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Medical Home Promising Practices Forum:


Central Massachusetts Medical Home. Quality Improvement Teams. Parent Groups ... Center for Medical Home Improvement (CMHI) Collaboration ... – PowerPoint PPT presentation

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Title: Medical Home Promising Practices Forum:

Medical Home Promising Practices Forum
  • Successes and Lessons Learned Highlights from
    the Field!

I saw the angel in the marble and carved until I
set him free.
Who We Are
  • PrimeCare Pediatrics, Ohio
  • Illinois Medical Home Project (IMHP)
  • Pennsylvania Medical Home Initiative --Educating
    Practices In Community Integrated Care (EPIC IC)
  • Florida Telehealth Connections
  • Central Massachussetts Medical Home Network
  • Center for Medical Home Improvement (CMHI), NH
  • National Medical Home Autism Initiative,
  • Suffolk Medical Home Network, New York

Why Were Here
  • We have been working to address core themes of
    this meeting
  • Family-Professional Partnerships
  • Community Based Systems
  • Transitions
  • Value
  • Look at what weve accomplished.

Family Professional Partnership
  • We Value
  • A trusting, collaborative, working partnership
    with families, respecting their diversity and
    recognizing that they are the constant in a
    childs life

Illinois Medical Home Project
  • QI teams include two parent partners from each
    of 16 practices.
  • The IMHP has a cadre of 32 active parent
  • The parent partners have helped each of the
    practices to better serve families through
  • Quality improvement feedback and needs
  • Developing information sheets on specific chronic
  • Developing family support groups.
  • Developing communication improvements.
  • Development care templates and other products

Center for Medical Home Improvement
  • Medical Home Improvement Parent as Partners
  • Model Established 1997
  • Parents as Authors
  • Do You Have a Medical Home? Exceptional Parent,
  • Parents as Advisors
  • Members of the NH Council on the Future of the
    Primary Care Medical Home and the NH Primary Care
    Task Force
  • Parents as Educators Co authors of CMHIs
  • Extra-Ordinary Care Improving Your Medical
    Home (PowerPoint and teaching guide)

Florida Telehealth Connections
  • Grandmothers as family health partners and
    cultural brokers to reach families in their
  • To provide liaison support to talk with families
    about health care, health insurance for their
  • To identify families with uninsured CSHCN and
    provide encouragement to come to the CHC to
    establish a medical home

Suffolk Medical Home Network
  • Integration of parent and consumer members into
    Developmental Disabilities Center Advisory
  • Establishment of Parent Partners to train medical
    school students and pediatric residents about
    developmental disabilities
  • Plan for appointment of family advisors to
    medical center

PrimeCare Pediatrics, Ohio
  • Dedicated parents on our core Medical Home Team
  • Parent Advisory Group that meets quarterly to
    advise, share and learn

Pennsylvania EPIC IC
  • EPIC IC has grown the participating parent
    partners to over 60 statewide
  • Parents
  • Paid stipend to attend practice team meetings
  • Reimbursed for travel childcare to attend EPIC
    ICs bi-annual conferences
  • Parents recruited via practice focus groups and
    resource nights

National MH Autism Initiative
  • Acknowledge Family as Key Partner
  • Designed ASD Medical Home Framework with family
    as the center of attention and collaboration.
  • Continually Involve Family Members
  • Convened Family Forum to solicit comments on
    Autism Service Guidelines for the Medical Home.

Central Massachusetts Medical Home
  • Quality Improvement Teams
  • Parent Groups
  • providers and/or staff attend
  • Providers and parents team up and present
    at community events  
  • Providers and parents creating community resource
    center and/or resource binder in practices   
  • Forms development
  • Family-based care coordination measurement study

Reaffirm the Value
  • Families are the synergistic movers and shakers
    that impact the system
  • Quality improvement partners
  • Resource development and sharing
  • Support to the practice community
  • Communication leaders

Community Based Systems
  • We Value
  • A family-centered, coordinated network designed
    to promote the healthy development and well being
    of children and their families

Pennsylvania EPIC IC
  • 62 practices have been trained in medical home
    principles. Practices include
  • - rural, urban, suburban
  • - hospital systems
  • - 6 PA DOH regions and 30 counties
  • 10,000 CYSHCN have been identified on practice
  • 29 practices have received funding for care

Central Massachusetts Medical Home
  • Parent Professional Advocacy League (Pal)
  • in-service at practice, response to Rosie D RFI,
    education sessions for patients providers
  • Central Mass Partnership (CMP) Collaboration
  • community based organizations linked to practices
    for outreach and trainings
  • Title V Collaboration
  • working together to enhance care coordination in
    primary care practices
  • Massachusetts Family Voices Collaboration
  • in-serve for families and providers, MH trainings
    for families
  • Center for Medical Home Improvement (CMHI)
  • joint meeting and learning sessions for families
    and providers

National MH Autism Initiative
  • ASD Medical Home Framework was designed to
    promote partnerships between medical home primary
    care practice and other community based services.
  • Service System Guidelines include a number of
    recommendations to support community based
  • Designed format (with others) for development of
    a State Plan to promote coordination of planning
    and delivery of services, involving all partners.

Suffolk Medical Home Network
  • Online and hardcopy Long Island resource
    directory of resources for CSHCN
  • Creation of a Long Island Toolkit for providing
    care coordination (including enrollment services,
    DME authorization, entitlements) to CSHCN
    available on website or in PDF by e-mail
  • Trainings for professionals and families in use
    of the Care Coordination Toolkit

PrimeCare Pediatrics, Ohio
  • Office based care coordinator
  • Lunch Lessons

Illinois Medical Home Project
  • The IMHP has developed strong relationships and
    partnerships with the
  • following community-based organizations/systems
    for a variety of activities
  • Child and Family Connections (CFCs) Early
    Intervention (EI)
  • Special Education in Public Schools
  • Division of Specialized Care for Children (DSCC)
    staff participate as facilitators for many of the
    QI teams other regional DSCC staff regularly
    attend QI team meetings.
  • The Family to Family Health Information and
    Education Center serves as a primary source of
    information for parents of children with special
  • The ARC of IL is collaborating with ICAAP on the
    Life Span program.
  • All Kids (IL Medicaid program) works
    cooperatively with the IMHP and ICAAP to ensure
    every child in IL has a Medical Home.
  • The ICAAP, IMHP, DSCC and other state agencies
    sponsored a medical home coloring contest for
    children in grades one through five, from which a
    2008 calendar was developed and widely
    disseminated. A 2009 calendar is in the works.

Center for Medical Home Improvement
  • Community Collaboration Communication Teams
  • Cross community teams meet with medical home
  • Create community wide values statement/education
  • online communication resource designed for
    families who have children or youth with special
    health care needs, and the health, educational
    and other professional partners with whom they
    regularly interact.
  • Careshare allows for family directed exchange of
    day to day information

Florida TeleHealth Connections
Spoke Site Specialist
Spoke Site CMS Enrollment And Care
  • Developed system for connecting care using

Hub Site Community Health Center
Spoke Site Med Center
Spoke Site Community Health Center
Reaffirm the value
  • Many creative ideas for
  • Trainings related to care coordination and
    connections with other systems/practices
  • Development of infrastructure (e.g., staff) to
    provide coordination
  • Use of technology to access distant systems of
  • Financing care coordination

  • We Value
  • The provision of high-quality, developmentally
    appropriate, health care services that continue
    uninterrupted as the individual moves along and
    within systems of services and from adolescence
    to adulthood

Pennsylvania EPIC IC
  • EPIC IC practices
  • completed surveys in 2005 2008 measuring
    transition activities
  • working on a posted transition policy
  • developing transition care plans
  • Family satisfaction with transition efforts
    measured via PA medical home family survey

Center for Medical Home Improvement
  • The Courtship of Family Medicine Adult Care
  • Progressive Transition Checklists
  • Transition Summaries
  • Staggered transfer of care (the dance) with
    consultative co-management

National MH Autism Initiative
  • Acknowledge Successful Transition as
    Responsibility of Medical Home
  • ASD Medical Home Framework identifies Transition
    to Adulthood as a key service function.
  • Service System Guidelines include a number of
    recommendations to support transition to adult

Illinois Medical Home Project
  • All 19 of the IMHP practices received training
    around transition issues at Learning Sessions.
    Presentations were given by experts on transition
    (Darcy Contri, RN, BSN, MPH Patience White, MD,
    MA) and shared with QI teams and promoted to
    Chapter members.
  • The Division of Specialized Care for Children
    (DSCC) hosts an annual statewide conference on
    transition during which Medical Home QI teams are
    invited to participate.
  • The DSCC surveys families it serves every three
    years to determine how services and supports can
    be improved. Transition issues remain a high
  • ICAAP and DSCC are writing a new grant to
    implement a medical home/integrated services
    project specific to transition issues.

PrimeCare Pediatrics, Ohio
  • Anticipatory guidance on ALL well visit sheets
  • Primary Care Physician and Care Coordinator
    interface directly with the new provider

Suffolk Medical Home Network
  • An annual Transition Institute, a day-long
    workshop for parents of youth ages 14 to 15 in
    transition to adulthood
  • Quarterly Transition Support Group meetings
    covering a variety of topics and providing an
    opportunity for open discussion
  • A masters level course at Stony Brook University
    covering Transition to Adulthood for education
    and health professionals working with CSHCN

Reaffirm the Value
  • Importance of training and understanding needs of
    transitioning young adults
  • Importance of tools to aid transitioning youth
  • Importance of care plans and starting early to
    develop links with adult care providers

  • We Value
  • A high-performance health care system with
    appropriate financing to support and sustain
    medical homes that promote system-wide quality
    care with optimal health outcomes, family
    satisfaction, and cost efficiency

PrimeCare Pediatrics, Ohio
  • Marked decrease in ER visits, hospitalizations
    and office scheduling errors
  • Reimbursement for careplan oversight completion
    through our state title V program

Pennsylvania EPIC IC
  • Care coordination time tracking study
  • Over 2 years
  • Tracked outcomes, focus, time on care
  • Practice reports
  • Partnership with PA Department of Public Welfare
    for cost effectiveness of medical home.

Center for Medical Home Improvement
  • Future of the Medical Home in New Hampshire
  • Grant supports care coordination to continue
  • Vet medical home and pilot Care Plan Oversight
    prospective payment of 225/year for CYSHCN
  • - Anthem NH
  • - Harvard Pilgrim Health Care
  • NH Council on the Future of the Primary Care
    Medical Home
  • NH Primary Care Task Force
  • Public Private Multi Payer Medical Home Pilot

Florida TeleHealth Connections
  • Telemedicine as a value
  • Solves access barriers
  • Geographical barriers
  • Network barriers
  • Time barriers
  • Is a potentially significant cost saver
  • E.g., reimburse for an office visit vs the cost
    of transportation, lodging, missed visits, etc.
  • Project contributed to state (Title V) efforts to
    develop Medicaid reimbursement for telemedicine

Suffolk Medical Home Network
  • Case studies of value to institutions of
    specialized care coordinators that maximize
    insurance coverage for services
  • Case studies establishing earlier inpatient
    discharge and maintenance on home care instead of
    placement in skilled nursing facility
  • Data compilation demonstrating efficiencies in
    insurance enrollment and access to Medicaid
    waiver coverage programs
  • Data supporting cost estimates for care
    coordination reimbursement

Illinois Medical Home Project
  • The evaluation component for Phase I of the IMHP
    (2004 to 2006) yielded the
  • following findings (see expanded PP at display
    table for more information)
  • Medical home practices demonstrated more
    efficiently managed healthcare through better
    care coordination and improved continuity of
  • Reduction in overall health costs, less use of ER
  • Positive outcomes for families
  • Increased satisfaction, reduced stress, less
    missed school and work days
  • Better treatment adherence and focus on
    preventive care
  • Better and enhanced use of community resources
  • Increased use of written care plans
  • The Division of Specialized Care for Children
    (state title V program) reimburses for care
    coordination services and phone consultation.
  • Beginning to see some private payers reimburse
    individual practices for care coordination
    services, eg. Blue Cross/Blue Shield, United

National MH Autism Initiative
  • As project promoted greater attention to ASD, it
    did so by recommending action steps that would
    promote more effective and efficient services for
    all children. (e.g., promotion of developmental
    screening and follow-up for all children.)
  • Project is an example of how to promote the
    application of medical home concepts for a single
    condition, in such a way that it brings attention
    to the value of the medical home for all

Reaffirm the Value
  • Multiple demonstrations that investment in
    Medical Home
  • Improves quality of care for children and
  • Creates efficiencies that can impact providers
    positively if they have the resources to develop
    the infrastructure
  • Reduces healthcare costs by reducing
    inappropriate use of healthcare
  • BUT, reimbursement and other financing strategies
    are necessary to develop and sustain the

How to Find out More????
  • Visit the display tables at the reception tonight
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