Enhancing Your Practice As A Medical Home Practical First Steps

1
Enhancing Your Practice As A Medical Home
Practical First Steps

• Desiree Pendergrass, MD, MPH
• Assistant Medical Director
• Manager, Child Medical Policy Provider
  Relations
• Children with Special Health Care Needs Services
  Program
• Purchased Health Services Unit
• Department of State Health Services

2
Overview

• What is a Medical Home?
• Common Barriers to the Medical Home
• The role of Family-Professional Partnerships
• Assessing Your Practice The Medical Home Index
  and Family Index
• Practical First Steps
• The Medical Home Learning Collaborative

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What Is a Medical Home?

• An approach to providing health care services in
  a high-quality, comprehensive, and cost-effective
  manner
• Provision of care through a primary care
  physician through partnership with other allied
  health care professionals and the family

4
Medical Home Common Elements

• Accessible
• Family-Centered
• Continuous
• Comprehensive
• Coordinated
• Compassionate
• Culturally Competent

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Who Is Part of a Medical Home?

• Primary care physician
• Family
• Child/youth
• Allied health care professionals
• Familys community
• Pediatric office staff
• If necessary, pediatric subspecialists

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Medical Specialists
Educational Services (including Early
Intervention)
Religious/ Spiritual Support
Child/Youth and Family
Parent Support Services
Mental Health Services
Financial Assistance
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CSHCN and the Medical Home

• Medical Homes are for everyone!
• Emphasis has been on designing the system for
  CSHCN
• Design the system for the most medically
  complex, and it will meet the needs of all.

AAP Making the Case for Medical Home A Review
of the Evidence
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Benefits of a Medical Home

• Increased patient and family satisfaction
• Establishment of a forum for problem solving
• Improved coordination of care
• Enhanced efficiency for children, youth, and
  families
• Efficient use of limited resources
• Increased professional satisfaction
• Increased wellness resulting from comprehensive
  care

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Common Barriers to Providing Medical Homes

• Pediatric primary care system is designed
• For the 80 of children who DO NOT have special
  health care needs
• To provide preventive care services and acute
  illness management
• To support single service encounter

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Common Barriers to Providing Medical Homes

• Knowledge of community resources
• Time
• Adequate reimbursement

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The Role of Family-Professional Collaboration

• Family-Centered Care Best Practice
• Promotes relationship in which family
  professionals work together to ensure the best
  services for the child family
• Recognizes respects the knowledge, skills and
  experience that families and professionals bring
  to the relationship
• Acknowledges that the development of trust is an
  integral part of a collaborative relationship

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The Role of Family-Professional Collaboration

• Facilitates open communication so families
  professionals feel free to express themselves
• Creates an atmosphere in which the cultural
  traditions, values, and diversity of families are
  acknowledged and honored
• Recognizes that negotiation is essential
• Includes acknowledgment of mutual respect for
  each others culture, values, and traditions

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Getting Started

• Walkthrough
• Medical Home Index
• Validated self-assessment and classification tool
• Measures a practice's progress
• Medical Home Family Index
• Provides valuable consumer perspective
• Used in combination with the Medical Home Index
• Identify Ways to Create Family-Professional
  Collaboration

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Getting Started

• Access the Medical Home Indexes at
• www.medicalhomeimprovement.org/outcomes.htm

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Getting Started

• Medical Home" is an evolutionary process rather
  than a fully realized status for most practice
  settings.

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Walkthrough

• Parking
• Physical space/environment (waiting room, exam
  room)
• Family Orientation/Check-in
• Appointments/visits
• All Care Needs (Well, Acute, Chronic)
• Community Linkages

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Assessing Your Practice The Medical Home Index

• Where is your practice on a continuum of Medical
  Homeness?
• Organizational Capacity
• Chronic Care Management
• Care Coordination
• Community Outreach
• Data Management
• Quality Improvement/Change

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Organizational Capacity

• Practice Mission
• Communication/Access
• Access to the Medical Record
• Office Environment
• Family Feedback
• Cultural Competence
• Staff Education

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Chronic Condition Management

• Identification of CYSHCN in your Practice
• Care Continuity
• Continuity Across Settings
• Cooperative Management Between Primary Care
  Provider (PCP) and Specialist
• Supporting the Transition to Adult Health Care
  Services
• Family Support

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Care Coordination

• Care Coordination/Role Definition
• Family Involvement
• Child and Family Education
• Assessment of Needs/Plans of Care
• Resource Information and Referral
• Advocacy

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Community Outreach

• Community Assessment of Needs for CYSHCN
• Community Outreach to Agencies and Schools

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Data Management

• Electronic Data Support
• Data Retrieval Capacity

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Quality Improvement/Change

• Quality Standards (structures)
• Quality Activities (processes)

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Medical Home Family Index

• Companion Survey to Medical Home Index
• Use with a cohort of families of CYSHCN who
  receive care in your practice

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Family-Professional Collaboration

• Have families fill out intake forms while in the
  waiting room to assess concerns and needs
• Put a suggestion box in the waiting room to help
  facilitate communication
• Make sure the office setting is reflective of
  various cultures and traditions that families
  honor

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Family-Professional Collaboration

• Speak to the family directly, using his or her
  name, and ask if they have questions at the
  beginning end of visit
• Make sure adequate time is given when scheduling
  CYSHCN, so there is time for communication with
  family
• Written information from the office to families,
  should be written in family-friendly language
• If possible, construct a family advisory group to
  the practice

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Practical First Steps

• Appropriate Coding
• Identification of CYSHCN
• Link to community resources
• Effective Communication
• Care Plan

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Appropriate Coding
Appropriate coding
Under coding
Over coding
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Appropriate Coding

• Learn E/M Coding Well
• Document to support your coding
• Know what you are being reimbursed
• Higher Level Evaluation Management (E/M) codes
• 99214
• 99215

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99214 Key Elements
PHYSICAL EXAM-detailed 5-7 systems (95) 12
elements (97) MDM-moderate Time 25 min

• HISTORY-detailed
• CC
• HPI-ext4 or gt
• ROS- 2-9
• PFSH- 1/3

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99214 Time

• CAN USE TIME-
• IF TOTAL VISIT gt 25 MINUTES (FACE TO FACE )
• IF OVER 50 COUNSELING OR COORDINATION OF CARE
• DOCUMENT COUNSELING/TOTAL TIME
• ( 13/25 MIN.)

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99215 Key Elements
PHYSICAL EXAM-comprehensive 8 or more systems
(95) 18 elements (97) MDM-high Time-40 min

• HISTORY-comprehensive
• CC
• HPI-ext4
• ROS-Com-10
• PFSH- Com 2/3

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99215 Time

• CAN USE TIME-
• IF TOTAL VISIT gt 40 MINUTES (FACE TO FACE )
• IF OVER 50 COUNSELING OR COORDINATION OF CARE
• DOCUMENT COUNSELING/TOTAL TIME
• ( 21/40 MIN.)

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Special Services and Reports Add-on Codes

• 99050 Services requested after office hours
• 99052 Services requested 10 PM to 8 AM
• 99054 Services requested Sunday and holidays
• 99058 Office services on an emergency basis

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Team Conferences

• Team conference Physician and interdisciplinary
  team (patient is not present)
• 99361 Simple, 30 minutes
• Report on tests, clarify instructions, adjust
  therapy
• 99362 One hour
• Advice on new problem, initiate therapy, discuss
  tests in detail
• Only infrequently paid by insurers

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Identification of CYSHCN

• A person age 21 years of age or younger who has
  or is at increased risk for a chronic physical,
  developmental, behavioral or emotional condition
  and who requires health and related services of a
  type or amount beyond those required by children
  in general.
• Maternal and Child Health Bureau 1995

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Identification of CYSHCN

• CAHMI Screener
• Flag chart/database
• Longer appointment times

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Link to Community Resources

• Care Coordination
• Early Childhood Intervention (birth to three)
• DSHS Case Management
• School
• Other

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Effective Communication

• Fax-back form
• Electronic Visit Summary
• Pre-visit phone call
• Care Notebook

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Care Plan

• An available source of information for parents to
  provide to the medical, educational and other
  care teams
• A quick reference with child-specific information
  in a medical emergency
• An action plan that the entire care team,
  including the family and patient develop, use to
  prioritize, assign tasks, implement and assess
  care

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Key Resources

• American Academy of Pediatrics The National
  Center of Medical Home Initiatives for Children
  with Special Health Care Needs
• http//www.medicalhomeinfo.org/
• Tools for families, youth, and health care
  providers
• Center for Medical Home Improvement
• www.medicalhomeimprovement.org
• Useful tools, assessments, and resources

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Medical Home Learning Collaborative

• Sponsored by the U. S. Maternal and Child Health
  Bureau
• Participants
• Texas Title V Team
• 3 practices
• Pedi Med Center Midland
• Baylor College of Medicine Transitional Clinic
  Houston
• Su Clinica Familiar - Harlingen
• Began February 2005 - Runs for 15 months

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Medical Home Learning Collaborative

• Goal/Mission
• Improve care for the growing population of
  children and youth with special health care needs
  by
• implementing and disseminating the Medical Home
  concept in a significant number of practices (3
  practices in each of 10 States)
• building state Title V program capacity to
  promote, sustain, and spread improvements after
  the completion of the project period

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Medical Home Learning Collaborative Practice
Team Accomplishments

• Parent partners
• Family Resource Bulletin Board
• Identification of CYSHCN
• Use of CAHMI Screener/Visit Survey
• Spanish translation of CAHMI Screener/Visit
  Survey
• Chart identification
• Medical Home Information
• Grand Rounds
• Resource Fair

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Medical Home Learning CollaborativePractice Team
Accomplishments

• Planning
• Pre-visit phone calls
• Identification of primary/personal physician
  (large multi-provider practice)
• Implementation of Care Plans
• Community
• Joint planning with local Early Childhood
  Intervention staff
• Coordination with local DSHS Case Managers

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Medical Home Learning CollaborativePractice Team
Accomplishments To Date

• Communication
• Electronic Visit Summary
• Improved communication with specialists through
  fax-back form

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Medical Home Learning Collaborative Title V Team
Accomplishments

• Medical Home Workgroup Strategic Plan
• Medical Home Brochure
• English and Spanish
• CSHCN Services Program Family Newsletter and
  Provider Bulletin Articles
• Presentations

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Closing thoughts

• Obstacles are those frightful things you see
  when you take your mind off your goals.
• Unknown

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Thank You

• Contact Information
• Desiree B. Pendergrass, MD, MPH
• Manager, Child Medical Policy Provider
  Relations
• Purchased Health Services Unit
• Department of State Health Services
• desiree.pendergrass_at_dshs.state.tx.us
• [phone], ext. 3132