on RSV, early intervention and CSHCN.

Other Medical Home-related Activities

• Clark County was one of 3 WA counties in the National Academy for State Health Policy's ABCD I Consortium grant (2000-03) to strengthen the capacity of the health care system to support the early development of children from low-income families. WA focused on improving the quantity and quality of Medicaid-covered well child (EPSDT) visits, including developing new Medicaid well child encounter forms.  In Clark, local public health nurses visited pediatric offices to provide information about Medicaid-covered well child services, and help using the new well-child encounter form. The pilot also provided information about early child development to families.

Cowlitz County

Team contact list | County CSHCN Data

Current and Upcoming Activities

• The Child and Adolescent Clinic (CAC) is collaborating with the Progress Center, the county’s main Early Intervention Provider to screen all their patients from birth through age 5 for developmental delay and parental concerns using the Ages and Stages Questionnaire.  The program is called Tracking Learning Children (TLC). View Presentation on developmental screening efforts by Hilary Gillette-Walch.
• Cowlitz Center of Foster Care Health: The Cowlitz MHLN team has been very involved in starting the Cowlitz Center of Foster Care Health, one of three sites in Washington State funded by DSHS to improve health for children in foster care.
  http://www.candac.com/Programs___Services.html#Foster Care Program
• Hilary Gillette-Walch, Program Director for
  the new foster care center and MHLN team member presented on the medical home work in Cowlitz at the November 2008 Children's Health Alliance Summit. View presentation (Powerpoint, 12MB) - "Building a Medical Home Brick by Brick: Strategies for Clinics Transforming Themselves into a Medical Home"
• In recognition of Dr. Phyllis Cavens' outstanding contributions as a community pediatrician, the American Academy of Pediatrics, Council on Community Pediatrics awarded her its national 2007 Local Heroes award.
• The Child and Adolescent Clinic in Longview was awarded a 2008 Healthy Tomorrow's Partnership Program from the American Academy of Pediatrics for their project "SUCCESSFUL LEARNING IN VULNERABLE PRESCHOOL CHILDREN THROUGH IMPROVED MENTAL HEALTH". It has been documented that 51 percent of children entering kindergarten in the largest school district in Cowlitz County are at “some risk” or “at risk” of not being ready to learn to read.  This is related to a high level of poverty in the community with associated maternal depression and childhood emotional and developmental problems. These children will be identified so that they and their families can receive support and mental health care from a collaboration of community organizations. The primary goal of the project is to improve the emotional and social development of children from pre-birth to age 6 who are at risk so that they are better prepared to learn when they enter school. This will involve: (1) finding vulnerable children from pre-birth to age 6 and engaging them in a medical home; (2) evaluating the development and mental health of the vulnerable children and the emotional status of their mothers using newly-introduced screening instruments; (3) referring identified children and parents to the collaborating agencies for additional help; (4) teaching families better ways to nurture their young children; and (5) conducting a community and family awareness campaign.
  
• Dr. Phyllis Cavens and other members of the Cowlitz County team have been leaders in county-wide efforts to improve mental health care for children.  The broad-based Child Psychiatry Coalition strategic initiatives include: A) every child is connected to a medical home.  This system of care will be the basis for delivery of children's mental health services.

  B) Children's mental health services in Cowlitz will have a community child psychiatry-based service model,

  C) children's mental health services delivery system members will implement standard screening, tracking and referral protocols,

  D) implement standard information sharing agreement and an electronic community children's mental health record as they provide team care in a collaborative co-management model,

  E) implement evidence-based practice programs for diagnosis and treatment.

• Further details are in the Sept. 22, 2006 Children's Community Resources Child Psychiatry Coalition Presentation to Cowlitz County Commissioners

• The Child Psychiatry Coalition is actively seeking funding for different components of their broader plan.  They have had discussions with the Cowlitz County Commissioners about using tax dollars to provide partial funding, and have applied for a number of grants. 
• Grant applications include: Healthy Tomorrow Grant "Successful Learning in Vulnerable Preschool Children through Improved Mental Health submitted by Dr. Caven's Child and Adolescent Clinic.  This grant proposal looks at finding vulnerable children from pre-birth to age 6 and engaging them in a medical home, development and mental health screening for vulnerable children and their mothers for emotional status using screening instruments; referring identified children and parents to collaborating agencies for additional help; teaching families better ways to nurture their young children, and conduct a community and family awareness campaign.
• The Child Psychiatry Coalition also received a $9200 CATCH Planning Grant: Community Medical Home for Child Psychiatry from the American Academy of Pediatrics in 2006. For more info: article, grant abstract
• Dr. Cavens gave a presentation about her county's medical home activities to the members of the statewide medical home strategic planning workgroup for children with special health care needs in November 2006.

Past Activities

• …Our desire is to create a clearinghouse model of information sharing for professionals and families in our community. Our long-term goal is to assure local support and resources for families of children of special health needs. This might be in the form of guest speakers, support groups, workshops, consulting medical specialists, etc. The role of the local Medical Home Leadership Team is to learn what is needed in our community and how to make that information available to all interested parties.

Other Medical Home-related Activities

• Cowlitz County was a WISE integrated services grant pilot site, and focused on how to do a common enrollment or application form for young children with special health care needs.
• Dr. Cavens and other providers who serve children in Cowlitz have successfully brought together countywide coalitions for a variety of issues including 1) increase the rate of pediatric immunizations and 2) address pediatric obesity through the Shape Down program.
• Reaching Children: Building Systems of Care (SCHIP) grant: "Creating Greater Clinic Involvement in Signing Up Children for Medical Insurance"(2001) led by Dr. Cavens
• CATCH Planning grant "Returning Medical Dropouts to Their Medical Homes" (2000)

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Kitsap County

Current and Upcoming Activities

• Blanket public awareness via quarterly mailing of Child Health Notes to primary care providers (PCPs) in county.
• Targeted outreach via lunchtime presentations to PCP office staff.  Adapted medical home "menu" for building a medical home for practices (from New England SERVE physician brochure).
• Update and maintain resource packets for distribution to PCP offices and families of CSHCN
• Added new public health nurse CSHCN Coordinator and parent to team; currently recruiting physician to join team

Past Activities include:

• Outreach focus to family practice clinics.
• Presentations to Naval Hospital Bremerton and Family Practice residents, Harrison hospital, and Peninsula Community Health Center (a free satellite clinic in the county which is receiving increasing numbers of referrals for children on Medicaid).
• Also pediatric outreach, especially to Bainbridge and Group Health Cooperative
• Provided a mini resource session at Holly Ridge Center’s Infant/Toddler Program Retreat.
• Developed and distribute packet of community resources for primary care providers on services for CSHCN and their families. Information can be posted on practice bulletin boards.

Other Medical Home-related Activities

• Kitsap County Interagency Coordinating Council

  (/www.kitsapicc.org/.) Kitsap County is fortunate to enjoy a well-rounded and well-attended County ICC, where families and professionals work together to meet the needs of children with disabilities birth to 6 years of age. Sub-committees include the Early Intervention Services (EIS) Committee, Early Hearing Diagnosis, Detection and Intervention (EHDDI) Committee, and the Transition Committee.

  The Kitsap EHDDI Committee members represent multiple agencies and interests in Kitsap County.  Agencies represented on the committee include Early Head Start, Harrison Hospital, Navy Hospital, Central Kitsap School District, Kitsap County Health District, Puget Sound Therapy Services, Holly Ridge Center, Kitsap County Family Resources Coordination and Family Conversations.   This positive, collaborative group is dedicated to improving early hearing detection, diagnosis and intervention for children in Kitsap County. They have been meeting regularly since November of 2003.

• The Transition Committee is a newly-formed group whose primary outcome is to improve transitions for children birth to six in our county. Membership consists of school district personnel, Head Start and Early Headstart partners, childcare providers, early intervention professionals, and other community members.

• AAP CATCH planning grant in 2000 to Bremerton-Kitsap County Health District for "Linking Migrant Refugee Children to Health Care." The Kitsap Prenatal & Young Child Health Care Council developed a culturally relevant action plan to link Hispanic immigrant and refugee children from birth to 18 years with child health care providers in Kitsap County. Population described through key informant interviews and an action plan developed with the assistance of a culturally competent consultant and representative parents. The action plan based on meeting the needs and reducing barriers identified by the parents of the target population through focus groups.

• Developmental Disabilities Resource Fair for individuals with developmental disabilities, family members, and others is an annual event sponsored by The Division of Developmental Disabilities Region V-Kitsap, Kitsap County Developmental Disabilities, The Kitsap County Parent Coalition, Arc of Kitsap/Jefferson Counties, and Kitsap County Early Intervention Services. More than 75 agencies, programs and support groups are represented including early intervention, parks and recreation, community services, residential agencies, employment vendors, governmental support, respite, support groups, advocacy, transportation and more! The keynote this year on fostering self-determination and self-advocacy was presented by Dr. Hank Bersani, Jr., Chair of the Division of Special Education at Western Oregon University and founder of Community Integration Associates; recipient of numerous awards and author of several publications.

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Lewis County

• The Lewis County Medical Home team participates in the Lewis County Autism Coalition.  Coalition activities include:
  • Families Forward Conference: Autism Awareness - September 23, 2011
  • The Coalition developed a roadmap for parents in the community to identify early signs of autism and find appropriate resources
    Lewis County Roadmap: English, Spanish

 

• The team distributes quarterly Child Health Notes (CHN) through the Lewis County Parent-to-Parent Program housed at Reliable Enterprises.  CHN provide diagnosis-specific information and resources for primary care providers and others on current health issues for children with special health care needs. www.reliableenterprises.org/ChildHealth.html

Other Medical Home-related Activities

• Parent to Parent team member SW Regional Coordinator for WA Family Voices Family to Family Health Education and Information Center (focus on children with special needs)
• Pope’s Kids Place provides local access to care for children with chronic health care needs. Pope’s Kids Place has dental, medical and respite programs.
• Pope’s Kids Place has had a Board of Review for a long time where all service providers for a child can come together and meet to formulate a plan.

Past Activities

• Lewis County Public Health received an American Academy of Pediatrics CATCH 2009-10 planning grant to develop a Lewis County Childhood Obesity Coalition (name later changed to more positive Lewis County Health Family Coalition).
  
• Healthy Tomorrows grant "Pre-emptive Behavioral Health Team Intervention for At-risk Children and Families" (2005) to Pope's Kids Place. Established a program to pre-emptively intervene with  children and adolescents who have difficult behavioral and emotional problems that put them at risk for school suspension and/or introducation to the juvenile justice system.
• "Facilitating Health Care for Children with Special Needs in Rural Southwest Washington State" (1999-2002). Federal HRSA grant to public-private partnership consortium comprised of Lewis County Children with Special Needs Program (LCCSN), the Seattle Children's Hospital
• with a satellite clinic in Olympia, and the University of Washington School of Pediatric Dentistry in Seattle. The project’s specific goals were to: (1) identify children with special healthcare needs in six rural Southwest Washington counties (Lewis, Cowlitz, Grays Harbor, Mason, Pacific and Wahkiakum) and ensure medical and dental care; (2) strengthen partnerships that would allow for provision of locally provided medical and dental care; (3) evaluate the benefits and challenges of outreach to rural special needs children; and (4) establish innovative outreach care models.
• "Lewis County Eating Disorders Program" - 1999 CATCH planning grant led by community pediatrician to develop a multidisciplinary, community-based treatment team involving nutritional, medical, and mental health components to provide care to those with eating disorders. After further assessing the problem through broad-based community meetings, a community-wide prevention program will be established.

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Thurston County

Team contact list | County CSHCN Data

Current and Upcoming Activities

• Parent team member recruiting additional members for team

Past Activities

• MHLN team gave Medical Home Tool kit to pediatricians’ office in Rochester to pilot
• Developed survey for primary care providers on mental health services for children
• Parent team member involved with parent training on using a care notebook to document child’s health and services. Parent also hosted legislators from her district to come spent time at her house with her family to learn about what life is like for families whose children have significant health care needs.
• Presentations to primary care providers about medical home and communty services

Other Medical Home-related Activities

• CATCH Grant 2006 "Children's Access to Care- Thurston County". A consortium of pediatricians will convene, led by the county public health officer, a pediatrician, to assess: 1) gaps in preventive health care for our uninsured and underinsured children; 2)barriers pediatric practices face to enrolling these children as regular patients, and 3) barriers families face to obtaining preventive health care for their children. The consortium will develop a plan to increase access to medical homes, including recommendations for ensuring public health programs promote this goal.

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