medical home collaboration
DESCRIPTION
Medical Home Collaboration. “WE DON’T KNOW WHAT WE DON’T KNOW”. Children with Special Health Needs-Overview. Care coordination Medical Home Initiative Pediatric Hi-Tech Personal Care Children’s Palliative Care Child Development Clinic Cleft Palate Clinic - PowerPoint PPT PresentationTRANSCRIPT
Medical Home Collaboration
“WE DON’T KNOW WHAT WE DON’T
KNOW”
Children with Special Health Needs-Overview
•Care coordination•Medical Home Initiative•Pediatric Hi-Tech•Personal Care•Children’s Palliative Care•Child Development Clinic•Cleft Palate Clinic•Rehab and Neurology clinics•Respite•Financial Technical Assistance •Community Nutrition•Newborn Screening•Newborn Hearing Screening Birth to age 21
Medical Home
CIS Early Intervention Collaborative
Team
Child Development
Clinic&
CSHN Services
Chittenden Social Worker
Our Medical Home Program
• Three pediatricians, Dr. Joseph Hagan, Dr. Jill Rinehart, Dr. Greg Connolly
• Two Pediatric Nurse Practitioners, Maryann Lisak &Ashley Boyd
• One main RN Care Coordinator Kristy Trask• Business manager, office manager, two office
assistants, six additional part-time nurses two medical assistants
• ~4500 Active Patient List
Medical Home History
• 1967: First published reference to “Medical home” was in the AAP’s Council on Pediatric Practice’s Standards of Child Health Care
• Defined Medical Home as the “respository of medical records” for a child, emphasized the importance especially for CSHCN
Medical Home History
• 1970’s: 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
Medical Home History• 1980’s:
The first Medical Home is attributed to Hawaii Pediatrician, Dr. Cal Sia
• 1992: AAP published first policy statement defining the medical home
Medical Home History1998:
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 McPhereson
“New Definition of Children with Specia Health Needs,”Pediatrics,1998
Medical Home History
2002: Medical Home Policy Statement was published that defines the concept of Medical Home we use today
Medical Home History
• 2002-2004 in VT: Medical Home Improvement Project
• 2006: ACP created “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care” promoting an “evidence based” medical home
13
Medical Home History
• 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.
• Linked to Affordable Care Act
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
• A part of the Affordable Care Act
Medical Home History
• Joint effort led to the National Center for Quality Assurance’s (NCQA) creation of Physician Practice Connections-Patient-Centered Medical Home (PPC®PCMH™)
• Created 2008 PPC®PCMH™ Standards
• March 2011, then 2014 PCMH guidelines
Medical Home Definition
• Accessible• Culturally Effective• Continuous• Comprehensive• Coordinated• Compassionate• Family Centered
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
Why is A Family- Centered Medical Home Important to family?
• Opportunity for the family to build a trusting and collaborative relationship with the pediatrician and office staff.
• Care coordination provides smooth facilitation among all members of the child’s care team including family, specialists, pharmacy staff, community and school services.
• Comprehensive source of complete patient medical history
Victoria Garrison, “Innovations in Medical Home,” VFN annual conference, April 2013
Franklin Cty PedsMousetrap St. Albans
Newport Peds
Rainbow PedsMPAM
Gifford
Green Mountain Pediatrics
Mousetrap Milton
Timber Lane SBTimber Lane
Mousetrap Peds Enosburg
Mousetrap Peds Swanton
Associates in PediatricsBarre Pediatrics
UPeds BurlUPeds Williston
Shelburne PedsRichmond Peds
Essex Peds
Brookside Peds
Cornerstone Peds
Dr. H. Taylor Yates Jr.
Dr. David Toll
Dr. Joe Nasca
Dr. Martin R. Luloff
Just So Peds
Women’s & Children’s Services
Pediatric Associates
Upper Valley Peds
Springfield Pediatric Network
Ryderbrook Peds
PedMed
Dr. Rebecca CollmanNVRH St. J Peds
H&R Peds
Mil
ton
Burli
ngt
onS.
Bu
rl
Benn
ingt
on
St.
John
sbur
y
Mid
dle
bury
Has been scoredHas anticipated NCQA recognition dateHas not started process
PCMH Recognition Status, VT Pediatric Practices as of 12/12St
. Al
bans
Mt. Ascutney Physicians Practice
South Royalton Health Center
Pediatric Collaborations Chittenden County
5 Key Elements of Highly Effective Care Coordination
The Concept
1. Needs assessment for care coordination and continuing care coordination engagement
2. Care planning and communication
3. Facilitating care transitions 4. Connecting with community
resources and schools5. Transitioning to adult care
The Person
Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009
A Framework for Highly Performing Pediatric Care Coordination
Care Coordination Functions
1) Provide separate visits & interactions2) Manage continuous communications3) Uses assessments for intervention4) Develop Care Plans (with families)5) Integrate critical care information6) Coach patient/family skills learning7) Support/facilitate all care transitions8) Facilitate care conferences 9) Use health information technology
for care coordination
Care Coordination Competencies1) Develops partnerships2) Proficient communicator3) Uses assessments for intervention4) Facile in care planning skills5) Integrates all resource knowledge6) Possesses goal/outcomes
orientation7) Approach is adaptable & flexible8) Desires continuous learning9) Applies solid team building skills10) Adept with information
technology
Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009.
Principles for Successful Use of SharedPlan of Care
1. Children, youth and families are actively engaged in their care.2. Communication with and among their medical home team is
clear, frequent and timely.3. Providers/team members base their patient and family
assessments on a full understanding of child, youth and family needs, strengths, history, and preferences.
4. Youth, families, health care providers, and their community partners have strong relationships characterized by mutual trust and respect.
5. Family-centered care teams can access the information they need to make shared, informed decisions.
McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: 2014 (in press), Lucille Packard Foundation for Children's Healthcare
Principles for Successful Use of SharedPlan of Care
6. Family-centered care teams use a selected plan of care characterized by shared goals and negotiated actions; all partners understand the care planning process, their individual responsibilities, and related accountabilities.
7. The team monitors progress against goals, provides feedback and adjusts the plan of care on an on-going basis to ensure that it is effectively implemented.
8. Team members anticipate, prepare and plan for all transitions (e.g. early intervention to school; hospital to home; pediatric to adult care).
9. The plan of care is systematized as a common, shared document; it is used consistently by every provider within an organization, and by acknowledged providers across organizations.
10. Care is subsequently well coordinated across all involved organizations/systems.
McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: 2014 (in press), Lucille Packard Foundation for Children's Healthcare
Partnership Care Planning Model
McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: An Implementation Guide. 2014, Lucille Packard Foundation for Children's Healthcare: Lucille Packard Foundation for Children's Healthcare.
Care Coordination Rounds
• Regular meetings (typically 1 hour) with practice care coordinator, physicians, CHT social worker, ( sometimes other community partners as needed)
• Discussion of patients (who needs more intervention and who is doing what part of the work)
• Systems issues
ECOMAP
Informal SupportsExtended Family
FriendsGroups
Religious OrganizationsCultural Supports
ClubsRecreation
Camps
Community and State Services CSCHN
Economic ServicesDevelopmental Services
Mental Health Early Intervention
Home Health ServicesChildren’s Palliative Care
WICChild Protection
Private TherapistsPersonal Care
SchoolTeachers
Case ManagerSpeechPT/OT
Other Services
MedicalSpecialists
Specialty ProvidersClinics
Financial SupportsInsurance
RespiteChildcare SubsidyEconomic services
Social SecurityFood Subsidy Employment
ChildcareTeachers
Genogram of Household MembersParentsSiblings
ChildExtended Family
Others
VG
CG5 yo
7 yo4 yo
Hagan, Rinehart and
ConnollyPediatricians
Shelburne Community
School Special
EducatorSpeech Language
Pathologist
School Physical Therapist
Occupational Therapist
Swimming at YMCA
Rue Kendrick-classroom
teacher
PCA
Debbie- Para-professional
S.&J., MGMfriends
(service dogs in training)
PetsmartTherapy Dogs of
Vermont
Dr. Hastings-Peds-Ophthalmology
Dr. Benjamin- physiatrist
Dr. D'Amico-Gastroenterologist
Dr. Filiano-Neurologist at
Dartmouth
Dr. Bauer-Peds Neurosurgeon at
Dartmouth
Dr. Tranmer-Neurosurgeon
CSHN Registered Dietitian
Apria
Medical Store
Keen Medical
Biomedic Appliances
CSHN Social Worker
Howard Center
Deborah Keel- Flexible Family FundingDelana-
BRIDGE
Shelburne Community School
Shelburne Nursery School
Community Alliance Church in Hinesburg
Children's Ministry
Outings- Sugar House, Echo, Lowes, town
activities, swimming etc.
Section 8 Housing
Wheels for Johnny-Fundraiser for handicap
accessible vehicle
SSI
SSA
PSE
Child Only Reach Up Grant
3 Squares Vermont
Champlain College- Healthcare Technology
Garrison, Victoria . Interview by Marley Donaldson. Personal interview. 26 Mar. 2013.
MedicalFamilyState/Education/Community
Family Story
Care Conferences
A facilitated, family-centered meeting (typically 1 hour) among the family, primary care, community providers, schools, formal and informal family supports to facilitate detailed communication about strengths, challenges, current services, and gaps in services. A coordinated plan of care is developed with goals, resources, and work load distribution among providers with family input and consent. Care conferences address communication issues, needs of the family and helps to resolve identified and anticipated needs.
Care Story
• Mary is a 4 year old with tuberous sclerosis whose self-injurious behaviors, tantrums, sleep dysfunction-- heading towards inpatient psychiatry hospitalization
• Despite having a VT developmental services waiver, respite care and a team of multidisciplinary medical experts at Mass General
• Intractable seizures seemed the least of her concerns in comparison to behaviors
• Strengths: strong parent involvement and expertise, loving respite family, Mary engaging, verbal with cognitive strength (can anticipate seizures)
Care Planning Patient/Family/Team Goals CICP Negotiated Actions Process and Outcome
measures
Less need for “crisis” intervention
Co-management from psychiatry, medical home and subspecialists
In-home behavioralist
Less need for police, mental health crisis support
Improve Sleep Same behavior plan across settings
Less communication errors about medicationsImproved work attendance
Increase Home Safety-of Mary and family
Improved psychopharmCSHN SW: Waiver allowed for enhanced access to in-home behavioralist
Innovation: region contracted with vendor outside of networkLess Crisis Need
Mary to attend schoolImprove social relationships
Communication opened between school, behavioral plans, family, medical home
Making academic gainsAttendance improvedCannot pick her out from peers
Outcomes of Shared Care Planning• Builds community collaboration and
communication across services• Builds knowledge base of services and
system of care• Determines most appropriate referrals,
reducing duplication and fragmentation.• Builds the capacity of primary care to provide
long term chronic care management• Addresses systems issues and barriers
proactively (i.e. financing, insurance poverty, access to care)
Pediatric Care Coordination Learning Collaborative
• 12 Vermont practices that serve children• Each with a quality improvement team of
provider, care coordinator and parent partner• Create 25 shared care plans with families
Building Partnerships Across the Community
Next Steps
• Reach out to the medical home care coordinators and get to know who they are.
• Invite CSHN social worker to initial visits, team meetings, One Plan reviews-help families build relationships early with other providers, support the work you are doing with families during your time with them.
• Suggest doing care conferences to PCP for your families where a meeting would be helpful to coordinate and problem solve.
• Offer to do presentations of your program to other service programs and vice versa (establish a contact) so you will have a go to person to talk through situations as they arise.
• Find out how other providers are working in their regions and what strategies they find helpful. Ask to shadow providers in other regions. Come observe a CIS-EI meeting in Chittenden or care conference.
THANK YOU!