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Transcript of 1 The Medical Home Leadership Network: Family, Health Care and Community Collaboration for Children...
1
The Medical Home Leadership Network:
Family, Health Care and Community Collaboration for Children with Special Health Care Needs
Kate Orville, MPHCo-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
2
Overview
What is a medical home? The Medical Home Leadership
Network Community medical home team
activities How to get involved
3
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
4
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.
5
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; 102:137-140
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It Takes a Village to Build a Medical Home
Families and primary health care providers don’t 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 StateMedical Home Leadership Network
Teams
Northwest
Regions
King & Pierce
Southwest
CentralEast
Regional Resource Teams(by MD team member)
CHPW Member Center
CHPW Affiliate Center
Non-CHPW affiliate
COWLITZCOWLITZWAHKIAKUMWAHKIAKUM
PACIFICPACIFIC
GRAYSHARBORGRAYSHARBOR
JEFFERSONJEFFERSON
CLALLAMCLALLAM
WHATCOMWHATCOM
SKAGITSKAGIT
MASONMASON
LEWISLEWIS
THURSTONTHURSTON
SAN JUANSAN JUAN
ISLAND
SNOHOMISHSNOHOMISH
KITSAPKITSAP
KINGKING
PIERCEPIERCE
KLICKITATKLICKITAT
BENTONBENTONWALLAWALLAWALLAWALLA
COLUMBIACOLUMBIA
GARFIELDGARFIELD
ASOTINASOTIN
WHITMANWHITMAN
FRANKLINFRANKLIN
YAKIMAYAKIMA
SKAMANIASKAMANIA
CLARKCLARK
OKANOGANOKANOGANFERRYFERRY
STEVENSSTEVENS
PENDOREILLEPEND
OREILLE
SPOKANESPOKANE
LINCOLNLINCOLN
ADAMSADAMSGRANTGRANTKITTITASKITTITAS
DOUGLASDOUGLAS
CHELANCHELAN
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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 Children’s 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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Add’l Team Activities
Pilot parent advisory group in MD’s 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)
22
Team Collaboration Benefits (1999 evaluation)
Greater awareness of and use of community resources “It’s increased my access and it’s
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)
24
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, Children’s 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
27
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
[email protected], 206-685-1279
WA CSHCN Program reps Leslie Carroll and Stacey DeFries
See national medical home website: www.medicalhomeinfo.org