The Medical Home Leadership Network: Family, Health Care and Community Collaboration for Children with Special Health Care Needs

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The Medical Home Leadership Network Family,
Health Care and Community Collaboration for
Children with Special Health Care Needs

• Kate Orville, MPH
• Co-Director
• Washington State
• Medical Home Leadership Network
• Center on Human Development Disability
• University of Washington
• ----------------------------------------
• January 23, 2004
• Community Health Plan of Washington
• 2004 Clinical Operations Meeting

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Overview

• What is a medical home?
• The Medical Home Leadership Network
• Community medical home team activities
• How to get involved

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What is a Medical Home?

• NOT a building
• but way of providing health care services that
  are
• Family-centered
• Coordinated
• Comprehensive
• Continuous
• Accessible
• Compassionate Culturally Sensitive

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In a Medical Home

• Children and their families receive the care that
  they need from a physician or other primary
  health care provider whom they know and trust.
• The pediatric health care professionals and
  parents act as partners to identify and access
  all the medical and non- medical services needed
  to help children and their families achieve their
  maximum potential.

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Medical Home Basics

• Primary care and acute care
• Links/collaboration/referral with specialty care
• Maintenance of comprehensive central record of
  info about child
• Links to community programs
• Care coordination
• Assistance with transition

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The Family Perspective

• A 24/7 relationship with my physician and/or
  office staff who know my child and know her
  needs who I can call any hour of the day, who
  are responsible, who listen and who care, who
  help me to feel competent about my knowledge and
  expertise when it comes to her care, who always
  ask What can I do for you today?.
• -- Mom of child with special needs

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• While all children can benefit from a medical
  home, it is particularly important for children
  with special health care needs and their families

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Children with Special Health Care Needs

• Children who have or are at increased risk for
  a chronic 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.
• Adopted by the AAP (October 1998). McPherson M,
  Arango P,
• Fox HB, A new definition of children with
  special health care
• needs. Pediatrics 1998 102137-140

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It Takes a Village to Build a Medical Home

• Families and primary health care providers dont
  have to do everything themselves
• Office staff, community partners, specialists,
  and health care administrators are available to
  help

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Medical Home and the Chronic Care Model

• Active, empowered patient/family
• Proactive practice team
• Supportive health care organization (information
  systems to ID patients, provide clinical support,
  reminders, incentives etc.)
• Links to and collaboration with community
  services and supports (family-to family support,
  public health etc)

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How Do We Achieve a Medical Home for Every Child
by 2010?

• MCHB/AAP Need for state-based, systematic
  approach
• ?National Medical Home Mentorship Network
• Washington State Medical Home Plan -Title V,
  WCAAP, Families,MHLN

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WA State Medical Home Goals

• Families, providers, insurers, policymakers and
  others will understand and endorse the medical
  home concept
• Health care providers will have the skills and
  knowledge to provide medical homes
• Families will have the skills and knowledge to
  provide medical homes

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Medical Home Leadership Network

• Statewide network of families and professionals
  who promote the availability and accessibility of
  medical homes for children and youth with special
  needs in their communities
• Supported by DOH MCHB CSHCN Program and US MCHB
  since 1994
• Large, active advisory board
• Housed at UW Center on Human Development
  Disability- Dr. Forrest C. Bennett, MHLN Director

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MHLN Teams

• Volunteer
• Interdisciplinary- PHN, FRC, MD, Family
• Community-based
• Strengthen and leverage existing networks and
  activities

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Washington State Medical Home Leadership Network
Teams
PEND OREILLE
WHATCOM
FERRY
OKANOGAN
SAN JUAN
SKAGIT
STEVENS
SNOHOMISH
CLALLAM
CHELAN
ISLAND
DOUGLAS
SPOKANE
JEFFERSON
LINCOLN
KITSAP
KING
MASON
GRAYS HARBOR
GRANT
ADAMS
KITTITAS
PIERCE
WHITMAN
THURSTON
FRANKLIN
GARFIELD
PACIFIC
YAKIMA
LEWIS
COLUMBIA
WAHKIAKUM
COWLITZ
BENTON
WALLA WALLA
ASOTIN
SKAMANIA
Regional Resource Teams (by MD team member) CHPW
Member Center CHPW Affiliate Center Non-CHPW
affiliate
KLICKITAT
CLARK
Regions
Northwest
Central
East
King Pierce
Southwest
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MHLN Team Members

• Promote the medical home concept and strategies
  to support medical homes
• Are well-informed, experienced resources for
  community colleagues
• Collaborate with other interested groups and
  provide technical assistance and consultation as
  time permits

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MHLN Teams, with Support of Project Staff

• Recruit team members
• Identify one or more barriers to medical homes to
  address
• Develop plan
• Identify needed technical assistance
• Implement plan
• Monitor activities
• Report at annual conference

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Yakima Team Activities

• MHLN team active in development of Childrens
  Village CV set up on medical home principles
• Presentations to local PCPs
• Family focus group on medical homes
• Co-developed medical home brochure in English and
  Spanish
• Local autism diagnostic team
• Early hearing and screening outreach

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Kitsap County Team Activities

• Development of local resource packets for
  services for CSHCN
• Presentations to community primary care providers
  on community resources

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Adams County Team Activities

• Child Health Notes
• Chart review of client charts at quarterly MH
  team meetings
• Presentations for parents and for physicians on
  medical homes
• Physician collaborating with CHPW on piloting new
  CSHCN program
• Presentation at AAP/Shriners Every Child
  Deserves a Medical Home

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Addl Team Activities

• Pilot parent advisory group in MDs practice
  (Skagit)
• Down syndrome EI presentation (Stevens)
• Newborn Hearing Screening Follow Up (Walla
  Walla, Yakima, Kitsap)
• Increase EI referrals for children with
  speech/language or autism concerns (Snohomish)
• Develop rotating list of pediatricians to accept
  CSHCN with no PCP (Clark)
• ID s CSHCN by diagnosis in the county (Cowlitz)

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Team Collaboration Benefits (1999 evaluation)

• Greater awareness of and use of community
  resources
• Its increased my access and its increased my
  referral a lot, probably close to 100 (MD)
• I feel more organized and competent that I know
  where to direct people (MD)

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Benefits cont.

• Greater access to MD community (PHNs, FRCs)
• Increased referrals (PHNs, FRCs)
• Enhanced credibility (all)
• Access to information grant opportunities
  (all)
• Expanded sense of community and momentum (all)

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DOH CSHCN Program Support for Collaboration
between Medical Home Contractors - Examples

• Medical Home Toolkit County Resource Lists
  (CCSN)
• Collaboration between family and professional
  organizations
• Adolescent Health Transition Notebook
• CHDD/CTU, Childrens Hospital, and Mary Bridge
• increase own medical homeness
• then share lessons learned with other tertiary
  care centers

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Upcoming Activities

• Continue to identify and promote simple key
  activities and strategies to providers and
  families
• Care notebooks/organizers for families
• Parent Advisory Groups
• Care plans/written instructions for families
• How to make medical homes work for families from
  diverse backgrounds?

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More activities

• Medical Home Website- links to
• community resources,
• diagnosis specific care guidelines
• patient handouts,
• tips on setting up a family-friendly practice
  etc
• Collaborate with health care plans to pilot ideas
  teams very interested
• Develop new grants
• Annual Medical Home conference

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Interested in Getting Involved?

• Contact your nearest local MHLN team
  www.medicalhome.org, under community teams
• Talk to Dawn Davis, CHPW 206-613-8917
• Kate Orville, WA Medical Home Leadership Network,
  University of Washington orville_at_u.washington.edu
  , 206-685-1279
• WA CSHCN Program reps Leslie Carroll and Stacey
  DeFries
• See national medical home website
  www.medicalhomeinfo.org

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Together we can do itEVERY CHILD DESERVES A
MEDICAL HOME !!