By Melinda Young
Case managers and care coordinators need such a wide range of knowledge about community resources to address their patients’ social determinants of health that resource tools can be a huge time-saver.
For a care coordination program involving complex pediatric patients, leaders developed a series of nearly two dozen resource guides they call playbooks. These playbooks come in hard copy and electronic versions and are kept up to date, says Lorena Flaa, BSN, RN, nursing care coordinator manager of the Indiana Complex Care Coordination Collaborative (IC4) at Indiana University School of Medicine.
“We started basing the playbooks on the needs of new coordinators and what they were struggling with the most,” Flaa says.
For example, the resource guides note how to help families find utility assistance. Other guides described how families could obtain necessary equipment and items that often are not covered by insurance. One guide might address how to find a special needs car seat for a child. It is broken down into what is available based on a person’s insurance funding sources.
“You could spend literally days trying to research this information,” Flaa says. “You’re spinning your wheels. By getting these playbooks, it’s going much quicker.”
These guides, which typically consist of a couple of pages, are comprehensive and time-consuming to create. Experts carefully vet each source. To be useful, playbooks have to be updated regularly with funding changes and regulatory changes.
But they can save care coordinators a great deal of time and make it far easier for them to help families find additional and essential resources that are not traditionally part of their medical care. For example, one two-page playbook is about wheelchair ramps. The playbook, created by the Indiana University School of Medicine department of pediatrics and supported by the Health Care Delivery System Innovations for Children with Medical Complexity, includes these main sections:
- How can a family obtain a ramp;
- Helpful tips regarding waivers;
- If patient has a Medicaid waiver;
- If patient has no funding source for a ramp;
- Types of ramps.
Under Helpful Hints, the playbook notes renters must obtain a signed agreement from the property owner for the installation of a ramp. They can give the letter to their waiver case manager.
The playbook also lists some resources for ramps for families without insurance funding. These resources are all local to patients, including an Indiana nonprofit organization called Servants at Work that builds ramps for low-income individuals with disabilities and no other funding sources.
Another two-page playbook describes respite care, which is temporary or periodic relief for primary caregivers of patients with disabilities.
“New care coordinators may not even know what respite care is, so this goes in a playbook,” Flaa says. “Someone who has been in the field for a long time will know what resources are available.” Nurse care coordinators could learn about these resources from social workers, but a written guide also is helpful.
The playbook includes respite care resources for people with Medicaid waivers as well as a description of long-term respite at a Medicaid-certified nursing facility. It lists examples of pediatric nursing facilities in Indiana. It also explains how people could hire a special needs babysitter, listing an online network for such specialists. It also lists other options, including churches that host special needs ministries, YMCA, and camps for youth with special needs.
There are links for some of the resources listed, and updates are noted along with a note on when the change occurred.
“It takes a long time to develop the playbooks,” Flaa says. “For an adaptive car seat [playbook], we contacted a local children’s hospital in Indianapolis. We knew an occupational therapist who ran a safe transportation department and asked him, ‘What is the best process for a new coordinator to make a referral to get this child the right kind of car seat?’”
Case managers and care coordinators need such a wide range of knowledge about community resources to address their patients’ social determinants of health that resource tools can be a huge time-saver. For a care coordination program involving complex pediatric patients, leaders developed a series of nearly two dozen resource guides they call playbooks.
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