Disclosures

1
Disclosures

• Accreditation and Designation Statements
• The American Academy of Pediatrics (AAP) is
  accredited by the Accreditation Council for
  Continuing Medical Education (ACCME) to provide
  continuing medical education for physicians. The
  AAP designates this live activity for a maximum
  of 1 AMA PRA Category 1 Credit(s). Physicians
  should claim only the credit commensurate with
  the extent of their participation in the
  activity. This activity is acceptable for a
  maximum of 1 AAP credit. This credit can be
  applied toward the AAP CME/CPD Award available to
  Fellows and Candidate Members of the American
  Academy of Pediatrics. The American Academy of
  Physician Assistants accepts AMA PRA Category
  1 Credits from organizations accredited by the
  ACCME. This program is approved for 1 NAPNAP CE
  contact hour of which 0 contain pharmacology (Rx)
  content per the National Association of Pediatric
  Nurse Practitioners Continuing Education
  Guidelines.
• Purpose of Course
• The American Academy of Pediatrics and National
  Center for Medical Home Implementation will be
  hosting a free four-part Webinar series beginning
  in April 2011. The purpose of the webinar series
  is to provide child health professionals with
  practical strategies for implementing medical
  home in practice. Each webinar will be led by
  recognized experts with the goal of educating
  participants about the value of the
  family-centered primary care medical home for all
  children and youth, especially in the daily
  delivery of preventive, acute, and chronic care.
  Faculty will point participants to practical
  tools and resources, and will provide strategies
  for improving quality of care and increasing
  patient/family partnership and satisfaction.
• Learning Objectives
• At the conclusion of this activity, participants
  should be able to
• Explain the primary care medical home and its
  relationship to Bright Futures 3rd Edition
  guidelines as a key preventive component
• Explore key actions/roles around partnerships
  with health care teams, engagement of families,
  and practice organization in providing
  preventive/acute care for children and youth
• State quality improvement strategies for
  implementation of effective preventive/acute care
  in the medical home
• Disclosure of Financial Relationships and
  Resolution of Conflicts of Interest for AAP CME
  Activities
• The AAP CME program aims to develop, maintain,
  and improve the competence, skills, and
  professional performance of pediatricians
  and pediatric healthcare professionals by
  providing quality, relevant, accessible, and
  effective educational experiences that address
  gaps in professional practice. The AAP CME
  program strives to meet participants' educational
  needs and support their life-long learning with a
  goal of improving care for children and families.
  (AAP CME Program Mission Statement, September
  2010).
• The AAP recognizes that there are a variety of
  financial relationships between individuals and
  commercial interests that require review to
  identify possible conflicts of interest in a CME
  activity. The AAP Policy on Disclosure of
  Financial Relationships and Resolution of
  Conflicts of Interest for AAP CME Activities is
  designed to ensure quality, objective, balanced,
  and scientifically rigorous AAP CME activities by
  identifying and resolving all potential conflicts
  of interest prior to the confirmation of service
  of those in a position to influence and/or
  control CME content. The AAP has taken steps to
  resolve any potential conflicts of interest.
• All AAP CME activities will strictly adhere to
  the Accreditation Council for Continuing Medical
  Education (ACCME) Standards for Commercial
  Support Standards to Ensure the Independence of
  CME Activities. In accordance with these
  Standards, the following decisions will be made
  free of the control of a commercial interest
  identification of CME needs, determination of
  educational objectives, selection and
  presentation of content, selection of all persons
  and organizations that will be in a position to
  control the content, selection of educational
  methods, and evaluation of the CME activity.
• The purpose of this policy is to ensure all
  potential conflicts of interest are identified
  and mechanisms to resolve them prior to the CME
  activity are implemented in ways that are
  consistent with the public good. The AAP is
  committed to providing learners with commercially
  unbiased CME activities.

2
Disclosures
3
Partnering with Patients and Families in the
Medical Home2011 CME Webinar Series brought to
you by the National Center for Medical Home
Implementation
The Role of the Medical Home in Preventive and
Acute Care Jill Rinehart, MD, FAAPKristy
Trask, RN April 27, 2011
4
Disclosures

• We have no relevant financial relationships with
  the manufacturers(s) of any commercial
  products(s) and/or provider of commercial
  services discussed in this CME activity.
• I do not intend to discuss an unapproved/investiga
  tive use of a commercial product/device in my
  presentation.

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Webinar Objectives

• By the end of this webinar, the participant will
  be able to
• Explain the medical home and its relationship to
  Bright Futures 3rd Edition guidelines as a key
  preventive component
• Explore key actions/roles around partnerships
  with health care teams, engagement of families,
  and practice organization in providing
  preventive/acute care
• State quality improvement strategies for
  implementation of effective preventive/acute care
  in the medical home

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Our Medical Home Program

• Three pediatricians, Dr. Joseph Hagan, Dr. Jill
  Rinehart, Dr. Greg Connolly
• Two Pediatric Nurse Practicioners, Maryann Lisak
  Tonya Wilkinson
• One main RN Care Coordinator Kristy
• Office manager, Scheduling manager, two office
  assistants, four additional part-time nurses, one
  medical assistant
• 5000 Active Patient List

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Medical Home History

• 1967 First published reference to Medical home
  was in the AAPs Council on Pediatric Practices
  Standards of Child Health Care
• Defined Medical Home as the respository of
  medical records for a child, emphasized the
  importance especially for CSHCN

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Medical Home History

• 1970s AAP first addresses the policy
  implications of the term medical home
• 1977 Fragmentation of Health Care Services for
  Children, Clarified the concept of single
  medical home for every child
• 1980s The first Medical Home is attributed to
  Hawaii Pediatrician, Dr. Cal Sia.
• 1992 AAP published first policy statement
  defining the medical home

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Medical Home History

• 1998 Called for imaginative methods, backed by
  insurance and government funding that must be
  developed and used to improve financing for care
  coordination and other needs
• Polly Arango and Merle McPherson
• New Definition of Children with Special Health
  Needs,Pediatrics,1998

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Medical Home History

• 2002 Medical Home Policy Statement was published
  that defines the concept of Medical Home we use
  today
• 2002-2004 in VT Medical Home Improvement Project
• Applied PDSA cycles to improving our practice
  towards medical home standards
• Created (formal) parent partnerships to advise
  our progress
• 2006 ACP created The Advanced Medical Home A
  Patient-Centered, Physician-Guided Model of
  Health Care promoting an evidence based
  medical home
• 2007 Bright Futures embraces the concept of
  Medical Home for all children and states that the
  Medical Home is the most effective model for the
  provision of health supervision.

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Medical Home History

• Joint effort led to the National Center for
  Quality Assurances (NCQA) creation of Physician
  Practice Connections-Patient-Centered Medical
  Home (PPCPCMH)
• Created 2008 PPCPCMH Standards
• March 2011 new PCMH guidelines

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Medical Home Definition

• Accessible
• Culturally Effective
• Continuous
• Comprehensive
• Coordinated
• Compassionate
• Family Centered

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Medical Home Definition

• The Medical Home is the model for 21st century
  primary care, with the goal of addressing and
  integrating high quality health promotion, acute
  care and chronic condition management in a
  planned, coordinated and family-centered manner
• National Center for Medical Home
  Implementation

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What the Julius Medical Home Was at HRC

• Incredible reputation
• Amazing Physicians
• 24/7 Coverage
• Nurses that were lactation specialists
• Integrated approach and interest in Matts whole
  life

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Our Medical Home Until 130pm 2/15/01
MEDICALHOME PRIMARY DOCTOR CARE COORDINATOR
DAYCARE
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And ThenAlong Came the Amazing Miss Kate

• Congenital Hydrocephalus
• Multiple revisions, infections, complications
• Cerebral Palsy, Epilepsy
• Downright remarkable

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Our Medical Home Post Diagnosis 135 pm 2/15/01
Specialists Neurosurgery Neurology Physiatrist End
ocrinology
Funding Insurers Medicaid FIT CSHN
MEDICALHOME PRIMARY DOCTOR CARE COORDINATOR
On-Going Care Team Social Worker OT/PT/SLP
Therapists Daycare Staff Aide
Respite Medicaid Aris FIT
CSHN Clinics Funding Equipment
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National Study-CSHN, 2005-6

• Surveyed 40,840 Children
• Measured 5 core medical home components
• Having a usual source of care
• Having a personal doctor or nurse
• Receiving all needed referrals for specialty care
• Receiving help as needed in coordinating
  health-related care
• Receiving family-centered care
• New Findings from the 2005-06 NS-CSHN,
  Strickland, B.et.al.Pediatrics, June 26, 2009
  Vol. 123

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National Study-CSHN 2005-6

• Good News
• 90 of CSHN and their peers had usual source of
  care and a personal MD or nurse
• BUT only half of CSHN and peers had access to
  medical home in all 5 aspects
• As family income increases, access to medical
  home increases
• Access is affected by race/ethnicity, health
  insurance status, severity of childs condition
• New Findings from the 2005-2006 NS-CSHN,
  B.Strickland, et.al.Pediatrics, June 26, 2009Vol.
  123

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Access to Medical Home

• Parents of CSHN who do have medical homes report
  less delayed or forgone care and significantly
  fewer unmet needs for health care and family
  support services
• But limited improvements since success rates
  first measured in 2001 NS-CSHN
• New Findings from the 2005-2006 NS-CSHN,
  B.Strickland, et.al., Pediatrics, June 26, 2009
  Vol. 123

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Care Coordination What Does It Look Like?

• A plan of care developed by the physician,
  CYSHCN, and family
• A central record with pertinent medical
  information kept in the primary care office
• When CYSHCN is referred for a consultation, the
  medical home assists the CYSHCN and family in
  communicating clinical issues
• The medical home evaluates and interprets the
  consultants recommendations for the CYSHCN and
  the family
• The care plan is coordinated with other community
  agencies

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What is Bright Futures?

• Gold standard for pediatric care provides
  detailed information on well-child care for
  health care practitioners.
• A national health promotion and disease
  prevention initiative that addresses children's
  health needs in the context of family and
  community

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Bright Futures and Medical Home
Bright Futures is an evidenced based approach to
preventive health care, that is best delivered in
the medical home.
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Medical Home Health Supervision

• At any given time we have 2 distinct populations
  in
• Pediatrics
• Relatively healthy need preventive health care,
  education and community support and,
• The pretty sick who need preventive health
  care, education, community support AND chronic
  care management

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Medical Home Definition

• Accessible
• Culturally Effective
• Continuous
• Comprehensive
• Coordinated
• Compassionate
• Family Centered

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Medical Home and Health SupervisionCoordinated,
Continuous

• Lacation Consultation
• Nurse phone call follow up
• First touchpoint with office after infant born
• Past 24 hours (stools, swallowing, engorgement)
• Feeding, jaundice
• Explore supports
• Baby blues

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Medical Home and Health SupervisionComprehensive

• 11 year old boy, Bright Futures Visit
• BMI 87, SMA II
• Strengths based assessment
• H-ome
• E-ducation
• A-ctivities
• D-rugs
• S-ex
• S-uicide
• S-afety

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Medical Home and Health SupervisionFamily
Centered, Comprehensive

• Parent Concerns Mom concerned about anxiety
  around swim meets and whether divorce adjustment
  ok
• Youth Concerns Warts-hands and fingers,
  biggest kid in 5th grade
• Physician Concerns Elevated BMI, needs
  Immunizations, puberty

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Medical Home and Health Supervision

• Strengths Based Assessment, developmental
  milestones of pre-adolescent
• Generosity likes younger kids, book buddy has
  special needs
• Independence self-reliance, supervises younger
  brother at Dads
• Mastery qualified New Englands 9 swim events
• Belonging loves school, has friends, loves
  Vermont

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Medical Home and Health Supervision

• Anticipatory Guidance
• Physical Growth/Development puberty, BMI
• Emotional Well-being decision making, dealing
  with stress, mental health concerns, puberty
• Risk reduction parents know friends
• Violence and Injury Prevention helmet, no guns,
  bullying

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Health Supervision in the Medical Home

• Conclude with readiness to change steps--switch
  from chocolate milk to skim at school, review
  healthy choices for food in all settings,
  identify opportunity for role as a
  babysitter/mothers helper in the neighborhood
• Support psychotherapy around divorce issues
• Immunizations HPV, Tdap, Menactra

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Medical Home Definition

• Accessible
• Culturally Effective
• Continuous
• Comprehensive
• Coordinated
• Compassionate
• Family Centered

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Family-Centered

• McKayla is a 12 year old with Nonketotic
  Hyperglycinemia
• Developmental Delay
• Choreoathetosis
• Seizures
• Dysphagia (G-Tube)
• Friend, classmate, daughter, niece

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Compassionate
Admitted for aspiration pneumonia
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Comprehensive

• Physician facilitates essentially all aspects of
  care
• Pediatric Resident communicates with
  neurometabolism program to adjust feedings/meds
• Family as experts provides medication lists,
  dietary history, clinical expertiseShes
  herself again!

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Evidence for Medical Home

• Comprehensive care for high-risk infants resulted
  in more outpatient visits, but fewer
  life-threatening illnesses, PICU admissions and
  PICU days
• Broyles RS, Tyson JEH, Heyne ET, et al.
  Comprehensive follow-up care and
  life-threatening illnesses among high-risk
  infants a randomized controlled trial, JAMA.
  2000284 (16)2070 2076

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Evidence for Medical Home

• For children with Asthma a decreased continuity
  of care is shown to increase hospitalizations
• Christakis D, Mell L, Koepsell TD, Zimmerman FJ,
  Connell RA. Association of lower continuity of
  care with greater risk of emergency department
  use and hospitalization in children. Pediatrics.
  2001107 (3)524 529

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Coordinated Care

• Teagan is a 2 year old with Kabuki (Make-up)
  Syndrome
• Had a Nissen and G-Tube placed in infancy for
  severe aspiration, oral aversion
• Late last fall, she presented with seizures
  associated with hypoglycemia
• Difficult IV access
• Sister, clown, cousin

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Coordinated Care

• PICC placed by anesthesia
• Dr. Mingin renal calculi surgery
• Labs coordinated by genetics, endocrine, GI, me
  (some first a.m., fasting, hypoglycemic,etc.)

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Comprehensive

• Dr. Modlinsky Anesthesia
• Dr. Mingin Pediatric Urology
• Dr. Hubble Pediatric ENT
• Dr. Sartorelli Pedi Surgery
• Dr. Hastings Pediatric Opthalmology
• Dr. Bingham Pediatric Neurology
• Dr. Soll Neonatology

• Pediatric Medical Home Dr. Rinehart (HRC)
• Pediatric Resident Team
• Dr. Guillot Pediatric Nephrology
• Dr. DAmico Pediatric Gastroenterology
• Dr. Kacer Endocrinology
• Dr. Burke Pediatric Genetics

42
Comprehensive

• Review of evidence base for medical home
• model found that 28 of 33 articles reported
• benefits of medical home over a range of
• outcomes
• Homer CJ, Klatka K, Romm D, et al. A review of
  the evidence for
• the medical home for children with special health
  care needs.
• Pediatrics. 2008122 (4)

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Comprehensive

• Having a medical home is associated with
• increased ease of use of community services by
• families
• Baruffi G, Miyashiro L, Prince CB, Heu P. Factors
  associated with ease of
• using community-based systems of care for CSHCN
  in Hawaii. Matern
• Child Health J. 20059 (suppl 2)S99

44
Comprehensive

• 2 brothers live with their dad and paternal
  Grandma in Burlington
• Scotty is 6, has CP
• Sam is 7 has Autism
• Chief Complaint Truancy
• Scotty unable to get a power chair because home
  is not accessible
• Accessible units not possible due to Sams
  sleep dysfunction

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Coordinated

• Care Conferences Kidsafe Collaborative,
  Burlington Housing Authority, Howard Center,
  Bridge Program, Burlington School district,
  Shelburne School District, psychologist, CSHN
  social worker, school nurses, PT, OT, SLP

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Compassionate

• BHA found a house in Shelburne, needed indoor
  modifications and a ramp
• Generous donor--donated supplies, labor
• Family moved in on March 29!

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CMHI National Outcomes StudyCost/Utilization

• Medical Home Index 43 Practices, 7 Plans/5
  States
• Higher overall MHI scores or higher domain scores
  for care coordination, chronic condition
  management, office organizational capacity
• Lower hospitalization rates
• Higher Chronic Condition Management domain scores
• Fewer ER visits
• Cooley, McAllister, Sherrieb, Kuhlthau,
  Pediatrics, July 2009

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Why is Care Coordination Important?

• Families spend 11 hrs/wk coordinating care for
  CYSHCN, which has consequences for

- Emotional/mental/ behavioral health of family
and CYSHCN
- Finances
- Employment
MCHB/NCHS. National Survey of Children with
Special Health Care Needs. 2002
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National Study of Care Coordination in Medical
HomeRich Antonelli, MD

• Hagan Rinehart counted unreimbursed care
  coordination activities (2004)
• 39 workdays
• 602 encounters
• 422 unique patients
• Level 1 typical child, no psychosocial aspect
• Level 2 CYSHCN, no psychosocial aspect
• Level 3 typical child, with psychosocial aspect
• Level 4 CYSHCN with psychosocial aspect

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Encounters by Level (HRP)
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Encounters by Staff Type (HRP)
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Direct Cost of CC by Staff Type
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Results

• Most care coordination done for typical children,
  not CYSHN
• Major cost driver is care coordination done by
  physicians
• Office based nurses resulted in less ED use and
  less unplanned office visits
• Antonelli RC, Stille CJ,Care , Antonelli DM,
  Coordination for CYSHCN A descriptive Multisite
  Study of Activities, Personnel Costs, and
  Outcomes, Pediatrics, Vol. 122 No. 1 July 2008

56
Signs of Success
57
Measuring the Medical Home

• Quality AssuranceDo you meet standards?
• National Committee for Quality Assurance (NCQA)
• 10 Standards Levels 1, 2, and 3
• Basic requirement for many pilots
• Quality ImprovementWhere are you on the medical
  home continuum?
• CMHI Medical Home Index (Validation Study 2003)
• Medical Home Family Index Survey
• Pediatric adult versions long short forms
• Jeanne McAllister

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Measuring the Medical Home

• Quality AssuranceDo you meet standards?
• National Committee for Quality Assurance (NCQA)
• 10 Standards Levels 1, 2, and 3
• Basic requirement for many pilots
• Quality ImprovementWhere are you on the medical
  home continuum?
• CMHI Medical Home Index (Validation Study 2003)
• Medical Home Family Index Survey
• Pediatric adult versions long short forms
• Jeanne McAllister

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NCQA Process

• VCHIP Project administrator, EHR representative
  (PCC), Office Administrator, Physician leader
• Create a binder- that proves you do what you say
  you do
• Your Choice 3 clinical conditions for which you
  have evidenced based guidelines incorporated into
  your record (Health Supervision, ADHD,
  Depression, Asthma, Obsesity) and have had for 3
  months

60
NCQA Process

• Benefits
• Self-evaluation
• Call return time
• Policies lab, patient scheduling,
  prescriptions, E.H.R.
• Identify areas for improvement
• PPPM reimbursement

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NCQA Process

• Challenges
• AAP just put together a by element response to
  the new 2011 NCQA guidelines
• This is Health Reform in Vermont
• Future Patient/Family feedback required (Medical
  Home Index?)

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Blueprint for Pediatrics

• Medical home
• NCQA scoring
• Access to Community Health Team
• Data Collection/submission/Docsite
• Electronic health record
• Per member per month

63
Signs of Success
How do we build quality into our Medical Home?
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Quality Improvement Strategies

• Practice Improvement Partnerships (Vchip)
• Medical Home EQIPP Course
• Bright Futures EQIPP Course
• PDSA cycles on building a team, ways to engage
  families, implementing clinical guidelines
  (Bright Futures, acute conditions, implementing a
  recall/reminder system)
• Self-assessment! (Medical Home Index)

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Building Medical Home Teams

• Care Coordinator
• Team Huddles
• Provider Meetings
• Staff Meetings
• Co-located Psychologist
• Pediatric Psychiatrist-Case consults every 2-3
  weeks
• New alliances Community Health Team, Medical
  social worker, Pediatric Registered Dietician

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Engaging Patients and Families

• Motivational Interviewing
• Family Centered Care
• Team building
• Empowering parents as experts and partners
• Medical Home Index
• Family Advisory Board

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Practice Organization

• Preparing for Office Visits (pre-visit
  forms)parent, youth
• Patient Registry-flag in E.H.R. for CSHN, or
  more time needed
• Access to clinical guidelines
• Care coordinator(nurse) connects with family
  after birth, ED visit, discharge from NICU, or
  Childrens Hospital
• Care Conferences brings families, communities
  together

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Take Home Points

• NCQA evolved from AAP medical home-Blueprint is
  health care reform in pediatrics in Vermont
• Care Coordination You are already doing it, and
  might as well get reimbursed for it
• Health Supervision for all children best done the
  Medical Home

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Thank You to Our Parent Partners

• Carolyn Brennan
• Kimberly Cookson
• Sandy Julius
• Scott Metevier
• Peggy Mann Rinehart
• Wendy Ruggles
• Theresa Soares
• Kate Michael Stein

70
Resources
Antonelli RC, Stille CJ,Care , Antonelli DM,
Coordination for CYSHCN A descriptive Multisite
Study of Activities, Personnel Costs, and
Outcomes, Pediatrics, July 2008 Baruffi G,
Miyashiro L, Prince CB, Heu P. Factors
associated with ease of using community-based
systems of care for CSHCN in Hawaii, Maternal
Child Health J, 2005 Broyles RS, Tyson JEH, Heyne
ET, et al. Comprehensive follow-up care and
life-threatening illnesses among high-risk
infants a randomized controlled trial, JAMA.
2000 Christakis D, Mell L, Koepsell TD, Zimmerman
FJ, Connell RA. Association of lower continuity
of care with greater risk of emergency department
use and hospitalization in children. Pediatrics.
2001 Cooley C, McAllister J, CMHI National
Outcomes Study Cost/Utilization, Pediatrics,
July 2009
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Resources

• Christakis D, Mell L, Koepsell TD, Zimmerman FJ,
  Connell RA. Association of lower continuity of
  care with greater risk of emergency department
  use and hospitalization in children. Pediatrics.
  2001
• Hagan, J.F, Duncan, P., Shaw, J., Bright Futures
  Guidelines for Health Supervision of Infants,
  Children and Adolescents, p.4
• Homer CJ, Klatka K, Romm D, et al. A review of
  the evidence for the medical home for children
  with special health care needs. Pediatrics. 2008
• MCHB/NCHS. National Survey of Children with
  Special Health Care Needs, 2002
• National Center for Medical Home Implementation
  Building Your Medical Home Toolkit,
  websitehttp//www.pediatricmedhome.org/
• Strickland, et.al.,New Findings from the
  2005-2006 NS-CSHN, Pediatrics, June 26, 2009

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Questions?
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Got Medical Home?

• Have a specific question or need regarding
  medical home?
• Contact us!
• Medical_home_at_aap.org800/433-9016 ext 7605