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The Medical Home System of Care in Connecticut

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Title: The Medical Home System of Care in Connecticut


1
The Medical Home System of Care in Connecticut





CT Department of Public Health J. Robert Galvin,
MD, MPH, Commissioner
2
What is a Medical Home?
  • Not a building, house or hospital, but rather…
  • An approach to providing health care services in
    a high-quality, cost-effective manner
  • A means for children families to receive care
    they need from a professional they know trust
  • An improved system where care coordination is the
    keystone

3
In a Medical Home…
  • Professionals families act as partners to
    identify access all medical non-medical
    services
  • These services help children families achieve
    their maximum potential
  • AAP believes that every child deserves a medical
    home

4
Medical Home Composition
  • Physician champion within practice
  • Nurse / Nurse Practitioner
  • Family / Parent Partner

5
AAP Medical Home Components
  • Accessible
  • Family-Centered
  • Continuous
  • Comprehensive
  • Coordinated
  • Compassionate
  • Culturally-Competent

6
ACCESSIBLE…
  • Care is provided in childs or youths community
  • All insurance, including Medicaid, is accepted
    changes are accommodated
  • Families or youth are able to speak directly to
    physician when needed

7
FAMILY CENTERED…
  • Recognition that family is principal caregiver
    center of strength support
  • Unbiased complete information is shared on an
    ongoing basis
  • Family is recognized as expert in their childs
    care youth are recognized as experts in their
    own care

8
CONTINUOUS…
  • Same primary pediatric health care professionals
    are available from infancy through adolescence
    young adulthood
  • Assistance with transitions, including those to
    other pediatric providers or into adult health
    care systems, are planned organized with child
    family

9
COMPREHENSIVE…
  • Health care is available 24 hours/day 7
    days/week 52 weeks/year
  • Preventive, primary tertiary care needs are
    addressed
  • Information is made available about private
    insurance public resources

10
COORDINATED…
  • Plan of care is developed by physician, child or
    youth, family and is shared with other
    providers, agencies, organizations involved in
    patients care
  • Central record containing all pertinent medical
    information maintained at practice
  • Families are linked to support, educational
    community-based services

11
COMPASSIONATE…
  • Concern for well-being of family child is
    expressed demonstrated
  • Efforts are made to understand empathize with
    feelings perspectives of family as well as
    child or youth

12
CULTURALLY COMPETENT…
  • Familys cultural background, including beliefs,
    rituals customs, are recognized, valued,
    respected incorporated into care plan
  • All efforts are made to ensure child or youth
    family understand results of medical encounter
    care plan, including provision of translators or
    interpreters as needed

13
Why is Medical Home System of Care so Important?
  • 120,000 (14) of CT children have special needs
  • 75,000 CT children under 18 have asthma
  • 20 of all visits to pediatricians office are
    developmental or behavioral in nature
  • 70 of children diagnosed with mental retardation
    are diagnosed by providers other than their
    pediatrician
  • 80 of parental concerns are correct and accurate

Olson AC. How to establish family professional
partnerships. Presented at International Family
Centered Care Conference Sept. 5, 2003 Boston,
MA
14
Medical Home Surveillance Screenings Assure
Early Detection of Genetic Disorders
  • Early detection means
  • Early access to services treatment
  • Cost savings for health educational system
  • Potential for improvement in quality of life for
    children families

15
Practices Use Standardized Tools
To improve outcomes, Medical Homes use nationally
standardized clinical practice tools
  • Pre-visit questionnaire
  • Screener Complexity Index forms
  • Individualized Health Plan (IHP)
  • Medical plan
  • Emergency health plan
  • Portable Care Plan for Families

16
Provider Benefits from Medical Homes
  • More proactive approach towards family
    involvement in decision making
  • Incorporation of new strategies at intake such as
    pre-visit questionnaire via phone interview to
    streamline visit/identify complexity of
    conditions
  • Office practice changes including use of daily
    log to verify tests and follow through on results
  • Interest in consolidating presenting case
    information in standardized fashion
  • Improved relationship with DPH other agencies

17
Family Benefits from Medical Homes
  • Greater voice in decision-making
  • Child/family needs assessment
  • Coordination of specialty care and services
  • Assistance in communicating with payers,
    providers, schools community services
  • Advocacy support

18
Family Benefits, cont.
  • Early continuous screenings for child
  • Briefer periods in office waiting rooms
  • Fewer hospitalizations
  • Fewer ER visits
  • Decreased health care costs
  • Important component of school readiness

19
Medical Home Learning Collaborative (MHLC) The
Beginning…
  • CT participation with the National Initiative for
    Childrens Healthcare Quality (NICHQ) the
    Medical Home Learning Collaborative (MHLC)
    commenced April 2003 and allowed for a more
    statewide, systems approach to the medical home
    that promotes the development of an
    infrastructure that will sustain itself into the
    future.

20
MHLC…The Beginning
  • Collaborative began with 3 practice sites
  • The Pediatric Center (Stamford)
  • Childrens Health Center at St. Marys Hospital
    (Waterbury)
  • Whitney Pediatric Adolescent Medicine (Hamden)

21
CTs 8 Current Medical Homes
  • The Pediatric Center (Stamford)
  • Childrens Health Center at St. Marys Hospital
    (Waterbury)
  • Long Wharf Pediatric Adolescent Medicine (New
    Haven)
  • Pediatric Medical Associates (New Haven)

22
CTs 8 Current Medical Homes
  • Pediatric Primary Care Center at Yale
  • Primary Care Center at CCMC (Hartford)
  • Roslyn Leslie Goldstein Childrens Health
    Center (Stamford)
  • Barbara Ziogas, MD (Farmington)

23
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24
Regional Support Children Youth with Special
Health Care Needs Centers
  • CT Childrens Medical Center for Children with
    Special Needs
  • Yale Center for Children with Special Health Care
    Needs

25
Conquest Through Collaboration
  • CHDI Childrens Fund of CT
  • Commission on Children
  • AAP - Connecticut Chapter
  • CT Medical Home Learning Collaborative
  • DPH, DCF, DMR, DSS, UCHC
  • Medicaid Managed Care Council
  • CT Child Health Development Infoline
  • CCMC Yale
  • Early Childhood Partners

26
CYSHCN Largest Pediatric Resource Consumer
  • Children and youth with special health care needs
    (CYSHCN) are those who have or are at increased
    risk for a 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.
  • CYSHCN consume 80 of pediatric health care
    expenditures

27
CYSHCN Reality for Families
  • 39.5 indicate their childs or youths condition
    impacts familys financial situation
  • 13.5 say they spend 11 hours/week coordinating
    care for their child or youth
  • 24.9 indicate families cut back on work due to
    childs or youths condition
  • 28.5 indicate families stop working due to
    childs or youths condition

MCHB/NCHS. National Survey of Children with
Special Health Care Needs. 2002
28
Barriers to Providing Medical Homes
  • Current pediatric primary care system is
    designed
  • For the 80 of children who DO NOT have special
    health care needs
  • To provide preventive care services acute
    illness management
  • To support single service encounters

Cooley WC. Developing primary care medical homes
for CSHCN. Presented at Institute for Leaders in
State Title V CSCHN Programs May 19, 2003
Baltimore, MD
29
The CT Medical Home Academy
  • To ensure durability sustainability, DPH will
    implement a Medical Home Academy (MHA) to
    establish a quality ongoing primary care practice
    improvement training system
  • MHA will educate pediatricians, family
    physicians, pediatric sub-specialists, nurses
    office staff, families, SBHCs communities

30
The CT Medical Home Academy
  • Will develop Connecticut-specific curriculum
    utilizing national statewide modules
  • Will be presented as a 1-day workshop on March 8,
    2005
  • Training will be sustained though webcasts,
    practice in-service trainings, CDs, audio
    cassette tapes

31
The CT Medical Home Academy Six Core Components
  • Practice Improvement
  • Family-Professional Partnerships
  • Developmental Health
  • Behavioral Health
  • CYSHCN
  • Transitioning Children Youth to Adulthood

32
Medical Home Steps for the Future
  • Evaluation of the medical homes what works,
    what doesnt
  • Ongoing training via Medical Home Academy (MHA)
  • Pediatric practice EPIC in-service trainings
  • Consumer community involvement in
    cross-training of MHLC sites centers teach
    pediatricians other providers about
    involvement providers teach centers about
    medical homes

33
In closing, Medical Homes…
  • Assure quality, efficient, family-centered care
  • Ease the burden of caring for children youth,
    including those with special needs
  • Improve family satisfaction
  • Improve health outcomes for CTs children
  • Decrease the cost of healthcare
  • Allow children families to reach their maximum
    potential

34
The Medical Home System of Care in Connecticut
CT Department of Public Health J. Robert Galvin,
MD, MPH, Commissioner
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