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 Care of Children with Complex Chronic

Conditions

Dennis Z. Kuo, MD, MHS, FAAPUAMS / Arkansas Children’s Hospital

Jane Sneed, MD, FAAPThe Children’s Clinic, Jonesboro, AR

June 2, 2011

Disclosures

Neither Dr. Kuo or Dr. Sneed have any relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

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

Looking Back…

The first and second webinars of this series:

History of medical home modelHealth care teams, family/professional partnerships, Bright Futures, quality improvementCare management of chronic condition (asthma)

Webinar Objectives

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

Illustrate the importance of building and maintaining multi-specialty teams in the provision of care for children and youth with complex chronic conditions Explore strategies for enhancing complex co-management working partnerships between specialty and primary care clinicians Explain how to effectively work with clinical teams and patients/families for successful and appropriate care transition planning from pediatric to adult care

Alex (name is changed)

Alex is a 3 month old child you have seen since birth. In the nursery, you noticed dysmorphic facies, low tone, undescended testes, and a heart murmur. He developed heart failure shortly after and required surgery to repair a large VSD.

Today, you suspect craniosynostosis on exam. He is developmentally delayed and small for age.

Alex’s needs

What specialists does he need? Cardiology, neurosurgery, urology, GI, genetics when older: ENT, developmental, neurology

What therapists does he need? Speech, swallowing, OT, PT, developmental

What is the role of his primary care provider? Checkups? Nutrition? Care coordination? Immunizations?

What is the role of his family? Should this have gone at the top of the list?

Complex Chronic Conditions

“Medically fragile” or “Medical Complexity”Usually described by:

Multiple subspecialists Technology dependence for basic health needs Frequent visits to tertiary care centers

High prevalence of neurodevelopmental disabilities and genetic disorders

Srivastava 2005; Cohen 2011, Pediatrics

Why consider these children separately?

Highest risk for adverse outcomes Medical, growth, developmental, social Tend to “fall through the cracks”

Most challengingMost satisfying?

The role of the Medical Home (on steroids?)

Bending the cost curve

Medicaid projected growth rate: 8.8% - higher than Medicare or national health spending Bend the curve: slowing the rate of increase

A small number of children are responsible for a majority of health care costs Medicaid: 10% of children = 72% of costs 0.4-1% of children = 12-15% of total costs, 20-25% of

hospitalized patients, and 45-50% of hospital days

Shortell (2009), JAMA; Kenney (2009), Health Affairs; Neff (2004); Berry (2011) unpublished, by permission

The high resource utilizers

The vast majority of the high resource utilizers have “complex” and “chronic” conditions Children who “fall through the cracks” Majority of costs are inpatient

Need to coordinate care and improve quality Integrated, organized systems Fundamental payment reform

Neff (2004); Fisher (2009) NEJM; Berry (2011), J Peds; Cohen (2011)

Building and maintaining multi-specialty teams for children with complex chronic

conditions

Consider: The components of care How the components work together The role of the Medical Home

How the Medical Home can initiate and lead co-management

Care components

Perrin et al. (2007) Arch Pediatr Adoles Med

The world that Alex’s parents see

Ray (1997, 2002)

The Chronic Care Model

From Wagner EH. Figure from Antonelli R (2005). Adapted from Bodenheimer (2002)

Chronic Care Model components

Care partnership supportDelivery system designDecision supportClinical information systems

When comprehensive care works

48% decrease in the number of hospital days and a $10.7 million decrease in payments to the tertiary care center Gordon JB Pediatr Adol Med 2007

55% reduction in ED visits Klitzner TS J pediatr 2010

40% reduction in inpatient costs, 27% decrease in hospital stays Casey PH Arch Pediatr Adolesc Med 2011

Courtesy of D. Bergman

Putting it all together: Co-management

Multiple health care professionals partner with families to provide a consistent direction of care

For children with complex chronic conditions: Integrates all components of care Reinforces the active role of the

PCP/Medical Home

Stille (2009)

Partners

Specialty care = straightforward Does not address all needs

Primary care = first point of access, immunizations, continuity Primary care sometimes not fulfilled when

child has multiple visits to specialty services Assumption that needs are being met

Community-based services Not always consistent

Families!Haggerty (2011). Academic Pediatrics

Primary care “Medical Home” as hub of coordination partnership

PCP Family

Specialist

Specialist

Specialist

Medical Home “functions”: explainer, interpreter, advisor, coordinator

PCP= the child’s Primary Care PRACTICE(not just one provider)

Slide courtesy of Chris Stille, MD

Spectrum of co-management

PCP as primary manager, specialist as consultant Less complex, few specialty needs

Specialist as primary manager, PCP less involved Appropriate for high complexity and if comprehensive

service exists at tertiary care centerCo-management

Medical Home has higher responsibility Medical Home acts as care coordinator Some children with complex chronic conditions have no

subspecialty “home”

Hack, Pediatric Annals 1997; Antonelli, 2005; adopted from C. Stille (2009)

Making co-management work

Define your roles Primary care physician has higher

responsibility Specialty provider provides decision

making support

Primary care physician can learn to care for higher complexity over time

Most PCPs welcome co-managementDon’t forget families!

Antonelli (2005); Kuo (2007); Kisker (1997)

Take the initiative

Recognize the components of comprehensive care that only PCP can deliver

PCP determines the additional level of involvement, due to varying experience PCP can provide improved access, continuity, and care

coordination for children and families Higher level of co-management likely improves care

outcomes due to improved accessInitiate communication with specialty colleagues

Determine your roles and be specific for what you needComfort will increase over time

Care partnership: Family-Centered Care

Essential, yet frequently misunderstood

Associated with more efficient use of health care resources for CYSHCN

Principles: Partnership approach to care Respect for diversity Information sharing is open and unbiased Care plans may be negotiated

Kuo (2011) MCHJ; Kuhlthau (2011) Acad Pediatr

Delivery System Design: Define Roles

Medical Home: ALWAYS good primary care First point of contact Anticipatory guidance Immunizations Care hub / care coordination Verify/Initiate Early Intervention

Act as “eyes and ears” for specialty teams Remind families that you can be first point of

contact

Additional roles

With good communication with specialty colleagues, may consider: Labs Medication initiation / adjustment Referrals to community services

Consider designating office staff (such as nurse) to be single point of contact Additional roles for office staff

Help families define their roles Foster children/families likely require extra attention

Kuo (2007). Pediatrics

Decision making support

Clinical care guidelines (e.g. AAP)Be familiar with common issues of

condition(s) High prevalence of neurodevelopmental

disabilities Recognize that many children have

feeding/growth issues, dysphagia, respiratory issues

Learn from specialty colleagues Regular communication; they will teach

you Eyes and ears / red flags

Define communication lines

Keep updated and continuous care plan Consider separate forms and someone to maintain

Methods of communication Email? Fax? Phone call? What will be communicated? – ask specialists Timing and frequency of communication Health care portals

If all else fails, encourage family to contact you and / or schedule regular follow-up visits

Clinical Information Systems

Track your children with special needs Particularly children with complex chronic conditions Quality of care measures

Utilize communication lines, including email, fax, phone

Clinical decision making tools

Conclusions

Comprehensive care can improve health outcomes and reduce utilization

Medical Home must take the lead to develop comprehensive care for children with complex and chronic health conditions

Co-management increases PCP involvement and can lead to improved outcomes

Thank you!

Questions?

Got Medical Home?

Have a specific question or need regarding medical home?

Contact us!

Medical_home@aap.org800/433-9016 ext 7605