1. Lost? Finding Your Medical Home Colleen A. Kraft, M.D., FAAP Harry L. Gewanter, M.D., FAAP, FACR

2. Care Partnership

What are my goals? Goals for my child?

What should I expect from my physicians and my community?

How can I enable our medical and community resources to provide the best care for (me) or my child?

3. Care Partnership

Healthy People 2020 Goals

Medical Home

Community

4. Healthy People 2020 Goals

Goals and Priorities for our Nation

Particular Goals for Special Populations

5. Healthy People 2020

All children should be served in a Medical Home

Families should have access to the insurance necessary to care for their children

6. Healthy People 2020

Families should be satisfied with the care they receive

Community Resources should be available to help any family in need

Community Resources should be easily accessible to families

7. Healthy People 2020

Youth with special health care needs should be able to transition to adult health care, insurance, and employment

8. Medical Home

Structure and Process of Care

Recognizes home as

• Headquarters for care

• A place for children and families to feel welcomed and recognized

• Link to community services

9. Medical HomeBackground

1980sClinic based care

Recognition for need to

• Coordinate care

• Involve families needs and expertise

• Develop community partnerships

10. Medical Home

1992 AAP Policy Statement

Maternal and Child Health Bureau definition of CSHCN

• Those who have or are at risk for chronic physical, developmental, behavioral, or emotional condition

• Require more frequent and/or intensive health and related services

11. Medical Home Benefits

Increased satisfaction

Forum for problem solving

Coordination of care

Efficiency of time and resources for

families

5. Increased wellness due to comprehensive care

12. Medical HomeCommon Elements

Accessible

Family Centered

Comprehensive

Continuous

Coordinated

Compassionate

Culturally effective

13. Access

Care provided in childs community

Range of insurances accepted

Public Transportation

Families may speak directly with Primary Care Provider

Physically Accessible

14. Family Centered

Physician known to child and family

Mutual responsibility and trust

Family recognized for its expertise

Information and options shared with families

Families play a central role in care coordination

15. Continuous

Care from infancy through young adulthood

Assistance with transitions

Hospital discharge planning

16. Comprehensive

Care delivered and directed by a well trained practitioner

Round the clock access by phone

Primary Care

• Immunizations

• Growth and Development

• Anticipatory Guidance

17. Comprehensive

Medical, Psychosocial, Educational, Developmental needs addressed

Information and Community Links

• Early Intervention

• Title V Programs

• SCHIP

• SSI

• Medicaid

18. Coordinated

Care among multiple providers, specialists, therapists

Central records kept

Plan of care developed with family or youth

Plan of care coordinated and shared with schools, community resources, other agencies involved in care

19. Compassionate

Concern and respect for individual, family

Understand and empathize

• Child or youth perspective

• Family perspective

20. Culturally Effective

Patients and familys cultural background respected

• Beliefs

• Rituals

• Customs

21. Culturally Effective

Written materials in patients language

Interpreters available

Family understands care plan

22. Medical Home

Understand the concept of a Medical Home

Understand how the Medical Home is an ideal venue for setting your (your childs) goals

Understand how the Medical Home is an ideal venue for communication and teamwork between physicians, families, and the Medical Village

23. Medical Home

Empower families as the expert in the overall care of their child

Understand what physicians need to know from parents in caring for their children

24. What do Physicians need from families?

Expert for your child

Community Link for Resources

Advocacy

25. Families as Experts

Parents as care coordinators

• Medical

• Social

• Educational

26. Care Coordination Role

Documentation and Communication

Summary Notebook

• Physicians/Specialists

• Therapists

• IFSP/IEP

• Educator Conferences/Notes

• Pictures

27. Care Coordination

Communication between specialists, therapists, schools

Best option for care

• You have a right to have options, and the Medical Home should provide the venue

28. Communication

New Needs

Transition and Milestones

29. Community Involvement

The inferior physician treats the disease; the good physician treats the person; the superior physician treats the community

• • • • Chinese Proverb

30. Complementary Roles

Physicians provide medical knowledge and information to community resources

Community resources provide avenues to help patients and families outside the office

Families are the link!

31. Link to Community Resources

Families as Experts in Navigating the System

Role in Community Organizations

Parent Consultants

32. Medical Home Plus

Information, Support, Resources for Parents and Professionals

Training

Technical Assistance

33. Enrich your community

Join local, statewide, and national networks

• Family Voices

• Arthritis Foundation

• Parent to Parent

• Down Syndrome Society

• The Autism Society

34. Enrich your community

Parent Training

• Partners in Policymaking

• Insurance and Waiver Training

• As They Grow

• Conferences

• Parent Education, Advocacy, and Training Center (PEATC) courses

35. Enrich your community

Understand your own developmental level as a parent

Start small

Use your experience as an advocate for your child to someday help another family

36. Advocacy

Community Organization Events

• ARC March

• Call to Action

Visiting Legislators

Tell your story

• We need to hear it!

37. Care Partnership

Role in the Medical Home

Role as Care Coordinator and Advocate for your child

Community

38. Thank you!