Jane Turner M.D.Dana Watt MSNJanuary 2013

Break out sessions spring 2012◦ ADHD as index condition◦ Focus on coordinating care are school and family

Webinar on social determinants of health

Face to face meeting fall 2012◦ Community resources (asthma as index condition)◦ Principles of family centered care – parent

perspectives

Webinars 2013 – third Friday of the month January: Pediatric Metrics and CSHCS February: Obesity March: ADHD April: ? Face to face meeting to learn from

each other?

We will ask care managers again about priority topics……..

Registry or EHR

1.Asthma: (ages 5-64) Self-Management Plan or Asthma Action Plan

2.Obesity (ages 2-17yrs) BMI Percentile

3.Tobacco (ages 13 and older) Percent smokers

4.Well Child Visits a. 15 months (6 total) HEDIS b. 3-6 years (1 per measurement year)

HEDISc. 2-21 years (1per measurement year) HEDIS

MCIR or EHR

1. Lead Screening: (Age 2) HEDIS Medicaid only

2. Immunizations a. Childhood Immunizations (age 2) HEDIS

b. Adolescent Immunizations (age 13) HEDIS

Utilization (Improvement over Baseline)

1. Primary care sensitive ED visits/1000 patients during measurement year compared to PO’s rate for prior year(s). (NYU algorithm)

2. Ambulatory Care Sensitive Hospitalizations

© NYU Wagner

•Asthma Admission Rate (2 to 17 years) •Diabetes Short-term Complications (6 to 17 years)•Gastroenteritis Admission (3 months to 17 years)•Perforated Appendix Admission (1 to 17 years) •Urinary Tract Infection (3 months to 17 years)

http://www.qualityindicators.ahrq.gov/Modules/PDI_TechSpec.aspx

Clinical Quality Metrics - Claims Based (Improvement over baseline)

1. Well Child Visits 15 Months Old - with 6 visits2. Well Child Visits 3-6 Years Old - 1 visit during measurement year3. Adolescent Immunizations - (MCIR*) Percent of youth who have received a. Meningococcal vaccine (11th to 13th birthdays) b. 1 Tdap or 1 Td (10th to 13th birthdays)

Clinical Quality Metrics – EHR or Registry Pay for Reporting: All who had a visit AND…

1. Asthma (ages 5-64): Asthma Action Plan or self- management plan was created/updated a. All asthma b. Persistent asthma

2. Tobacco Use (13 years and older): Smoking status was recorded

3. Obesity (2-17 years): BMI Percentile was recorded

1. Notification of hospital admissions & discharges

2. Tracking referrals of high-risk patients to community resources (10.7* )

3. Follow-up of high-risk patients with community referrals for next steps (10.8*)

4. One or more members of PO or practice unit has completed formal training in a nationally or internationally-accredited self-management support program and works with/educates practice unit staff members to actively use self- management support concepts and techniques. (11.8*)

5. Self-management support is offered to all patients with the chronic condition selected for initial focus (based on need, suitability, and patient interest). (11.2*)

Starting in late spring 2013, MDC will report◦MiPCT Quality metrics◦Cost of care for key chronic illnesses: ADHD, Asthma

and Obesity for pediatric practices ◦Gaps in care

Data is to be updated every 2 months Practices must get the reports from their PO https://www.michigandatacollaborative.org/MDC/assets/

MiPCT_Dashboards_Reports_UG.pdf

Jane Turner, MD, FAAPChief Medical Consultant

CSHCS

Prior to October 1, 2012, children and youth enrolled in CSHCS and Medicaid were all in fee for service (straight) Medicaid.

The transition to Medicaid Health Plans began Oct 1 and many children/youth who were not previously on the MiPCT list are now eligible for your services.

These are children/youth with severe and complex health conditions.

What is CSHCS?

Who is eligible and how is eligibility determined?

What are the benefits of CSHCS?

How can care managers improve the care for children and youth on CSHCS?

Who else is coordinating their care?

CSHCS is an important component of Michigan’s Title V program (Maternal Child Health) that addresses the medical needs of children and youth with special health care needs.

The mission of the program is spelled out in Michigan’s public health code.

Diagnosis Severity of Condition Chronicity of Condition Need for Treatment by a Physician

Specialist (pediatric subspecialist)

• The individual must have a CSHCS qualifying diagnosis where his activity is or may become so restricted by disease or deformity as to reduce his normal capacity for education and self-support.

• Psychiatric, emotional and behavioral

disorders, attention deficit disorder, developmental delay, mental retardation, autism, or other mental health diagnoses are not covered by the CSHCS Program

• Cancer• Cerebral palsy• Cleft lip/palate• Liver disease• Club foot• Hypospadius• Spina bifida• Paralysis• Hemophilia

• Cystic fibrosis• Hearing loss• Insulin-dependent

diabetes• Muscular dystrophy• Certain heart

conditions• Epilepsy• Kidney disease• Sickle cell anemia• Certain vision

problems

The severity criteria are met when it is determined by the MDCH medical consultant that specialty medical care is needed to prevent, delay, or significantly reduce the risk of activity becoming so restricted by disease or deformity as to reduce the individual’s normal capacity for education and self-support.

A condition is considered to be chronic when it is determined to require specialty medical care for not less than 12 months.

The condition must require the services of a medical and/or surgical subspecialist at least annually, as opposed to being managed exclusively by a primary care physician.

Subspecialist sends a report to CSHCS – often through the local health department.

The Medicaid Health Plan submits a MERF with medical reports from subspecialist.

A pediatrician at CSHCS reviews the reports and decides if the child/youth meets eligibility criteria.

Reports from primary care are not accepted.

• Since CSHCS does not cover primary care, the “system of care” around each child has excluded primary care. Primary care will now be an integral part of the child/youth’s system of care.

• Families who have primary care docs were encouraged to choose a plan that contracts with that practice.

• Families who did not have primary care doc were encouraged to sign up with a practice that is prepared to care for CYSHCN.

A major function of CSHCS is to ensure access to pediatric subspecialty care.

There is the risk that access to appropriate pediatric subspecialists will be jeopardized.

CSHCS is working with Medicaid and plans to ensure that children and youth continue to receive the services and supplies they need.

Families have been encouraged to sign up for a health plan that participates with the child’s specialty providers.

If the subspecialists are not in the plan’s network, the plan is to authorize continued care with that subspecialist until the family and the plan both agree that it is safe to transition care to an in-network subspecialist.

• Access to mental health services is problematic in Fee for Service Medicaid.– Community Mental Health – Severity/chronicity criteria– Long waits for services

• Medicaid Health Plans provide up to 20 outpatient mental health visits per year.

• CSHCS children/youth will now have access to outpatient mental health services.

Access to the most appropriate subspecialist in Michigan (out of state if no one in MI)

Special therapies not usually covered by insurance

Orthodontics if related to the CSHCS qualifying condition (i.e. cleft palate)

Respite care Children’s Multidisciplinary Services clinics

Team of specialists specific to the condition Social work and psychology “one stop shopping” Team members talk to each other Team generates a care plan including

recommendations of all team members Greater than the sum of the parts

• Cardiology• Cleft Lip/Palate/Facial• Cystic Fibrosis• Diabetes• Endocrinology• Hematology/Oncology• Hemophilia• Myelodysplasia (Spina Bifida)• Pulmonary/Severe

Asthma/Vent• Lead Toxicity• Sickle Cell Disease• Multiple Handicap

/Disability/Chronic Disease• Infectious Disease

• Apnea• Neurology• Neuromuscular• Amputee/Limb deficiency• Feeding Program• Rheumatology• Genetics• AIDS• Immunology• Gastroenterology/Nutritional

Deficiencies• Nephrology• Metabolic Disease• Weight Management

Practice level coordination◦ MiPCT care manager and practice team

Plan level coordination ◦ MHPs have case managers

Local Health Department◦ CSHCS nurse

CMS clinic care plan

MHP contact list on our website Local Health Department – link on our web

site Children’s Multidisciplinary Services

◦ Check with your local health department for clinics in your region

Work with the family to assess all the child/youth’s needs

Communicate with the MHP case manager Communicate with the local health

department Document who is doing what so efforts are

not duplicated and the family doesn’t get confusing messages

Remember the family is at the center of the child’s system of care

Family members are usually experts in their child’s care.

Be sure to involve family in all decisions. The Family Center can link families with

other families and offer resources.