Services for Children with Special Needs March 23, 2011 1 Agenda - - PDF document

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Services for Children with Special Needs

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March 23, 2011

Agenda

• About the ADRC
• Services for Children with Special Needs

Services for Children with Special Needs

• Background – Gertrude Carter, M.D.
• CalOptima – Peter Scheid, M.D.
• California Children’s Services – Hoda Kaddis, M.D., F.A.A.P.
• Regional Center of Orange County – Peter Himber, M.D.
• OC HCA Behavioral Health Services/Children & Youth Services –

Marcy Garfias, L.C.S.W.

• Transitions – Linda O’Neal, M.A.

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,

• Case Study and Q&A

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Supported by the California Health and Human Services Agency and U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services under Grant CFDA 93.779

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ADRC OC Program Function

Information & Resource Referrals Information & Resource Referrals Options Counseling Advice & Assistance Options Counseling Advice & Assistance Community Education & Outreach Community Education & Outreach

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Assistance with Transitions Assistance with Transitions

Information & Resource Referrals

Call the County of Orange Office

• n Aging at 1-800-510-2020

Speak to an Information p & Assistance Referral Specialist

Find resources online at www.adrcoc.org

The searchable directory includes many resources to help you

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Visit any of the 3 ADRC partner locations

Please refer to your handout for a list of locations close to you

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Services for Children with Special Needs

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Learning Objectives

• Know the services offered by key agencies
• Determine most appropriate resource

Determine most appropriate resource

• Understand how to prepare and assist families applying

for services

• Make appropriate referrals

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• Know transition supports for children as they reach

adulthood

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Background

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Gertrude Carter, M.D. CalOptima, Chief Medical Officer

CalOptima’s Health Care Delivery System

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Peter Scheid, M.D. CalOptima, Medical Operations Medical Director

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CalOptima’s Mission

To provide members with access to quality health care services delivered in a cost-effective and compassionate manner

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What does CalOptima cover?

• Physician services
• Hospital services
• Medical supplies
• Prescription drugs
• Lab tests and X-rays
• Prenatal care
• Immunizations
• Durable medical equipment
• Prosthetics and orthotics
• Transportation
• Hospice
• Long-Term Care

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• Physical, speech and
• ccupational therapy
• Early and Periodic Screening,

Diagnosis and Treatment (EPSDT) for Children

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What is “carved out” of CalOptima?

• CalOptima contracts with the California Department of

Health Care Services for Medi-Cal health benefits

• Medi-Cal benefits “carved out” of CalOptima’s contract:
• Mental health services
• Psychotropic medications
• California Children’s Services
• Personal care services

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What is “carved out” of CalOptima?

• CalOptima contracts with Managed Risk Medical

Insurance Board (MRMIB) for Healthy Families benefits

• Healthy Families benefits “carved out” of CalOptima’s

contract with MRMIB:

• Dental & vision access through plan selected at enrollment
• Mental health services for serious emotional disturbance

(Covered by Children & Youth Services)

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• California Children’s Services

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How is eligibility determined?

• Medi-Cal
• Orange County Social Services Agency
• Children
• Pregnant Women
• CalWorks/TANF
• Persons with Disabilities
• Persons aged 65 and over
• Social Security Administration
• Persons receiving Supplemental Security Income (SSI) or
• State Supplemental Payment (SSP)

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• Healthy Families Program
• MRMIB

Newly Assigned Members

• What does CalOptima know?
• Name
• Gender
• Gender
• Address
• Phone number
• Aid code (reason for Medi-Cal eligibility)
• What don’t we know?
• Diagnoses

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• Diagnoses
• Medical needs
• Barriers to care

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CalOptima’s Delivery System

• 2/3 of Medi-Cal and all Healthy Families members

receive care through delegated health networks (see list in hand-out)

• 1/3 of Medi-Cal members receive services through

CalOptima Direct or CalOptima Care Network (CalOptima works directly with providers)

• Populations in CalOptima Direct Administrative
• Transitioning members, Medi-Medi, Share of Cost

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• Populations receiving care through CCN
• Long-Term Care Aid Codes
• Foster Care (~4,000)
• Members with Hemophilia
• Other condition-specific populations

CalOptima Delivery System

Health Plan

• Identification of Children with Special Needs
• Health Risk Assessments
• Disease Management/Health Education
• Grievances and Appeals
• Customer Service Community Liaison

Health Network

• Customer Service, Community Liaison
• Provider Forums
• Identification of Children with Special Needs
• Case Management for moderate and high

risk members

• Utilization Management
• Initial Appeals

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Provider

• Direct patient care, identification of clinical needs
• Case management for low risk members
• Primary care coordination
• Initiation of referral process
• Interaction with HN and Plan to obtain services

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CalOptima Services

• Early Identification of children with special needs
• Health Risk Assessments
• Patient Surveys
• Utilization Data
• Utilization Data
• Case Management referrals
• Case Management screening to determine needs
• Development of Individual Care Plan
• Trained nurses and support staff help determine needs,

identify resources, and coordinate care between all providers

• Regional Center Liaison

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• Pediatric Specialty Case Manager
• In development: Pediatric-specific interdisciplinary care

teams

CalOptima Services

• Provider Support
• Continuing Medical Education
• Consultation (i.e., doctor to doctor)
• Resource manual for providers
• Behavioral health support
• Member and Family Support
• Health Education
• Disease Management
• Community Liaison (customer service)

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• Community Liaison (customer service)
• Regional Center Liaison
• Forum with other stakeholders to improve services
• RCOC, CCS, School Nurses

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Support For CalOptima Members

• CalOptima Customer Service and Member Liaison

Program for seniors, people with disabilities, chronic conditions or who are homeless conditions or who are homeless

• (714) 246-8500
• (888) 587-8088
• www.caloptima.org
• 1120 W. La Veta Avenue

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Orange, CA 92868

California Children’s Services Orange County

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Hoda Kaddis, M.D. Medical Director

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CCS Organizational Structure

Children’s Medical Ser ices Three State Regional Offices Local County CCS Offices Services Central State Office in Sacramento Offices Offices

Overall Program Policy Development Monitoring counties, CCS approved facilities and providers, and consulting Determination of Eligibility and Benefits, Authorization

• f Services, and Direct

Therapy

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CCS Eligible Medical Conditions

• Serious chronic catastrophic disabling disfiguring conditions,

such as:

• Cancer
• HIV infection
• HIV infection
• Congenital heart defects
• Cleft lip and palate
• Insulin dependent diabetes
• Hemophilia
• Hearing loss
• Extreme prematurity
• Kidney failure
• Severe burns

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• Severe burns
• Traumatic brain injuries.
• Medical Therapy Program provides OT/PT for:
• Spastic CP
• Other disabling conditions, such as Muscular dystrophy

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CCS Eligibility Requirements

• 0 - 21 years old
• Residents of OC
• Eligible medical condition
• Financial criteria
• Under 40K
• Healthy Families
• Medi-Cal

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• Over 40K or other insurance if estimated out-of-pocket expenses

are more than 20% of family’s income

• Medical Therapy Program does not require financial eligibility

CCS Services

• Serves 13,000
• 68% Medi-Cal
• 20% Healthy Families
• 12% straight CCS
• Covered conditions carved out of managed care
• Refer a child with a diagnosed eligible condition to CCS

for treatment

• PT /OT in the medical therapy units on public school

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grounds

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CCS Services

• Medical treatment from approved providers and facilities
• nly with prior authorizations
• Except emergency treatment

p g y

• Payment for treatment of eligible conditions only
• Services coordination with managed care, PPOs, RCOC,

and school districts

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CCS Enrollment Process

• Referral by fax, mail or in person by anyone
• Medical documentation
• Reports
• Labs
• X-rays
• Demographic and insurance information
• Application and services agreement for non Medi-Cal or

HF li t

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HF clients

• Eligibility determination within 5 working days
• Authorizations for treatment

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Who Pays for CCS Services?

• Commercial insurance pays first then CCS
• CCS pays for authorized for medical treatment

p y

• Provided by CCS approved providers
• To treat only the CCS condition
• Not for primary care
• Submit claims to fiscal intermediary agency

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CCS Tips and Advice

• PCP determines if treatment is for eligible condition
• Follow through with the paperwork and application process
• Only eligible conditions
• Not covered by CCS, may be covered by other agencies
• Primary care, school physicals, immunizations, colds, ear infections
• Mental, behavioral or psychiatric disorders, developmental delay,

learning disabilities and autism

• Need coverage for other medical and health services

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g

• For medication, take CCS authorization and prescription

to pharmacy

• A denial can be appealed

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For More CCS Information

• California Children’s Services

200 W. Santa Ana Blvd., Suite 100 Santa Ana, CA 92701 Santa Ana, CA 92701

• Phone: (714) 347-0300
• Fax : (714) 347-0301
• www.ochealthinfo.com/ccs

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Services for Children with Special Needs

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Peter Himber, M.D. Chief Medical Officer

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RCOC Basics

• Regional Centers established by Lanterman Act
• 21 Regional Centers in California

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• Serve ~ 216,000
• Non-profit organizations contracts with State of California
• Administered by Department of Developmental Services

(DDS)

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(DDS)

RCOC Basics (cont.)

• Only Regional Center in O.C.
• 3 Programs with different eligibility criteria and services

g g y

• ffered
• Early Start: 0 - 3 years old (~2800 consumers)
• Prevention: 0 - 3 years old (~ 300 children)
• Lanterman: 3 years old - adult (~14,000 consumers)
• Annual budget ~ $250 million

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• Shared clients
• 41% Medi-Cal
• 5% CCS

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RCOC Goals

• Normalization - regardless of degree of disability, each

individual has right to:

• Live as normal as possible

p

• Make own choices
• Live as independently
• Community integration - opportunity to benefit from and

participate in all daily living experiences

• Education
• Employment

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• Socialization
• Go to extraordinary lengths to avoid institutionalization

Funding for RCOC Services

• Entitlement, not based on financial status
• Most services are free (may change)

( y g )

• Mandated payor of last resort and we are required to look

for alternative resources including:

• CalOptima
• OC Mental Health
• School
• Other government programs

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• CCS
• Private Health Insurance

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RCOC Is The Payor Of Last Resort

• Families must access other services first
• Examples:

Examples:

• 2 year old boy with speech delay
• RCOC pays for evaluation and determines he needs speech therapy
• Pediatrician refers for speech therapy through CCS, CalOptima or other health

plan

• If all others deny coverage, then RCOC funds for speech therapy
• 5 year old girl with behavioral concerns
• School district pays for behavioral services related to academic performance
• nly

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• nly
• RCOC funds for in-home behavioral services

RCOC Programs

• Programs:
• Early Start: 0 - 3 years of age
• Prevention: 0 - 3 years of age
• Lanterman: 3 years - adult
• Each has their own eligibility criteria and services offered
• State determines eligibility criteria
• RCOC follows legal requirements
• Services based on the needs of the child

Referral can be made b an one

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• Referral can be made by anyone

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RCOC Prevention Program

• Children 0 - 3 years old at risk for substantial

developmental disability

• 2 or more risk factors for developmental disability such as
• 2 or more risk factors for developmental disability such as

prematurity, seizures, birth illness or injury

• Parent has a developmental disability
• 33 - 49% delay in one area, such as speech or motor skills
• Services:
• Assess and develop program plan within 60 days
• Periodic developmental monitoring

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• Case management
• Referral to other resources, such as Hanen, Head Start,

CalOptima or CCS

• Parent training

RCOC Early Start Program

• Children 0-3 years old with:
• Condition with established risk of developmental delay, such as

Down Syndrome

• Significant developmental delay
• Significant developmental delay
• 0 - 23 months: 33% delay in 1 or more areas
• 24 - 36 months: 50% in 1 area or 33% in 2 or more areas
• Services:
• Assess and develop program plan within 45 days
• Case management
• Therapy (speech, occupational and physical) if not provided by

alternative resources such as CalOptima CCS or private

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alternative resources such as CalOptima, CCS or private insurance

• Behavioral Services
• Respite
• Referral to other resources

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RCOC Lanterman Program

• Children over 3 years old with a permanent, significant

developmental disability

• Expected to continue for a lifetime
• Present before age 18
• Eligible conditions
• Autistic Disorder
• Cerebral Palsy
• Epilepsy
• Intellectual Disability
• Other condition functions similar to or requires same services as intellectual disability
• Substantial disability in at least 3 areas of major life activity

E l d l l hi t i di d d l i

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• Excludes solely psychiatric disorders and learning

disabilities

• Eligibility criteria much stricter than Early Start (90% of

Early Start kids do not qualify)

RCOC Lanterman Timeline

• 15 working days from referral to complete assessment
• 120 calendar days of assessment to determine eligibility

120 calendar days of assessment to determine eligibility

• 60 days of eligibility determination to develop

Individualized Program Plan (IPP)

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RCOC Lanterman Services

• Individualized based on need
• Service coordination and advocacy; examples:
• Schools
• CCS
• CCS
• Department . of Rehabilitation
• Residential placement/services
• Day programs/activities
• Vocational programs
• Respite
• In-home behavioral services
• UCI Neurodevelopmental Clinic

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For More RCOC Information

• RCOC
• Intake: (714) 795-5344
• Mailing Address: P.O. Box 22010

g Santa Ana, CA 92702-2010

• www.rcocdd.com
• Comfort Connection - Family Resource Center
• (714) 558-5400 or (888) FRC-BABY
• Provide information and support to all families, even if not eligible

for RCOC services

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• Lending library
• Computer access

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Health Care Agency Behavioral Health Services Children and Youth Services

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Marcy Garfias, L.C.S.W. Central Programs Program Manger

CYS Basics

• County agency
• Children, adolescents, and transitional age youth with

g y serious, emotional, or mental problems

• Provides mental health services
• Person-centered
• Family-focused
• Culturally and language appropriate
• Evidenced-based

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• Coordination with SSA, Probation and schools

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CYS Structure

• 3 primary departments
• Regional Services
• Mental Health Services Act (MHSA) Services
• Central Services
• Crisis assessment (714) 517-6353
• Medi-Cal beneficiaries
• Indigent youth under 18

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CYS Regional Services

• Out-patient population
• 0 - 20 years old
• Special education students
• Medi-Cal beneficiaries
• Healthy Families beneficiaries with serious emotional

disturbance (SED)

• Wards and dependents of court (group homes)
• Indigent
• Services
• Mental health

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• Mental health
• Therapeutic behavioral
• Evidence-based treatment
• Medication monitoring
• Coordination with school districts

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CYS Regional Services Locations

• South: 6 sites
• North: Placentia
• West: Westminster
• East: Santa Ana
• Costa Mesa

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• Mission Viejo: 2 sites
• Outpatient contract services: 18 sites

CYS MSHA Services

• 0 - 18 and 16 - 25 transitional age youth (TAY)
• Un/underserved seriously emotionally disturbed children and

families

• Homeless or at risk of being homeless, hospitalized, or

incarcerated

• Ethnic and linguistic populations to assist children and families to

access mental health services.

• Services
• Full service partnerships
• Mentoring

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• Mentoring

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MSHA Contracted Services

• Services for Children and Adolescents
• Renew: Full Service Partnership (FSP)
• Focus: FSP
• In-Home Crisis Stabilization
• In Home Crisis Stabilization
• Crisis Residential
• Outreach and Engagement
• Project Together: Mentoring
• Services for TAY
• STAY: FSP
• FOCUS: Children & TAY FSP

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• FOCUS: Children & TAY FSP
• Youthful Offender Wraparound (YOW): FSP
• Crisis Residential
• Social Rehabilitation Program
• Girls Court

CYS Central Services

• 0 - 17 years old
• Dependents at Orangewood Children and Family Center (OCFC)
• Wards (Juvenile Hall and Probation Camps)
• Probation youth
• Foster youth
• Youth at risk for out-of-home placement and/or hospitalization
• Services
• Mental health services
• Evidence-based treatment
• Medication monitoring

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• Medication monitoring
• Therapeutic behavioral services
• Wraparound services

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CYS Central Services Units

• Clinic and Evaluation Guidance Unit
• Probation: Juvenile Hall, Juvenile Drug Court & Probation Camps
• Orangewood OCFC
• Continuing Care Placement Unit (CCPU)
• Child Abuse Prevention Team (CAST)
• Therapeutic Behavioral Services (TBS)

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• Wraparound Services
• Youth Reporting Centers (YRCs): North & Central

CYS Referral and Enrollment

• Regional outpatient referrals
• Medi-Cal walk-in or call for appointment
• Healthy Families contact health network
• Orange County Mental Health Plan 1-800-723-8641

g y

• Special Education referrals
• School district as part of an IEP
• MHSA program referrals
• CYS outpatient program
• SSA
• Probation

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• Probation
• Crisis assessment team
• Central programs referrals
• SSA
• Probation

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Who Pays for CYS Services?

• Medi-Cal
• Healthy Families for beneficiaries with serious

ti l di t b emotional disturbance

• School district
• MHSA
• Health insurance

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• County
• Out-of-pocket

For More CYS Information

• CYS Central Administration
• (714) 834-5015
• 405 W. 5th Street, STE. 590, Santa Ana, CA 92701
• Behavioral health services directory and contracted

programs

• www.ochealthinfo.com

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Education and Transition Programs

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Linda O’Neal, M.A. Transition Specialist

Special Education Eligibility

• Visual impairment
• Deaf blindness
• Mental retardation
• Speech or language
• Other health impairment
• Traumatic brain injury
• Established medical

disability p g g impairment

• Orthopedic impairment
• Specific learning disability
• Autism

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disability

• Emotional disturbance
• Multiple disability

Autism

• Hard of hearing
• Deafness

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Individual Education Plan (IEP) Process

• Child is enrolled in school
• K - 12
• No older than 22

f

• Parent submits written request for assessment
• School develops assessment plan
• Within 15 days of request
• Written
• Parent has 15 days to sign, return and give permission to assess
• School holds IEP meeting with parents
• Withi

60 d

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• Within 60 days
• Written IEP reviewed
• All sign
• IEP implemented soon as possible and reviewed annually
• Parent can request review at any time
• ITP development process
• Typically informal individualized assessment
• Standardized assessment tools less commonly used

Individual Transition Plan (ITP)

• Implemented by 16th birthday
• Most districts begin process around 15th birthday
• Part of IEP and is reviewed annually
• Education (post and secondary)

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• Employment
• Independent Living

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• Transition planning
• Preparation for post-secondary education

Transition Services

• Employment preparation
• Specialized job development
• Job coaching
• Case management
• Benefits planning & management

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p g g

• Travel training
• Self-advocacy and self-sufficiency skills training

Who Pays for Secondary Transition Services?

• Social Security

Administration

• SSU/SSDI
• School district
• Regional Center
• Work Incentives
• CalOptima
• Out-of-pocket
• Other

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• Workability 1, CA

Department of Education

• Department of Rehabilitation
• OC Health Care Agency

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OC Health Care Agency, Mental Health

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www.tknlyouth.info

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• Required by law since 2004
• To help students access services after school
• Higher education

Summary of Performance Report

• Higher education
• Training
• Employment
• Independent living
• Includes
• IEP
• Summary of academic achievements

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• Summary of functional performance
• Record of accommodations, modifications and assistive technology
• Makes recommendations to help student achieve post-

school goals

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More Special Ed Information

• Contact local school district
• Orange County Transition Program Contact List

Orange County Transition Program Contact List

• Linda O’Neal
• loneal@iusd.org
• (949) 936 - 5040

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Case Study

May, a five-year old, was in a serious car accident. May, a five year old, was in a serious car accident. May received a traumatic brain injury, which resulted in severe cognitive impairment. The accident also resulted in left sided paralysis.

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Planning Committee & Speakers

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