Educating Practices in Community Integrated Care for Children with Special Health Care Needs

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Educating Practices in Community Integrated Care
for Children with Special Health Care Needs

• Pennsylvania Chapter, AAP
• A Medical Home Initiative
• of the MCHB

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Community Integrated Care for Children with SHCN

• Federal MCHB
• Medical Home Initiative
• EPIC-IC Education/QI Program
• Demonstration Projects
• Advocacy
• Pennsylvania DOH Program
• Support EPIC-IC
• Care Coordination Demonstration Projects
• Child Care Education about children with SHCN

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Other EPIC Programs

• Immunization Education
• Stop Child Abuse Now (SCAN)
• Smoking Cessation

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Case Presentation
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Why should you care about children with SHCN?

• Increasing numbers of children with SHCN--time,
  cost
• Opportunity for improvement
• Health care system built around acute care, not
  chronic care
• Families want more involvement in care process
• More care provided in the home and community
• Primary care practice staff want to provide the
  best care possible

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Take
Home Message

• Primary care practices can
• Develop patient/family centered care
• Identify and monitor children with SHCN
• Improve coordination of care and communication
• Improve documentation to enhance coding and
  reimbursement.
• Improve how the primary care practice team
  provides chronic care through systems change
• Facilitate patient access to services in
  practice and community

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Community Integrated Care for Children with
SHCN

• Who are Children with SHCN?
• What is a Medical Home?
• Where should we focus?
• How does this relate to our practice?
• How can we improve our practice?

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Who are children with special health care needs?

• Children with Special Health Care Needs are
  those who have or are at increased risk for a
  chronic physical, developmental, behavioral, or
  emotional condition and who also require health
  and related services of a type or amount beyond
  that required by children generally. (Maternal
  and Child Health Bureau 95)

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Children with Special Health Care Needs
600
360
140
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2
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Epidemiological Statistics of Children with
Special Health Care Needs (1994) 18 of
Children or 12.6 million (0-18 years of age)
CwSHCN Typical Avg.

• Avg. Annual School Absences 7.4 2.8
  3.6
• with Health Insurance 88.8 86.4
  86.8
• with Usual Source of Care 94.4 93.2
  93.4
• not Satisfied with Care 17.9 13.6
  14.7
• with Unmet health Needs 12.9 6.4
  7.6
• Avg. Annual Physician Contacts 6.4 2.6
  3.3
• Avg. Annual Hosp.Days/1000 691 122
  225

Newacheck et al. Pediatrics, Vol 102, No. 1,
July. 1998, pp 117-121
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Annual Cost of Medical Care for Children with SHCN
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A Medical Home

• Is an approach and process to providing care
• Is not a building
• Is a partnership with the child, family and
  practice care staff
• Emphasizes the primary care practice as the
  home where the family and child
• Feel recognized and supported
• Find a centralized base for medical care
• Find connection to other medical and non-medical
  community resources

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Components of Care in a Medical Home

• Family-Centered
• Accessible
• Comprehensive
• Continuous
• Coordinated
• Compassionate
• Community-Based
• Culturally-Competent
• Provided in an Environment of Trust and Mutual
  Responsibility

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Identifying Challenges to Medical Home Care

• TIME, TIME, TIME
• (and reimbursement)
• Organized systems of care
• Adequate parent-professional partnerships
• Knowledge
• Communication
• Coordination
• Medical staff turnover
• Awareness of community resources and programs

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Physicians and Parents Ranking of Services

• Ranking
• Service
  Physicians Parents
• Respite care
  1 9
• Day care
  2
  21
• Parent support groups
  3 3
• Help with behavior problems 4
  10
• Financial information or help 5
  2
• After-school child care
  6 20
• Assistance with physical
• household changes
  7 15
• Vocational counseling
  8 6
• Psychological services
  9 5
• Homemaker services
  10 22
• Recreational opportunities 13
  4
• Information about
• community resources
  14 1
• Dental treatment
  16 8
• Summer camp
  19 7

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Benefits to the Practice

• Increased professional satisfaction
• Improved coordination of care
• Efficient use of limited resources
• Streamlined office procedures
• Compensation for the additional care provided

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Benefits to Patient/Family

• Increased quality of care
• Increased patient and family satisfaction
• Improved communication with physician and staff

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Benefits to the Community

• Improved coordination of care
• Increased integration of CSHCN into schools and
  extracurricular activities

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Community Services for Children with SHCN and
Their Families

• Role of Primary Care Practice in Community
  Services
• Child Welfare
• Social Services
• Early Childhood Services
• Education
• Mental Health
• Community Based Therapies
• Public Health
• Family Support
• Spiritual Support

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Changing a primary care practice is like trying
to change the tire on a bicycle while you are
riding it
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Getting Started

• Identify the team within the practice
• Evaluate practice
• Identify the CSHCN in the practice
• Select a parent advisor
• Share concepts and goals with practice staff

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Identifying the Team

• A practice team includes
• Primary care clinician
• Nurse manager/care coordinator
• Office manager
• Parent advisor

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Evaluating the Practice

• Medical Home Index
• Medical Home Family Index

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Identifying CSHCN

• Utilize severity scoring tools available
• Define chronic conditions within the practice
• Use ICD-9 codes and Flu shot list to identify
• Review utilization reports to determine those
  children seeing gt 1 specialist on a regular basis
• Determine how to identify the chart i.e., using
  color coded charts, stickers, and binders

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Select a Parent Partner

• Identify potential parent advisors who will
  provide effective input
• Communicate role and responsibilities of parent
  advisor
• Be open to constructive feedback regarding
  practice policies and procedures

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Share Concepts/Goals With Practice Staff

• Present the broad, general topics of the medical
  home and role of parent advisors to all members
  of your practice
• Meet with your practice team to choose and plan
  your first improvement project
• Implement practice wide
• Review with your practice team
• What worked
• What did not
• Celebrate your success

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Key Factors for Success

• Unifying leadership
• Common goal
• Thorough planning
• Staff buy-in
• Communication plan
• Small steps first
• Learn from your mistakes

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Practical Applications

• Scheduling
• Use a telephone script for all schedulers to
  easily identify those children requiring extra
  time
• Parent Advisors
• Develop Tips sheet for parents
• Act as a resource for other families of CSHCN
• Provide community resource information for the
  practice

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Practical Applications

• Coordination of Care
• Complete care plans or summaries for each child
  with SHCN. One copy for chart, one for family.
• Fax back forms being used to facilitate
  communication with subspecialists
• Develop flow sheets for specific diseases that
  providers and staff will use for care

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Practical Applications

• Reimbursement
• Conduct coding sessions for staff to understand
  correct coding for CSHCN
• Update encounter forms to include CPT and ICD9
  codes that reflect the population seen
• Develop progress note templates to ensure
  accurate documentation

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Compensation

• Coding
• Documentation
• Data Collection
• Managed Care Negotiation

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Coding for Children with Complex Medical Needs

• No specific code exists for additional time and
  effort required
• Use appropriate E M code following
  documentation guidelines
• Remember if its not documented it didnt happen

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Coding for Children with Complex Medical Needs

• Preventative medicine service codes (99381-99397)
  with the use of E/M codes (99201-99215) and the
  25 modifier
• Counseling and/or risk factor reduction codes
  (99401-99412)
• Team conferences (99361-99362)
• Telephone calls (99371-99373)

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Coding for Children with Complex Medical Needs

• Care plan oversight services (99375-99376)
• Prolonged physician service (99354-99359)
• Office or other outpatient service codes
  (99201-99215)
• Consultations (99241-99245)
• Modifier 21/09921

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Summary

• This is introductory material a starting point
  to create an ongoing process to
• Develop a patient/family--physician/practice
  relationship of care
• Improve how the primary care practice team
  provides chronic care
• Integrate comprehensive care of the child with
  the community

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Other EPIC IC Trainings Available

• Family Centered Care
• Care Coordination
• Practice Management/Care Design
• Transition

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Where Do We Go From Here?

• Develop the infrastructure, develop the process
• Start with a few small steps
• Recognize that change needs to be gradual
• Implement medical home strategies one at a time
• After strategies have been implemented for a few
  months, evaluate progress

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Contact Information

• EPIC IC Program
• [phone]
• Email at paaap_at_voicenet.com
• Helpful Websites

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Home is the place where When you go there They
have to take you in R. Frost