Disclosures Accreditation and Designation Statements The American Academy of Pediatrics (AAP) is...

Disclosures

Accreditation and Designation StatementsThe American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAP designates this live activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity is acceptable for a maximum of 1 AAP credit. This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of Pediatrics. The American Academy of Physician Assistants accepts AMA PRA Category 1 Credits™ from organizations accredited by the ACCME. This program is approved for 1 NAPNAP CE contact hour of which 0 contain pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners Continuing Education Guidelines.

Purpose of CourseThe American Academy of Pediatrics and National Center for Medical Home Implementation will be hosting a free four-part Webinar series beginning in April 2011. The purpose of the webinar series is to provide child health professionals with practical strategies for implementing medical home in practice. Each webinar will be led by recognized experts with the goal of educating participants about the value of the family-centered primary care medical home for all children and youth, especially in the daily delivery of preventive, acute, and chronic care. Faculty will point participants to practical tools and resources, and will provide strategies for improving quality of care and increasing patient/family partnership and satisfaction.

Learning ObjectivesAt the conclusion of this activity, participants should be able to: Describe selected essential clinical and procedural elements needed in medical home practices to deliver chronic care for patients and their families Explain the importance and application of patient population management in the delivery of care for children with a chronic health conditions Explore the delivery of effective chronic care through a case study on pediatric asthma care in the medical home

Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities The AAP CME program aims to develop, maintain, and improve the competence, skills, and professional performance of pediatricians and pediatric healthcare professionals by providing quality, relevant, accessible, and effective educational experiences that address gaps in professional practice. The AAP CME program strives to meet participants' educational needs and support their life-long learning with a goal of improving care for children and families. (AAP CME Program Mission Statement, September 2010).The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest.All AAP CME activities will strictly adhere to the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity.The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.

Disclosures

Name/Role

Relevant Financial Relationship(s)

(Please indicate Yes or No)

Name of Commercial Interest(s)

(Please list name(s) of proprietary entity) AND Nature of Relevant

Financial Relationship(s)(Please list: Research Grant,

Speaker's Bureau, Stock/Bonds excluding mutual funds,

Consultant, Other - identify)

Disclosure of Off-Label (Unapproved)/Investigational Uses of Products

AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or

demonstrate pharmaceuticals and/or medical devices that are not approved by the FDA and/or medical or surgical procedures that involve an unapproved or

“off-label” use of an approved device or pharmaceutical.

(Do intend to discuss or Do not intend to discuss)

Thomas Kliztner, MD, PhD, FAAP, Physician Representative,

Planning Committee Member YesProgenitor Cell Therapy,

Amorcyte Do not intend to discuss

Linda Lindeke, PhD, RN, CNP, Planning Committee Member No None Do not intend to discuss

Marie Y. Mann, MD, MPH, FAAP, Planning Committee Member Yes

NovoNordisk,Baxter Healthcare Do not intend to discuss

William Schwab, MD, FAAP, Planning Committee Member No None Do not intend to discuss

Deborah McWilliams, MD, FAAP, Faculty No None Do not intend to discuss

Tammy Schmit, RN, Faculty No None Do not intend to discuss

Michelle Esquivel, MPH, AAP Staff, Planning Committee Member No None Do not intend to discuss

Angela Tobin, AM, AAP Staff, Planning Committee Member No None Do not intend to discuss

Corrie Pierce, AAP Staff, Planning Committee Member No None Do not intend to discuss

Disclosures

Commercial Supporters There is no commercial support associated with this course.

Product-Specific Advertising / Links to Product WebsitesNo product-specific advertising of any type appears in this activity. No links to product websites appear in this activity.

List of Principal Faculty and Credentials Deborah McWilliams, MD, FAAPTammy Schmit, RN

Name of Medium or Combination of Media Used Live webinar course

System requirementsPC-based attendeesRequired: Windows® 7, Vista, XP or 2003 ServerMacintosh®-based attendeesRequired: Mac OS® X 10.4.11 (Tiger®) or newer

Questions? Contact Corrie Pierce at [email protected] Privacy and Confidentiality Statement

At the American Academy of Pediatrics (AAP), we take the issue of privacy very seriously. We do not sell, distribute, barter, or transfer personally identifiable information obtained from a user to a third party without your consent. Any information collected on the Web site is only used for the purpose stated.The AAP list is only for important communications, and your e-mail address will not be sold or provided to third parties. You will not receive advertising or promotional materials on this list.The AAP may use “cookie” technology to obtain non-personal information from its online visitors. We do not extract personal information in this process nor do we provide this information to third parties. We also do not contact you based on the information in your cookie file.The AAP has taken steps to make all information received from our online visitors as secure as possible against unauthorized access and use. All information is protected by our security measures, which are periodically reviewed.

© COPYRIGHT AMERICAN ACADEMY OF PEDIATRICS, ALL RIGHTS RESERVED.American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL, 60007, 847-434-4000

Partnering with Patients and Families

in the Medical Home

2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation

The Role of the Medical Home in Chronic Care Management

Deborah McWilliams, MD, FAAPTammy Schmit, RNMayo Clinic, Minnesota

May 10, 2011

Disclosures

We have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Looking Back…

The first webinar of this series:

Medical Home in Preventive and Acute Care (April 27 – archived online) Health care teams, family/professional partnerships History of medical home model The importance of quality improvement

Webinar Objectives

By the end of this webinar, the participant will be able to:

Describe selected essential clinical and procedural elements needed in medical home practices to deliver chronic care for patients and their families

Explain the importance and application of patient population management in the delivery of care for children with a chronic health conditions

Explore the delivery of effective chronic care through a case study on pediatric asthma care in the medical home

1) Changing landscape2) Assessing current needs of our practice3) Putting a structure into place4) Aspects of Spread/Maintenance

Pediatric Asthma Care Management

Unique aspects of our clinic

Large subspecialty clinicPrimary care

55% patients/dependents (self-insured) Pediatricians + Family Medicine (5 sites)

16 Pediatricians, 7 PNP, residency program 49 Fam Med, 11 FNP/PA’s, residency program

Issues with appointment access Prevalence of current pediatric asthma = 12%

Relatively low ER/Hosp utilization for asthma Hosp 0.2/1000 Healthy People 2010 Target

0.8/1000 ER 0.8/1000 Healthy People 2010 Target 1.7/1000


1) Changing landscape2) Assessing current needs of our

practice3) Putting a structure into place4) Aspects of Spread/Maintenance


1) Changing landscape MN Baskets of Care Healthcare Home MN Community Measurement

2) Assessing current needs of our practice3) Putting a structure into place4) Aspects of Spread/Maintenance

Baskets of Care Proposed Plan MN legislature

Classify severity onceAssess control twice a yearSpirometry min once a year

Once every 2 yrs for intermittent asthma

Peak flow monitoring (when spirometry not available)

Home assessment when neededFlu shots yearly, pneumococcal q 5 yrsIdentify/treat comorbid conditionsWritten Asthma Action PlansSpecific Education

“Healthcare/Medical Home” Certification

(Mayo Clinic, certified Feb 2011)

These 2 slides adapted from FAQ sheet developed by Steve Hagedorn, MD

The core principle is the same: The needs of the patient come first. The way we define and address our patient’s needs is changing. We use a team approach, with all team members working to the full extent of their licensure. We assess and address our patient’s needs beyond their chief complaint. We address the needs of our patient population whether they are seeing us in the office or not. We work more closely to coordinate care with the ED, hospital, care facilities and community partners.

The traditional paradigm we use to care for our patients is unsustainable. We are responsible for ever increasing numbers of patients. Advances in medicine and public health have resulted in a much older and medically complex patient population. We are expected to effectively deliver a broad range of preventive and chronic care services to our patients … A physician does not have time, resources or energy during a face-to-face office visit to accomplish this work. A new approach is needed.© 2011 Mayo Clinic

Tier Approach

Is it ethical to “tier” our patients?Our goal is to provide the right care, at the right time, in the right location, with the right provider. In our traditional model, we frequently provide unnecessary care to our healthy patients, and inadequate care to our sickest patients.

We need to develop systems to remain engaged with those patients and respond to their needs in a timely fashion to the best of our ability. By tiering our patients, based on their medical and psychosocial complexity, we are able to design and apply systems of care to better meet their needs.

© 2011 Mayo Clinic

MN Community Measurement


Asthma well controlled (symptom questionnaire)

Not at increased risk of exacerbations Pt reported ER Visits + Hosp util < 2 in last yr

Current written asthma action plan

Ages 5-50. Pts trigger reporting via billing after 2 visits.


Empower patients … but

Potential concerns: Systems issues … “Pullable” info system, searchable

registry External quality metrics “Exceptionism” “Not fair” = Not all asthmatics (visit driven) … for us =

35% = inclusion of subspecialty patients Potentially large impact …estimated 3188 pts at our sites Philosophical decisions


1) Changing landscape2) Assessing current needs of our

practice3) Putting a structure into place4) Aspects of Spread/Maintenance


1) Changing landscape2) Assessing current needs of our practice

Checking our assumptions Critical self-assessment New Rules

3) Putting a structure into place4) Aspects of Spread

Future steps Cost justification

Assessing our Needs

Step 1: Checking our assumptions

First check = small retrospective sample2nd/3rd Q 2008: all ICD9 asthma visits (n=96), 5 sites

10% AAP ever (4 % last year) 53% asthma severity documented ever (10% in FM

w/o referral) 21-48% Subspec referral rate (peds vs FM) Symptom questionnaire use none Education ???

As time has passed …. has this held true?

Intake of 1444 (25% subspecialty rate)

ER/Hosp < 2/year Meet MNCM goal 1395 (96.6%) Do not meet goal 49 (3.4%)

Current AAP Within last year 161 (11.2%) > 1 year ago 90 (6.2%) Never 1193 (82.6%)

As time has passed …. has this held true?

Intake of 818 (at first site)

Asthma Questionnaires Well controlled 509 (62.2%) Not well controlled 216 (26.4%) Poorly controlled 93 (11.4%)

Influenza vaccine 61%

Assessing our Needs

Step 2: Critical Self-Assessment (Where are we?)

No registry“Soft” diagnosisVariable nursing involvement Variable pt education availability Information not pull-able Inconsistent documentationNo “standard” of care (NAEPP/NHLBI)Minimal use of Asthma Action PlansMinimal (no?) support to school system

Critical self-assessment

Assessing our Needs

Step 3: New Rules (2009) Registry Agree to agree

“MDs prefer to practice alone together” Evidenced based care

Meet patient in a different way Right Care, right time, right place More longitudinal, less reactive

Care team model Less hierarchical, trust in others Work to full level of licensure

Need metrics for assessment Need admin support for forms “Cocoon of Support” = school system, family

Medical Home

Build an environment that values … Pt engagement/centeredness MD engagement Teamwork Evidenced based medicine Transparency – measurement and decision

making Continuous improvement – striving for excellence Systems approach – focus on efficiency

New Rules: Addition of RN Care Managers

Addition of RN Care Managers

New role not used in our practices before

How do systems match with their job role and the role of others

Always kept in mind the team effort

What things needed to change?

How could this role enhance care?

What might the barriers be?

© 2011 Mayo Clinic

Addition of RN Care Manager

Sneak peak to the future

(i.e…. Did it work ????)

Note: in the following slides, it will become evident what outcomes were most important to us by what metrics we followed (i.e., you might pick something different) …

Addition of RN Care Manager

Sneak peak to the future

(i.e…. Did it work ????)

Note: in the following slides, it will become evident what outcomes were most important to us by what metrics we followed (i.e., you might pick something different) … however, we hope their might be some general learnings from our experience that can be shared with others.

Results of Asthma Symptom Questionnaire

Notes: This includes ALL questionnaires (ex: handed out by care team, admin by CM, etc) New patients are being identified continually throughout this timeframe

© 2011 Mayo Clinic

Over past month: How much did Asthma impact activity?

(for all responses answered at First Site, N=2289)

0: Not at all

1: Almost Never

2: A little

3: Moderate

4: A lot

© 2011 Mayo Clinic

Work/School days missed = our “financial payoff”

© 2011 Mayo Clinic

Why might we have seen improvement?

© 2011 Mayo Clinic


1) Changing landscape2) Assessing current needs of our practice3) Putting a structure into place

Enrollment Criteria Competencies Define RN “actions” Medical Rule Set Communication Plan Metric Development

4) Aspects of Spread/Maintenance

Putting a Structure into Place

Looking back, what was important? Enrollment/Graduation Criteria Competencies Expectations of RN “action”

Symptom assessment Needs assessment (barriers/technique/equipment) Form completion

Medical Rule set (NAEPP/NHLBI Guidelines) Develop tools

Questionnaires Database

Communication with rest of care team Metrics (outcomes and cost/effort)

Structure: Enrollment

Enrollment Criteria Ages 5-18, current primary care patient “Persistent” Asthma Asthma not under Good Sx Control (Red, Yellow) Active Health-care Utilizers (ER/Hosp)

Graduation: “Green” (well controlled) for a year

No maintenance med No ER/Hosp use

CM is also a resource for general asthma questions

Need IT tools … but process must be done first

Structure: Competencies

Triage/assessment Knowledge Documentation Pt Education Facilitator Communication

© 2011 Mayo Clinic

NO

Administer/Record Peds Asthma

Mgmt Questionnaire

Assess Triggers Assess Triggers

Determine recommended action for tx/fup Per Fig 12/15 +

NAEPP


NAEPP Fig 13/16Later: Fig 17/18


NAEPP Fig 13/16Later: Fig 17/18

Assess education needs

· Smoking cessation· AeroChamber training· Survival skills· Lifestyle skills

Assist patient in obtaining education

Recommend/Schedule influenza

vaccine

Assess/Assist family with form completion

· Asthma Action Plan· Inhaler school form· Authorization for Release of

Medical Information· MA nonformulary

Assess Equipment Needs

· AeroChamber· Peak Flows· Med Refills

AssessmentArm

EducationArm

AdministrativeArm

Record information in database, including

time each of the processes take.

Assess “Asthma Control” Level Per Fig 12/15

NAEPP

Red

Yellow

Green

FYI Inbox PCP

Inbox PCP re need for step up in care* Contact patient

with recs

Direct communication

with MD/NP team re need for eval

* Contact patient with recs

Complete chart documentation/Arrange follow-up (i.e., reminder Inbox message)

Contact Patient

Is the patient having an acute episode of asthma?

YES

Triage asthma exacerbation for

distress

Review asthma plan in asthma action plan and

providerI/R/P

Ensure patient has all needed to

manage asthma acute episode

Follow-up as needed for acute

episode

Plan contact to discuss long-term

management

Structure

Visio: makes RN “actions” concrete and systematic

© 2011 Mayo Clinic

Structure: Medical Rule set (NAEPP/NHLBI)allows RNs to perform full assessment w/

recommendations

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007

Structure: Tools

Other tools: EMR Hot buttons for ordering

Meds Spirometry

EMR Flowsheets Track pts longitudinally over time

Website information/links Standard Asthma Action Plan Educational flow sheet/ patient education

materials Questionnaires Database

Structure: Communication within the Care Team

Goals:

1) Develop processes

ex: phone calls, electronic communication

2) Way to identify asthmatics

ICD9 codes poor way to identify asthmatics

1531 pts: 785 from ICD9s

27 from ER/Hosp use

644 Albuterol on med list (LPN)

75 Med refill/form requests, triage call (RN/Sec)

3) Shift “spirit” of team work Engage the whole team, including the “front line” with concrete processes

Structure: Communication within the Care Team

Tools to improve communication SBAR

Situation, Background, Assessment, Recommendation Coaching sessions/ access to medical expert Debriefing Group meetings Feedback from the practice –Ask, ask, ask

Decrease the sense of hierarchy … everyone has valuable input

Structure: Gather Metrics that you need719 days of experience (484 pts in CM)

Total (%) Non visit

RN time MD/NP involved

Initial full asthma CM

assess

484(15.1%)

86% 35.7 min 73% (7.1 min, 5.2 min )

Partial Asthma Control assess

1516(47.3%)

94% 27.8 min 55%(4.9 min, 2.7 min)

Twice/year Full assessment

172(5.4%)

92% 39.4 min 76%(5.0 min, 3.8 min)

Provider f/u visit 203(6.3%)

65% 21.2 min 43%(6.8 min, 2.9 min)

F/u re: med change, acute

620(19.4%)

84 % 22.9 min 40 %(6.5 min, 2.5 min)

Education 208(6.5%)

77% 33.5 min 60%(7.5 min, 2.6 min)

Total 3203 88% 28.6 avg 3.4 min avg © 2011 Mayo Clinic

Structure: Gather Metrics that you need

719 days of experience (484 pts in CM)

Total (%) Non visit


Initial full asthma CM

assess

484(15.1%)

86% 35.7 min 73% (7.1 min, 5.2 min

)

Partial Asthma Control assess

1516(47.3%)

94% 27.8 min 55%(4.9 min, 2.7

min)

Twice/year Full assessment

172(5.4%)

92% 39.4 min 76%(5.0 min, 3.8

min)

Provider f/u visit

203(6.3%)

65% 21.2 min 43%(6.8 min, 2.9

min)

F/u re: med change, acute

620(19.4%)

84 % 22.9 min 40 %(6.5 min, 2.5

min)

Education 208(6.5%)

77% 33.5 min 60%(7.5 min, 2.6

min)

Total 3203 88% 28.6 avg 3.4 min avg

Average 4.0 contacts/yrAverage 4.0 contacts/yr

For those in Care ManagementFor those in Care Management

1.8 hr/pt/year RN1.8 hr/pt/year RN13.6 min/pt/yr MD/PNP13.6 min/pt/yr MD/PNP

This allows us to justify FTE needs This allows us to justify FTE needs and plan better over time, including and plan better over time, including need for blocked “nonvisit” time for need for blocked “nonvisit” time for

MD/NPsMD/NPs© 2011 Mayo Clinic

Structure: Gather Metrics that you needHow else did RNs spend their time? (719 days, 484

pts in CM)

Total (%)


Prof correspond(PCP, pharm)

531(12.6%)

12.5 min 46% (11.8 min, 5.4

min )

Other 1234(29.2%)

14.6 min 29 %(5.7 min, 1.6 min)

Missed phone call attempt

2458(58.2%)

11.2 min 2.4%(5.1 min, 0.1 min)

Total 4223 12.3 min avg = 56 min/pt/yr

10.5 min avg= 5.5 min/pt/yr

© 2011 Mayo Clinic

Structure: Gather Metrics that you needHow else did RNs spend their time? (719 days, 484

pts in CM)

Total (%)


Prof correspond(PCP, pharm)

531(12.6%)

12.5 min 46% (11.8 min, 5.4 min )

Other 1234(29.2%)

14.6 min 29 %(5.7 min, 1.6 min)

Missed phone call attempt

2458(58.2%)

11.2 min 2.4%(5.1 min, 0.1 min)

Total 4223 12.3 min avg = 56 min/pt/yr

10.5 min avg= 5.5 min/pt/yr

Hmmm…Hmmm…

11.2 min/missed phone call11.2 min/missed phone call

= 0.15 FTE !! (for 484 pts)= 0.15 FTE !! (for 484 pts)

(Also 0.1 FTE making letters)(Also 0.1 FTE making letters)

This allows us to look for areas to This allows us to look for areas to increase efficiencies, including increase efficiencies, including

involvement of others in care team involvement of others in care team and other technology than just and other technology than just

telephone usetelephone use© 2011 Mayo Clinic



Keep It Real Start small…build on success Measure what you need Change in culture occurs over time

Aspects of Spread/Maintenance

If I could give you a hug over the phone, I would this is the first time I have felt like someone cares for my daughter.

The other day when picking him up school he was playing dodge ball and running with the other kids and was doing great, I thought “sweet"!!!!

Motivation …Keep it real

Early Parent Feedback (N=53, 6 months in)

How helpful was Very some equiv not helpfulHaving someone else besides our 75 % 8 % 14 % 3 %PCP we can contact w/asthma concerns

Checking to see if we have any 61 % 5 % 28 % 5 %Needs for refills or extra equipment

Phone calls to home to see 53 % 19 % 22 % 5 %How my child is doing (sx check)

Having written Asthma Action Plan 54 % 26 % 17 % 3 %To use when my child is having sx

Checking to see if we would like extra 44 % 17 % 33 % 5 %Info or education on asthma

Early Parent Feedback (N=53, 6 months in)

Before CM After CM

Comfort level managing asthma = E/VG 46.1% 88.9%Rate child’s asthma care = E/VG 80.5% 86.1%Would definitely recommend care here 80.6% 86.1%

(to others with asthma)

E = ExcellentVG = Very Good

Maintenance: Start Small with Attainable Victories

First 6 months of Care Management, Site 1 (start Mar 2009)

2nd-3rd Q’08 Goal (n=180)

Current AAP 2% 20% Current Severity 41% 60%



2nd-3rd Q’08 Goal 2nd-3rd Q’09 (n=180) (n=234) Current AAP 2% 20% 48.1% Current Severity 41% 60% 75.3%



2nd-3rd Q’08 Goal 2nd-3rd Q’09 2nd-3rd Q’10 (n=180) (n=234)(n=213) Current AAP 2% 20% 48.1% 73.7%Current Severity 41% 60% 75.3% 92.5%

Aspects of Spread/Maintenance

Metrics, metrics, metrics What are we accomplishing? What are we doing (task-wise)?

What would have been done by MDs What would have not been done otherwise

What does this “cost”? $$ RN/MD times

What might we assume will change over time?

Where are areas for improved efficiencies? IT improvements Use of other care team members

Got Medical Home?

Have a specific question or need regarding medical home?

Contact us!

[email protected]/433-9016 ext 7605

Disclosures Accreditation and Designation Statements The American Academy of Pediatrics (AAP) is...

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Transcript of Disclosures Accreditation and Designation Statements The American Academy of Pediatrics (AAP) is...