Medical Home Collaboration. “WE DON’T KNOW WHAT WE DON’T KNOW”

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Medical Home Collaboration

Transcript of Medical Home Collaboration. “WE DON’T KNOW WHAT WE DON’T KNOW”

Page 1: Medical Home Collaboration. “WE DON’T KNOW WHAT WE DON’T KNOW”

Medical Home Collaboration

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“WE DON’T KNOW WHAT WE DON’T

KNOW”

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Children with Special Health Needs-Overview

•Care coordination•Medical Home Initiative•Pediatric Hi-Tech•Personal Care•Children’s Palliative Care•Child Development Clinic•Cleft Palate Clinic•Rehab and Neurology clinics•Respite•Financial Technical Assistance •Community Nutrition•Newborn Screening•Newborn Hearing Screening

Birth to age 21

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Medical Home

CIS Early Intervention Collaborative

Team

Child Development

Clinic&

CSHN Services

Chittenden Social Worker

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Our Medical Home Program

• Three pediatricians, Dr. Joseph Hagan, Dr. Jill Rinehart, Dr. Greg Connolly

• Two Pediatric Nurse Practitioners, Maryann Lisak &Ashley Boyd

• One main RN Care Coordinator Kristy Trask• Business manager, office manager, two office

assistants, six additional part-time nurses two medical assistants

• ~4500 Active Patient List

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Medical Home History

• 1967: First published reference to “Medical home” was in the AAP’s Council on Pediatric Practice’s Standards of Child Health Care

• Defined Medical Home as the “respository of medical records” for a child, emphasized the importance especially for CSHCN

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Medical Home History

• 1970’s: AAP first addresses the policy implications of the term “medical home”

• 1977: “Fragmentation of Health Care Services for Children,” Clarified the concept of single medical home for every child

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Medical Home History

• 1980’s: The first Medical Home is attributed to Hawaii Pediatrician, Dr. Cal Sia

• 1992: AAP published first policy statement defining the medical home

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Medical Home History1998:

Called for “imaginative methods, backed by insurance and government funding [that] must be developed and used to improve financing for care coordination and other needs…”

~Polly Arango and Merle McPhereson

“New Definition of Children with Specia Health Needs,”Pediatrics,1998

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Medical Home History

2002: Medical Home Policy Statement was published that defines the concept of Medical Home we use today

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Medical Home History

• 2002-2004 in VT: Medical Home Improvement Project

• 2006: ACP created “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care” promoting an “evidence based” medical home

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Medical Home History

• 2007: Bright Futures embraces the concept of Medical Home for all children and states that the Medical Home is the most effective model for the provision of health supervision.

• Linked to Affordable Care Act

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What Is Bright Futures?

• Gold standard for pediatric care provides detailed information on well-child care for health care practitioners.

• A national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community

• A part of the Affordable Care Act

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Medical Home History

• Joint effort led to the National Center for Quality Assurance’s (NCQA) creation of Physician Practice Connections-Patient-Centered Medical Home (PPC®PCMH™)

• Created 2008 PPC®PCMH™ Standards

• March 2011, then 2014 PCMH guidelines

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Medical Home Definition

• Accessible• Culturally Effective• Continuous• Comprehensive• Coordinated• Compassionate• Family Centered

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Medical Home Definition

The Medical Home is the model for 21st century primary care, with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated and family-centered manner…

~National Center for Medical Home Implementation

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Why is A Family- Centered Medical Home Important to family?

• Opportunity for the family to build a trusting and collaborative relationship with the pediatrician and office staff.

• Care coordination provides smooth facilitation among all members of the child’s care team including family, specialists, pharmacy staff, community and school services.

• Comprehensive source of complete patient medical history

Victoria Garrison, “Innovations in Medical Home,” VFN annual conference, April 2013

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Franklin Cty Peds

Mousetrap St. Albans

Newport Peds

Rainbow PedsMPAM

Gifford

Green Mountain Pediatrics

Mousetrap Milton

Timber Lane SBTimber Lane

Mousetrap Peds Enosburg

Mousetrap Peds Swanton

Associates in PediatricsBarre Pediatrics

UPeds Burl

UPeds Williston

Shelburne PedsRichmond Peds

Essex Peds

Brookside Peds

Cornerstone Peds

Dr. H. Taylor Yates Jr.

Dr. David Toll

Dr. Joe Nasca

Dr. Martin R. Luloff

Just So Peds

Women’s & Children’s Services

Pediatric Associates

Upper Valley Peds

Springfield Pediatric Network

Ryderbrook Peds

PedMed

Dr. Rebecca CollmanNVRH St. J Peds

H&R Peds

Mil

ton

Bu

rlin

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Ben

nin

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St.

Jo

hn

sbu

ry

Mid

dle

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Has been scoredHas anticipated NCQA recognition dateHas not started process

PCMH Recognition Status, VT Pediatric Practices as of 12/12S

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Mt. Ascutney Physicians Practice

South Royalton Health Center

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Pediatric Collaborations Chittenden County

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5 Key Elements of Highly Effective Care Coordination

The Concept

1. Needs assessment for care coordination and continuing care coordination engagement

2. Care planning and communication

3. Facilitating care transitions 4. Connecting with community

resources and schools5. Transitioning to adult care

The Person

Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009

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A Framework for Highly Performing Pediatric Care Coordination

Care Coordination Functions

1) Provide separate visits & interactions2) Manage continuous communications3) Uses assessments for intervention4) Develop Care Plans (with families)5) Integrate critical care information6) Coach patient/family skills learning7) Support/facilitate all care transitions8) Facilitate care conferences 9) Use health information technology

for care coordination

Care Coordination Competencies1) Develops partnerships2) Proficient communicator3) Uses assessments for intervention4) Facile in care planning skills5) Integrates all resource knowledge6) Possesses goal/outcomes

orientation7) Approach is adaptable & flexible8) Desires continuous learning9) Applies solid team building skills10) Adept with information

technology

Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009.

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Principles for Successful Use of SharedPlan of Care

1. Children, youth and families are actively engaged in their care.2. Communication with and among their medical home team is

clear, frequent and timely.3. Providers/team members base their patient and family

assessments on a full understanding of child, youth and family needs, strengths, history, and preferences.

4. Youth, families, health care providers, and their community partners have strong relationships characterized by mutual trust and respect.

5. Family-centered care teams can access the information they need to make shared, informed decisions.

McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: 2014 (in press), Lucille Packard Foundation for Children's Healthcare

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Principles for Successful Use of SharedPlan of Care

6. Family-centered care teams use a selected plan of care characterized by shared goals and negotiated actions; all partners understand the care planning process, their individual responsibilities, and related accountabilities.

7. The team monitors progress against goals, provides feedback and adjusts the plan of care on an on-going basis to ensure that it is effectively implemented.

8. Team members anticipate, prepare and plan for all transitions (e.g. early intervention to school; hospital to home; pediatric to adult care).

9. The plan of care is systematized as a common, shared document; it is used consistently by every provider within an organization, and by acknowledged providers across organizations.

10. Care is subsequently well coordinated across all involved organizations/systems.McAllister, J., et al., Achieving a Shared Plan of Care for Children and

Youth with Special Health Care Needs: 2014 (in press), Lucille Packard Foundation for Children's Healthcare

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Partnership Care Planning Model

McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: An Implementation Guide. 2014, Lucille Packard Foundation for Children's Healthcare: Lucille Packard Foundation for Children's Healthcare.

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Care Coordination Rounds

• Regular meetings (typically 1 hour) with practice care coordinator, physicians, CHT social worker, ( sometimes other community partners as needed)

• Discussion of patients (who needs more intervention and who is doing what part of the work)

• Systems issues

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ECOMAP

Informal SupportsExtended Family

FriendsGroups

Religious OrganizationsCultural Supports

ClubsRecreation

Camps

Community and State Services CSCHN

Economic ServicesDevelopmental Services

Mental Health Early Intervention

Home Health ServicesChildren’s Palliative Care

WICChild Protection

Private TherapistsPersonal Care

SchoolTeachers

Case ManagerSpeechPT/OT

Other Services

MedicalSpecialists

Specialty ProvidersClinics

Financial SupportsInsurance

RespiteChildcare SubsidyEconomic services

Social SecurityFood Subsidy Employment

ChildcareTeachers

Genogram of Household MembersParentsSiblings

ChildExtended Family

Others

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VG

CG5 yo

7 yo4 yo

Hagan, Rinehart and

ConnollyPediatricians

Shelburne Community

School Special

EducatorSpeech Language

Pathologist

School Physical Therapist

Occupational Therapist

Swimming at YMCA

Rue Kendrick-classroom

teacher

PCA

Debbie- Para-professional

S.&J., MGMfriends

(service dogs in training)

Petsmart

Therapy Dogs of Vermont

Dr. Hastings-Peds-Ophthalmology

Dr. Benjamin- physiatrist

Dr. D'Amico-Gastroenterologist

Dr. Filiano-Neurologist at

Dartmouth

Dr. Bauer-Peds Neurosurgeon at

Dartmouth

Dr. Tranmer-Neurosurgeon

CSHN Registered Dietitian

Apria

Medical Store

Keen Medical

Biomedic Appliances

CSHN Social Worker

Howard Center

Deborah Keel- Flexible Family FundingDelana-

BRIDGE

Shelburne Community School

Shelburne Nursery School

Community Alliance Church in Hinesburg

Children's Ministry

Outings- Sugar House, Echo, Lowes, town

activities, swimming etc.

Section 8 Housing

Wheels for Johnny-Fundraiser for handicap

accessible vehicle

SSI

SSA

PSE

Child Only Reach Up Grant

3 Squares Vermont

Champlain College- Healthcare Technology

Garrison, Victoria . Interview by Marley Donaldson. Personal interview. 26 Mar. 2013.

MedicalFamilyState/Education/Community

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Family Story

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Care Conferences

A facilitated, family-centered meeting (typically 1 hour) among the family, primary care, community providers, schools, formal and informal family supports to facilitate detailed communication about strengths, challenges, current services, and gaps in services. A coordinated plan of care is developed with goals, resources, and work load distribution among providers with family input and consent. Care conferences address communication issues, needs of the family and helps to resolve identified and anticipated needs.

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Care Story

• Mary is a 4 year old with tuberous sclerosis whose self-injurious behaviors, tantrums, sleep dysfunction-- heading towards inpatient psychiatry hospitalization

• Despite having a VT developmental services waiver, respite care and a team of multidisciplinary medical experts at Mass General

• Intractable seizures seemed the least of her concerns in comparison to behaviors

• Strengths: strong parent involvement and expertise, loving respite family, Mary engaging, verbal with cognitive strength (can anticipate seizures)

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Care Planning Patient/Family/Team Goals CICP Negotiated Actions Process and Outcome

measures

Less need for “crisis” intervention

Co-management from psychiatry, medical home and subspecialists

In-home behavioralist

Less need for police, mental health crisis support

Improve Sleep Same behavior plan across settings

Less communication errors about medicationsImproved work attendance

Increase Home Safety-of Mary and family

Improved psychopharmCSHN SW: Waiver allowed for enhanced access to in-home behavioralist

Innovation: region contracted with vendor outside of networkLess Crisis Need

Mary to attend schoolImprove social relationships

Communication opened between school, behavioral plans, family, medical home

Making academic gainsAttendance improvedCannot pick her out from peers

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Outcomes of Shared Care Planning• Builds community collaboration and

communication across services• Builds knowledge base of services and

system of care• Determines most appropriate referrals,

reducing duplication and fragmentation.• Builds the capacity of primary care to provide

long term chronic care management• Addresses systems issues and barriers

proactively (i.e. financing, insurance poverty, access to care)

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Pediatric Care Coordination Learning Collaborative

• 12 Vermont practices that serve children• Each with a quality improvement team of

provider, care coordinator and parent partner• Create 25 shared care plans with families

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Building Partnerships Across the Community

Next Steps

• Reach out to the medical home care coordinators and get to know who they are.

• Invite CSHN social worker to initial visits, team meetings, One Plan reviews-help families build relationships early with other providers, support the work you are doing with families during your time with them.

• Suggest doing care conferences to PCP for your families where a meeting would be helpful to coordinate and problem solve.

• Offer to do presentations of your program to other service programs and vice versa (establish a contact) so you will have a go to person to talk through situations as they arise.

• Find out how other providers are working in their regions and what strategies they find helpful. Ask to shadow providers in other regions. Come observe a CIS-EI meeting in Chittenden or care conference.

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THANK YOU!