Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation

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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 Care of Children
with Complex Chronic ConditionsDennis Z. Kuo,
MD, MHS, FAAPUAMS / Arkansas Childrens
Hospital Jane Sneed, MD, FAAPThe Childrens
Clinic, Jonesboro, AR June 2, 2011
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Disclosures

• Neither Dr. Kuo or Dr. Sneed have any relevant
  financial relationships with the manufacturers(s)
  of any commercial products(s) and/or provider of
  commercial services discussed in this CME
  activity.
• We do not intend to discuss an unapproved/investig
  ative use of a commercial product/device in our
  presentation.

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Looking Back

• The first and second webinars of this series
• History of medical home model
• Health care teams, family/professional
  partnerships, Bright Futures, quality improvement
• Care management of chronic condition (asthma)

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Webinar Objectives

• By the end of this webinar, the participant will
  be able to
• Illustrate the importance of building and
  maintaining multi-specialty teams in the
  provision of care for children and youth with
  complex chronic conditions
• Explore strategies for enhancing complex
  co-management working partnerships between
  specialty and primary care clinicians
• Explain how to effectively work with clinical
  teams and patients/families for successful and
  appropriate care transition planning from
  pediatric to adult care

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Alex (name is changed)

• Alex is a 3 month old child you have seen since
  birth. In the nursery, you noticed dysmorphic
  facies, low tone, undescended testes, and a heart
  murmur. He developed heart failure shortly after
  and required surgery to repair a large VSD.

• Today, you suspect craniosynostosis on exam. He
  is developmentally delayed and small for age.

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Alexs needs

• What specialists does he need?
• Cardiology, neurosurgery, urology, GI, genetics
• when older ENT, developmental, neurology
• What therapists does he need?
• Speech, swallowing, OT, PT, developmental
• What is the role of his primary care provider?
• Checkups? Nutrition? Care coordination?
  Immunizations?
• What is the role of his family?
• Should this have gone at the top of the list?

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Complex Chronic Conditions

• Medically fragile or Medical Complexity
• Usually described by
• Multiple subspecialists
• Technology dependence for basic health needs
• Frequent visits to tertiary care centers
• High prevalence of neurodevelopmental
  disabilities and genetic disorders

Srivastava 2005 Cohen 2011, Pediatrics
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Why consider these children separately?

• Highest risk for adverse outcomes
• Medical, growth, developmental, social
• Tend to fall through the cracks
• Most challenging
• Most satisfying?
• The role of the Medical Home (on steroids?)

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Bending the cost curve

• Medicaid projected growth rate 8.8 - higher
  than Medicare or national health spending
• Bend the curve slowing the rate of increase
• A small number of children are responsible for a
  majority of health care costs
• Medicaid 10 of children 72 of costs
• 0.4-1 of children 12-15 of total costs,
  20-25 of hospitalized patients, and 45-50 of
  hospital days

Shortell (2009), JAMA Kenney (2009), Health
Affairs Neff (2004) Berry (2011) unpublished,
by permission
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The high resource utilizers

• The vast majority of the high resource utilizers
  have complex and chronic conditions
• Children who fall through the cracks
• Majority of costs are inpatient
• Need to coordinate care and improve quality
• Integrated, organized systems
• Fundamental payment reform

Neff (2004) Fisher (2009) NEJM Berry (2011), J
Peds Cohen (2011)
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Building and maintaining multi-specialty teams
for children with complex chronic conditions

• Consider
• The components of care
• How the components work together
• The role of the Medical Home
• How the Medical Home can initiate and lead
  co-management

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Care components
Perrin et al. (2007) Arch Pediatr Adoles Med
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The world that Alexs parents see
Ray (1997, 2002)
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The Chronic Care Model
From Wagner EH. Figure from Antonelli R (2005).
Adapted from Bodenheimer (2002)
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Chronic Care Model components

• Care partnership support
• Delivery system design
• Decision support
• Clinical information systems

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When comprehensive care works

• 48 decrease in the number of hospital days and a
  10.7 million decrease in payments to the
  tertiary care center Gordon JB Pediatr Adol Med
  2007
• 55 reduction in ED visits Klitzner TS J pediatr
  2010
• 40 reduction in inpatient costs, 27 decrease in
  hospital stays Casey PH Arch Pediatr Adolesc Med
  2011

Courtesy of D. Bergman
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Putting it all together Co-management

• Multiple health care professionals partner with
  families to provide a consistent direction of
  care
• For children with complex chronic conditions
• Integrates all components of care
• Reinforces the active role of the PCP/Medical Home

Stille (2009)
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Partners

• Specialty care straightforward
• Does not address all needs
• Primary care first point of access,
  immunizations, continuity
• Primary care sometimes not fulfilled when child
  has multiple visits to specialty services
• Assumption that needs are being met
• Community-based services
• Not always consistent
• Families!

Haggerty (2011). Academic Pediatrics
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Primary care Medical Home as hub of
coordination partnership
PCP the childs Primary Care PRACTICE (not just
one provider)
Specialist
Specialist
PCP
Family
Medical Home functions explainer, interpreter,
advisor, coordinator
Specialist
Slide courtesy of Chris Stille, MD
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Spectrum of co-management

• PCP as primary manager, specialist as consultant
• Less complex, few specialty needs
• Specialist as primary manager, PCP less involved
• Appropriate for high complexity and if
  comprehensive service exists at tertiary care
  center
• Co-management
• Medical Home has higher responsibility
• Medical Home acts as care coordinator
• Some children with complex chronic conditions
  have no subspecialty home

Hack, Pediatric Annals 1997 Antonelli, 2005
adopted from C. Stille (2009)
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Making co-management work

• Define your roles
• Primary care physician has higher responsibility
• Specialty provider provides decision making
  support
• Primary care physician can learn to care for
  higher complexity over time
• Most PCPs welcome co-management
• Dont forget families!

Antonelli (2005) Kuo (2007) Kisker (1997)
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Take the initiative

• Recognize the components of comprehensive care
  that only PCP can deliver
• PCP determines the additional level of
  involvement, due to varying experience
• PCP can provide improved access, continuity, and
  care coordination for children and families
• Higher level of co-management likely improves
  care outcomes due to improved access
• Initiate communication with specialty colleagues
• Determine your roles and be specific for what you
  need
• Comfort will increase over time

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Care partnership Family-Centered Care

• Essential, yet frequently misunderstood
• Associated with more efficient use of health care
  resources for CYSHCN
• Principles
• Partnership approach to care
• Respect for diversity
• Information sharing is open and unbiased
• Care plans may be negotiated

Kuo (2011) MCHJ Kuhlthau (2011) Acad Pediatr
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Delivery System Design Define Roles

• Medical Home ALWAYS good primary care
• First point of contact
• Anticipatory guidance
• Immunizations
• Care hub / care coordination
• Verify/Initiate Early Intervention
• Act as eyes and ears for specialty teams
• Remind families that you can be first point of
  contact

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Additional roles

• With good communication with specialty
  colleagues, may consider
• Labs
• Medication initiation / adjustment
• Referrals to community services
• Consider designating office staff (such as nurse)
  to be single point of contact
• Additional roles for office staff
• Help families define their roles
• Foster children/families likely require extra
  attention

Kuo (2007). Pediatrics
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Decision making support

• Clinical care guidelines (e.g. AAP)
• Be familiar with common issues of condition(s)
• High prevalence of neurodevelopmental
  disabilities
• Recognize that many children have feeding/growth
  issues, dysphagia, respiratory issues
• Learn from specialty colleagues
• Regular communication they will teach you
• Eyes and ears / red flags

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Define communication lines

• Keep updated and continuous care plan
• Consider separate forms and someone to maintain
• Methods of communication
• Email? Fax? Phone call?
• What will be communicated? ask specialists
• Timing and frequency of communication
• Health care portals
• If all else fails, encourage family to contact
  you and / or schedule regular follow-up visits

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Clinical Information Systems

• Track your children with special needs
• Particularly children with complex chronic
  conditions
• Quality of care measures
• Utilize communication lines, including email,
  fax, phone
• Clinical decision making tools

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Conclusions

• Comprehensive care can improve health outcomes
  and reduce utilization
• Medical Home must take the lead to develop
  comprehensive care for children with complex and
  chronic health conditions
• Co-management increases PCP involvement and can
  lead to improved outcomes

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Thank you!

• 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