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The Medical Home Model: Caring for Children with Special Health Care Needs

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Title: The Medical Home Model: Caring for Children with Special Health Care Needs


1
The Medical Home Model Caring for Children with
Special Health Care Needs
Home Is Where the Heart Is
  • State, Healthcare Providers and Families as
    Partners

2
The National Initiative for Childrens Healthcare
Quality
3
NICHQs Mission
  • To eliminate the gap between what is and what
    can be in health care for all children.

4
About NICHQ
  • NICHQ is an action oriented organization
    dedicated exclusively to improving the quality of
    childrens health care
  • NICHQ is a resource for health care and
    improvement organizations, foundations, and
    government agencies seeking to improve care for
    children
  • NICHQ is a national organization
  • Home Office Cambridge, MA
  • National cadre of key advisors
  • Geographically distributed staff

5
NICHQs Success Will Be Gauged By Whether
  • Children achieve
  • Their greatest potential with
  • No needless harminjury, pain, suffering, death
  • Families
  • Are optimally able to provide for, promote, and
    support their child
  • Communities
  • Are best able to support healthy children and
    families
  • Society
  • Achieves these results with
  • Equality
  • No waste

6
What we doChange Practice to Improve Care and
Outcomes
  • Innovate
  • Discover, invent, and share good ideasready for
    use in childrens health care
  • Demonstrate
  • Undertake targeted initiatives to demonstrate the
    feasibility of improving care and outcomes
  • Accelerate Adoption
  • Work with health care delivery organizations,
    families, government, and others so that better
    models are widely and rapidly adopted

7
NICHQs Bold Improvement Agenda
  • Prevent Childhood Obesity
  • Provide Seamless, Evidence Based, Family Centered
    Care for Children with Chronic Conditions
  • Purge Harm from Childrens Health Care
  • Promote Equity in Care

8
Our Services
  • Training and Transforming Care
  • Learning Collaboratives In person and across
    distance
  • Action Networks and Spread Initiatives
    Accelerating learning, spreading better care
  • Annual Childrens Forum
  • Toolkits
  • Jump Start and Jump Ahead Introductory and
    Advanced QI Methods and Tools for Childrens
    Health Care
  • Setting the National Agenda for Change
  • Federal and State Childrens Quality Policy
  • Measurement
  • Improvement
  • Health Information Technology
  • Payment
  • Creating and Sustaining Improvement Resources
  • Local, State, Regional and Federal programs to
    sustain change

9
7th Annual Forum March 19-21, 2008 Miami,
Florida Intercontinental Hotel
10
Our Partners
  • Health Care Improvement Organizations
  • Institute for Healthcare Improvement
  • Improving Chronic Illness Care Program
  • Center for Health Care Strategies
  • Family Voices, Spina Bifida Association, CHADD,
    Epilepsy Foundation
  • Child and Adolescent Health Measurement
    Initiative
  • Foundations
  • David and Lucile Packard Foundation
  • Robert Wood Johnson Foundation
  • Commonwealth Fund
  • California Endowment and Health Care Foundations
  • Government
  • State NY, California, VT Departments of Health
  • Federal Maternal and Child Health Bureau, AHRQ,
    CMS

11
Together we can make health care better for every
child!
12
Before we begin.
  • This is really hard work complexabstract
  • Remind you (and me) why we are doing this
  • Patient 1 Infant with complex genetic disorder,
    skin breakdown, severe developmental delay,
    Cambodian refugee family, non-English speaking.
    Foster care.
  • Patient 2 Girl with dozens of surgeries for
    complex congenital anomalies, failure to thrive,
    mild developmental delay, maternal substance
    abuse.
  • Create a system where any parent, any child, and
    society knows that that child and family will get
    the right care, the right way, the right time to
    efficiently and effectively achieve the best
    outcome

13
Objectives
  • Describe core elements necessary for
  • full implementation
  • spread of the medical home model
  • Share how
  • Maternal Child Health Bureau (MCHB),
  • Title V
  • primary care and
  • specialty clinicians have worked/can work
    successfully to implement the medical home

14
A Medical Home is
  • Accessible
  • Family Centered
  • Continuous
  • Comprehensive
  • Coordinated
  • Horizontal
  • Vertical
  • Longitudinal
  • Compassionate
  • Culturally Effective

15
Defining medical homebasic, good, better, great
  • A medical home is a community-based primary care
    setting which provides and coordinates high
    quality, planned
  • family-centered health promotion
  • chronic condition management

16
The Patient/Family the Community-Based
Medical Home at the crossroads, integrating
  • Vertically Among health care systems/specialists
    /PCPs/others
  • Horizontally Among supportive community
    agencies/schools

Health Care
Longitudinally.
Community Supports
Medical Home
17
Why Medical Home Spread Slow
  • Lack of awareness
  • Limited operationalization
  • Pragmatic barriers
  • Time
  • Knowledge
  • Role definition
  • Reimbursement
  • Limited skills in the methodology of changing
    practice behavior.
  • Are there any other obstacles to spread?

18
Hypothesis
  • Application of four key concepts
  • Medical Home/Care Model for Child Health
  • Collaborative Model
  • Model for Improvement
  • Model for Spread
  • Together with support from a capable
    regional/state/local resource (Title V)
  • Will result in acceleration of spread of Medical
    Home

19
Care Model for Child Health in a Medical Home
Supportive, Integrated Community
Informed, Activated Patient/Family
Prepared, Proactive Practice Team
Prepared, Proactive Practice Team
20
Model for Improvement
What are we trying to
Aim
accomplish?
How will we know that a
Measures
change is an improvement?
What change can we make that
Ideas
will result in improvement?
Act
Plan
Study
Do
From Associates in Process Improvement
21
IHI Breakthrough Series(12 month time frame)
Participants (10-100 teams)
Select Topic (develop mission)
Prework
Develop Framework Changes Measures
Dissemination Holding the Gains Publications Congr
ess etc.
P
P
P
A
D
A
D
A
D
Expert Meeting
S
S
S
LS 2
LS 1
LS 3
Planning Group
AP1
AP2
AP3
Supports Email Phone Conferences Visits
Monthly Team Reports
LS Learning Session AP Action Period
Parent Training
Parent Training
Parent Training
Title V Training
Title V Training
Title V Training
22
Modifications to BTS Design
  • Participants
  • State Title V Programs, each of whom recruited
  • 2-3 Primary Care Practice Teams
  • MHLC II Broader State Team AAP/AAFP, Medicaid,
    Parent
  • Faculty
  • Clinical, Title V, and Parent Chair
  • Teams
  • Physician, Staff (Nurse/Care Coordinator), Parent
  • Topic
  • Medical Home, aka, Chronic Care Model for CYSHCN
  • Added emphasis on Cultural Competency (MHLC II)

23
IHI Framework for Spread
Leadership -Topic is a key strategic
initiative -Goals and incentives/policies
aligned -Executive sponsor assigned -Day-to-day
managers identified -Aim developed
Set-up -Adopter audiences -Successful sites
-Key partners
-Infrastructure supports to enable
adoption -Initial spread strategy (leverage
system structure)
Social System -Early adopters -Key
messengers -Communities
-Technical support -Transition issues
Better Ideas -Develop the case -Describe the
ideas

Communication (awareness technical)
24
Participant States
  • MHLC I
  • Connecticut
  • Colorado
  • Florida
  • Ohio
  • Oklahoma
  • Louisiana
  • Michigan
  • North Carolina
  • New York
  • Utah
  • Virginia
  • Wisconsin
  • MHLC II
  • DC
  • West Virginia
  • Vermont
  • Illinois
  • Maine
  • Maryland
  • Minnesota
  • Texas
  • Pennsylvania
  • practice team, but no State Agency

25
Aim Medical Home Learning Collaboratives
  • To improve care for children with special health
    care needs/youth by implementing the Medical Home
    concept
  • To foster substantial relationships between Title
    V programs and their states primary care
    community, enabling Title V to
  • Support improvement in practices and
  • Spread improvement across their State

26
Participants Teams-Practices
  • 3 Teams from each State
  • 43 Community Based, Group Practice
  • 22 Community Hospital or Network Group Practice
    (e.g., Marshfield Clinic, Bassett Health)
  • 25 Academic Primary Care Sites
  • 9 Solo Practice
  • Team Members
  • Physician, nurse/other office staff/care
    coordinator, parent partner

27
Measures
  • ED visits
  • Unplanned Hospitalization rates
  • Family worry
  • Front office satisfaction
  • Medical Home Index
  • Care Plans
  • Practice Satisfaction

28
Medical Home Learning Collaborative IMedical
Home Index Pre and Post Measures
29
Medical Home Learning Collaborative IIMedical
Home Index Pre and Post Measures
30
Results MHLC I
31
Results-MHLC II
32
ResultsMHLC II
33
Qualitative Results Title V
  • Most valuable activities and insights
  • Conduct walk-through of practices
  • Connect teams to state resources
  • Assist with care coordination
  • Outreach to broad variety of audiences
  • Practices need help working with families
  • Positive impact on how to implement change and
    promote adoption of new models
  • Additional support, training, infrastructure
    needed
  • Spread Challenging
  • Tool developed
  • Internal collaboratives successful and ongoing

34
Qualitative Results-Parents
  • Parents can be very effective in this process
    because they can counter assumptions health care
    providers make about the way things work"
  • "There are things I can do, like pre-register my
    child for appointments...my pediatric clinic and
    the hospital are willing to do many things to
    make things better for my family. I never would
    have known what to ask for, as a new parent,
    before the medical home training"

35
Qualitative Results-Practices
  • The MHLC "helped the practice focus on achievable
    steps to initiate a true medical home
  • "the small changes have made a world of
    difference in our practice...
  • Specific changes (self-report)
  • 70 streamlining access
  • 64 have designated care coordinator
  • 63 working with community agencies
  • 60 partnering with families
  • 50 using some form of registry
  • Simplification, prioritization needed

36
Why Medical Home Spread Slow
  • Lack of awareness
  • Not Directly Addressed, Other (ACP, NCQA) Efforts
  • Limited operationalization
  • Better, but still complex
  • Pragmatic barriers
  • TimeEinstein rules!
  • Knowledge--Yes
  • Role definition--Yes
  • ReimbursementIn part. See NCQA/PC Medical Home
  • Limited skills in the methodology of changing
    practice behavior--Yes

37
Hypothesis
  • Application of four key concepts
  • Medical Home/Care Model for Child Health
    Simplify
  • Collaborative Model
  • Model for Improvement
  • Model for Spread Not well adopted/applied
  • Together with support from a capable
    regional/state/local resource (Title V)
  • Partners necessary (not sufficient)
  • Trainingdata, coaching, practice issues
  • Resources and priorities
  • Will result in acceleration of spread of Medical
    Home

38
Step By Step Approach with Simplified Medical
Home Model
  • A Guide to Assisting Practices to Implement
    Medical Home
  • 1 Engage parents as partners at practice level
  • 2 Identify, categorize complexity, and create a
    registry of CYSHCN
  • 3 Use planned encounters
  • 4 Develop strategy and identify specific roles
    for care coordination and communication at the
    practice level

39
Spread FrameworkIn Words
  • Leadership Setting the agenda and assigning
    responsibility for spread
  • Set-Up for Spread Identifying the target
    population and the initial strategy to reach all
    sites in the target population with the new ideas
  • Better Ideas A description of the new ideas and
    evidence to make the case to others
  • Communication Methods to share awareness and
    technical information about the new ideas
  • Social System Understanding the relationships
    among the people who will be adopting the new
    ideas
  • Knowledge Management Observing and using the
    best methods for spread as they emerge from the
    practice of the organization
  • Measurement and Feedback Collecting and using
    data about process and outcomes to better monitor
    and make adjustments to the strategy

40
Revised Spread Planner
  • Spread Planner for Medical HomeA Tool for Title
    V and Other State Level Leaders
  • Leadership
  • To what extent is spread of the Medical Home
    model a strategic objective of the key leadership
    organizations in your state (i.e., Title V, AAP,
    and Family Voices)?
  • Are the goals/incentives of other key
    stakeholders within the state aligned with
    Medical Home spread?
  • Is there support for Medical Home implementation
    at a policy level?
  • How has the recent focus on medical home affected
    your efforts?

41
Joint Principles of the Patient-Centered Medical
Home
  • The Patient-Centered Medical Home (PC-MH) is an
    approach to providing comprehensive primary care
    for children, youth and adults. The PC-MH is a
    health care setting that facilitates partnerships
    between individual patients, and their personal
    physicians, and when appropriate the patients
    family.
  • American Academy of Family Physicians (AAFP)
  • American Academy of Pediatrics (AAP)
  • American College of Physicians (ACP)
  • American Osteopathic Association (AOA)

42
Joint Principles of the Patient-Centered Medical
Home
  • Personal physician
  • Physician directed medical practice
  • Whole person orientation
  • Care is coordinated and/or integrated
  • Quality and safety
  • Enhanced access
  • Payment

43
National Committee for Quality Assurance (NCQA)
Physician Practice Connections
  • Practice Requirements
  • For Certification

Source 2006 National Committee for Quality
Assurance
44
NCQA PPC Standards Intent
  • 1. Access and Communication
  • The practice provides patient access during and
    after regular business hours, and communicates
    with patients effectively
  • 2. Patient Tracking and Registry Functions
  • The practice has readily accessible, clinically
    useful information on patients that enables it to
    treat patients comprehensively and systematically
  • 3. Care Management
  • The practice maintains continuous relationships
    with patients by implementing evidence-based
    guidelines and applying them to the identified
    needs of individual patients over time and with
    the intensity needed by the patients

45
NCQA PPC
  • 4. Patient Self-Management Support
  • The practice collaborates with patients to pursue
    their goals for optimal achievable health
  • 5. Electronic Prescribing
  • The practice seeks to reduce medical errors and
    improve efficiency by eliminating handwritten
    prescriptions and by using drug safety checks and
    cost information when prescribing
  • 6. Test Tracking
  • The practice works to improve effectiveness of
    care, patient safety and efficiency by using
    timely information on all tests and results

46
NCQA PPC
  • 7. Referral Tracking
  • The practice seeks to improve effectiveness,
    timeliness and coordination of care by following
    through on consultations with other
    practitioners.
  • 8. Performance Reporting and Improvement
  • The practice seeks to improve effectiveness,
    efficiency, timeliness and other aspects of
    quality by measuring and reporting performance,
    comparing itself to national benchmarks, giving
    physicians regular feedback and taking actions to
    improve
  • 9. Interoperability
  • The practice maximizes use of electronic
    communication to improve timeliness,
    effectiveness, efficiency and coordination of care

47
Better ideas
  • Can you make the case for adoption of the Medical
    Home model?
  • Set Up
  • What is your implementation plan for spread?
  • How will you attract new adopters (e.g., use a
    broad based communication campaign, identify and
    use opinion leaders, share comparative data)?
  • What technology will you need (registries, web
    sites)?
  • Who are the key messengers?

48
Measurement and Social System
  • How will you measure improvement at the practice
    level?
  • How will you measure improvement at the State
    level?
  • How will you provide feedback?
  • Social System
  • Are there vehicles to link stakeholders at State
    and local level?

49
Other Health System Components
  • Vertical Coordination Primary and Specialty Care
  • Case example Children with Epilepsy
  • Horizontal Coordination Community/Public Health
    Resources
  • Case example Handoffs between newborn hearing
    screening, specialty care, primary care, and
    early intervention

50
Ten Rules for Redesign
  • Care is based on continuous healing relationships
  • Care is customized according to patient needs and
    values
  • The patient is the source of control
  • Knowledge is shared and information flows freely
  • Decision making is evidence-based
  • Safety is a system property
  • Transparency is necessary
  • Needs are anticipated
  • Waste is continuously decreased
  • Cooperation among clinicians is a priority
  • Institute of Medicine, Crossing the Quality Chasm
    (2001)

51
Design principles of the Hearing Screening
Learning Collaborative
  • Newborn and family at center family source of
    control
  • All stakeholders at same table information
    shared freely, cooperation, transparency
  • Create sense that all in same system
  • Focus on idealized system design - safety
  • Used reliability principles -safety
  • Prevent initial failure
  • Identify failure and mitigate
  • Critical failure mode functions, redesign
  • Focus on handovers and interface of care system
    -cooperation
  • Develop integral role of PCP/Medical Home and
    notion of co-management continuous healing
    relationships

52
Design of change package
  • Expert panel preferred change package according
    to chronology of care
  • Phases of process
  • Preparation and planning
  • Screening
  • Confirmation of diagnosis
  • Treatment/amplification
  • Enrollment in Early Intervention
  • State infrastructure development

53
Key change concepts
  • Standardization
  • Scripts for failed screen
  • Fax-back forms to enhance communication
  • Process of referral to specialists
  • Consideration of failed newborn screen as
    critical test result
  • Consider people as in the same system
  • Listen to the customers
  • Reduce wait time (for an appointment)
  • Give people access to information

54
Measurement strategy
  • of newborns who do not pass with verified PCP
    in hospital record
  • of newborns with results of newborn screening
    available for first newborn visit
  • of infants who did not pass the screening
    phase who get a complete audiologic evaluation by
    3 months of age
  • Mean age of infants at completion of audiologic
    evaluation
  • Time to third available new appointment with
    the audiologists (in days)
  • of infants with abnormal audiologic evaluation
    with notification of PCP/MH within 2 days
  • of infants with PHL who are offered
    amplification/treatment by 3 months of age
  • of infants with PHL with an initial IFSP by 6
    months
  • of infants who did not pass unable to find
    through outreach by 3 months of age

55
Parent experience of care measures
  • Developed by parent partners
  • of parents who were told and got a copy of the
    results of the newborn screen
  • of PCPs who had the results of the newborn
    screen available at the time of the first newborn
    visit
  • of parents who always were able to get the
    help they needed for questions related to their
    infants hearing loss
  • of parents who always were able to get
    specific information they needed

56
Lessons Learned
  • Improving handovers with standardized
    communication tools enhances information transfer
    across the system
  • Conversations about roles, responsibilities and
    accountability for care management improves care
    processes for clinicians and families
  • Partnering with families in the design and
    improvement processes accelerates improvement
  • Simple ideas work work out processes on paper
    while developing larger data systems
  • Fax back forms
  • Identification of roles and responsibilities
  • Structure of the state system matters

57
Lessons learned (cont.)
  • Identifying a system failure as early as possible
    helps reduce delays and loss to follow up
  • Use every failure as an opportunity to learn
    about your system
  • Standardizing processes and providing redundancy
    in birth hospitals helps to locate parents after
    discharge
  • Changes to the appointment system for the
    diagnostic evaluation improves completion rates
  • All parts of the system should emphasize the
    importance of establishing early communication
    approaches with the infant while in the decision
    process about communication options

58
Percent of newborns who do not pass with
verified PCP in hospital record
59
Percent of newborns who do not pass the
hospital based hearing screening with multiple
contacts on the screening form for follow-up
60
Time to third available new appointment for
ENT/ORL
61
Awareness and Access to Care for Children and
Youth with Epilepsy--Aim
  • To improve systems of care for children and youth
    with epilepsy, especially those residing in
    medically underserved areas.
  • To design care for children and youth with
    epilepsy to be timely, effective, safe, patient-
    and family-centered, and equitable.
  • To apply the model and lessons that proved
    successful in the first Medical Home Learning
    Collaborative to the care of children with the
    specific condition of epilepsy.

62
Highlights
  • Application of Advanced Access concept to
    specialty care
  • Service Level Agreements, Practice Redesign
  • Engagement of parents in learning collaborative
    process (see video)
  • Increased use of home medication lists, attention
    to comprehensive care

63
Aim
  • Improve the health and well being of Children and
    Youth with Special Health Care Needs (CYSHCN) and
    their families through building the capacity of
    state Title V programsin concert with other
    state based partnersto create and sustain
    effective community based systems of care

64
Defining System of Care
  • a family-centered coordinated network of
    community-based services designed to promote the
    healthy development and well being of children
    and their families.

65
A well-functioning system of services will
coordinate and integrate the full range of needed
child and family services, among them health
care, education, and social services, with the
goal of optimizing outcomes for the children and
families it serves Perrin at al. Through any
door
66
Specific Aim
  • With a focus on transforming the health care
    component of the system of care by
  • Spread of the medical home and
  • Strengthening co-management relationships between
    the medical home and specialty care (vertical
    coordination)

67
Three Phases
  • Planned innovation program
  • Implementation
  • Reflection

68
Planned Innovation
  • Identify successful state level strategies of
    enhancing health care and other community
    services
  • Synthesize a new framework
  • Assess validity of framework through expert
    review and (limited) field testing.

69
Implementation
  • Two sequential learning collaboratives
  • Each focusing on two categorical programs--
    Epilepsy and Newborn Hearing Screening -- while
    working with State Title V Leadership on applying
    the system framework.
  • State Teams
  • Practice Teams (Epilepsy, Hearing Screening)

70
Reflection
  • Analysis of results
  • Synthesis
  • Recommendations for further action
  • Preparation of dissemination materials

71
Focus of innovation
  • Approaches that work
  • System creation
  • Supporting primary care, specialty care, public
    health system capabilityenabling spread
  • Addresses financing, quality, population health
    simultaneously
  • Within and outside of Title V

72
Help Me Grow- (Connecticut)
  • Child Health Provider
  • Language/Behavior/Parenting Concerns
  • 1-800-Help Me Grow
  • Referrals Language Eval Play and Support
    Groups
  • Two Week Follow-Up Contact Enrolled
  • Feedback to Child Health Provider

73
Design Process
  • Desired performance characteristics
  • Identification potential sites/programs/systems
  • Screening, visits, summary
  • Synthesis
  • Expert review
  • Test
  • Revise
  • Roll out

74
What do you think?
  • How should Title V support improvement in
    clinical care?
  • Direct coaching and support at practice level?
  • Partnership in establishing regional support
    services?
  • Provision of core resources (developmental
    screening, data systems, care coordination
    training and support)
  • What are the most effective approaches to
    supporting better care that you have seen? Most
    innovative?
  • How have changes in programs and policies (SCHIP,
    Medical Home, others) influenced your thinking?

75
IHIs Triple Aim Optimize the Health System
Across Three Dimensions
76
System Components IHI Triple Aim
  • Individuals and families
  • Partnership, Joint planning, Patient controlled
    record
  • Redesign of primary care services and
    structures
  • Team, vertical coordination
  • Population health management
  • Useful segmentation , health info, public
    health 
  • Cost control platform
  • System integration
  • Developing workforce, Strategic planning
  • Execution, including spread, of strategic
    initiatives
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