Pediatric Patient Centered Medical HomeLEADERSHIP EDUCATION IN NEURODEVELOPMENTAL DISABILITIES (LEND) GROUPMarch 2013

Patti Barovechio MN BSN CCM CPURCSHS Statewide Care Coordinator SupervisorDHH/Office of Public Health

OBJECTIVES

• Examine the essential characteristics of a Pediatric Patient Centered Medical Home (PCMH)

• Define Children with Special Health Care Needs (CSHCN)

• Brief review of national/state initiatives and Medicaid reform in Louisiana related to MH’s

• Discuss the essential role of care coordination and planned transitions for CSHCN

• Review the Tiger Care PCMH Care Coordinator Model

Pediatric Patient Centered Medical Home Coordinating Care

Carrie is a 3 year old who is new to Louisiana presents to a local clinic. She has Down Syndrome and has had heart surgery in the past. She has never been in our school system or in Early Head Start. Her vision is suspect, as she holds everything up close and cocks her head to the side. She is pleasant, outgoing and does not usually have temper tantrums. Her speech is difficult to understand. She walks with an unsteady gait and has decreased muscle tone. She has had no therapies to date. She takes no medications. Carrie has no insurance and Mom is concerned.

AAP Pediatric Patient Centered MH-History – Pediatric Medical Home

• 1967 AAP Medical Home (center of medical record)

• 1992 AAP Medical Home (MH) Policy Statement

• 2000 Future of Pediatric Education (FOPE) II Report

• 2007 AAP, AAFP, ACP, AOA “Joint Principles” Patient Centered Primary Care Collaborative

• 2008 NCQA PCMH Certification – AAP input

Patient Centered Medical Home (PCMH)-Medical Home Current Trends

•Healthy People 2010 - expanded for 2020 Goals

•2010 Patient Protection and Affordable Care Act

•MH Medicaid reform in 25 States

•MH Model Evolving → research/demonstration projects ongoing

Children with Special Health Care Needs (CSHCN)

• “those 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”

(McPherson et al., 1998 Adopted by AAP, MCHB, HRSA, US DHH)

Children with Special Health Care Needs CSHCN or CYSHCN

• Advances in medical technology → increased life expectancy for children with severe/chronic health conditions → move from institutionalized care

• CSHCN also includes ADHD, Asthma, ASD…

• CYSHCN ↑ risk for chronic physical, developmental, behavioral or emotional conditions

• Multiple-complex needs requiring coordinated resources/specialist care

Children with Special Health Care Needs (CSHCN)- Health Care Challenges

• Scheduling and Coordinating care for a CSHCN a challenging task…

• LA 28.7% of family members report reducing or quitting work → places additional financial burden on the family

(CSHCN Survey 2009/10)

Compared to Children without special health care

needs…

ANNUALLY MORE THAN:

2 X’s the number PCP visits7 X’s non-physician visits

5 X’s the Prescriptions4 X’s the hospitalizations

7 X’s as many hospital days

(Newacheck & Kim S Achieves Pediatric Adolescent Medicine Jan 2005)

National Survey of Children with Special Health Care Needs 2009/2010

Conducted by the CDC

National 15.1% CSHCN ~ 11,203,616

16.9% of families living UNDER the FPL

Louisiana 18.6% CSHCN ~ 207,840

20.9% of families living UNDER the FPL

National Survey Data- CSHCN

• Large sample size-powerful studyIndependent random samples all 50 states 196,159 households screened/ ID CSHCN Minimum 750 CSHCN interviews in each

stateState and local area integrated telephone survey

• Reliable data: www.childhealthdata.org

• Strategic planning for population care needs

Pediatric Patient Centered MH-Benefits/Goals – Medical Home

• Community level primary care →

eliminate disparities link to resources

Reduce ER visits

Decrease long-term disability →

Increase independence

• Transition services → support life-long active participation in health maintenance activities

Effective/Efficient Care

= $ Control $

=

Sustainable Health Care

Pediatric Patient Centered MH-AAP Defining Characteristics

• Family centered

• Accessible • Continuous

• Coordinated

• Comprehensive • Compassionate • Culturally effective

Pediatric Patient Centered MH-Family Centered

• Consistent PCP provider → partnership with patient/family

• Patient/Family/Physician → mutual responsibility & trust

• Family center of strength/support → expert in child’s care

• Clear/unbiased/complete information shared with family

• Family/youth →care coordination

Pediatric Patient Centered MH - Accessible

• Community location

• Linked to public transport (where available)

• Physically accessible - ADA

• Expanded hours-open scheduling

• Phone access/technology use

• Insurance/Medicaid accepted

Pediatric Patient Centered MHContinuous

•Ongoing relationship with PCP

•Assistance through transitions

•Primary Care Physician participates to fullest extent possible with inpatient/specialty care

Pediatric Patient Centered MH–Comprehensive

• Preventative/Primary/Tertiary health careAccess to full compliment of sub-

specialist Diagnostics• Periodic Screenings/Early Intervention• Patient/Family needs identified/addressed Medical

Family/Community Educational Psychosocial Developmental

Pediatric Patient Centered MH-Coordinated

•Plan of care developed by PCP/Patient/Family

Families Helping Families*

•Care Coordinatorschedule/link/follow-up

•Disseminate care plan emergency care plan

Pediatric Patient Centered MH-Compassionate

• Concern for the well-being of the patient/family

• Expressed in verbal/non-verbal interactions

• Efforts made to understand/empathize with feelings/perspectives of family/child or youth

Pediatric Patient Centered MH Culturally Effective

• Family/patient Cultural background recognized/valued/respected

• All efforts made to ensure patient/family understand result of medical encounter and care plan *translators – spoken and sign language

Pediatric Patient Centered MH-Transitions from Youth to Adult

• Got Transition - National initiative www.gottransition.org

• Initiate at 12-14 years

• Transition issues → Care Coordination EssentialHealth/wellness Education/vocational planning Guardianship and legal/financial issues Community supports/recreationHealth insuranceTransportation

Pediatric Patient Centered Medical HomeTransition Health Care Parent/Youth Information Excerpts

• Take charge of your health information▫ Do you know what medicines you are taking and WHY? If NO – ASK!▫ Call your drugstore for your own medicines. The phone number is on the

bottle…

• Be your own health care advocate▫ Do you know what your health issues are?▫ Do you know the danger signs that mean that YOU need emergency help very

soon or NOW!...

• Plan for transfer to a doctor who treats adults▫ Talk to your doctor about how and when you should start seeing a doctor who

treats adults. ▫ Ask your doctor about any resources they know that might be helpful for you…

• Plan for independence:▫ Know what you feel comfortable doing on your own and what new skills you want to have to

experience new events on your own. What are the social skills that adults have? Make a list & talk with your family and doctor.

▫ What health insurance plan will you have when you’re 18 or 26?...

Pediatric Patient Centered Medical Home Developmental and Behavioral Disorder Screening

• Comprehensive Care –ScreeningEarly detection=early intervention=improved outcomes

• 2006 AAP Policy Statement → Developmental surveillance with every preventative care visit throughout childhood

• Screen all patients at 9-18-24 (30) -36 months and any time a patient’s surveillance yields concern Reliable/Valid/Sensitive instruments

ASQ and MCHAT

Patient Centered Medical Home-Medical Home Model of Care - Louisiana

•Louisiana Health Care Reform Act 2007

•Louisiana Health Care Quality Forum (LHCQF)

•Expand health insurance coverage in the state

•HIT plan to support healthcare practices

Pediatric Patient Centered Medical HomeLouisiana Medicaid

• Kidmed-Community Care Network

• Bayou Health Plans – Managed Health Care

Pre-Paid Plans – capitated managed care model, traditional risk-based - fee for service

Shared Plans – enhanced primary care case management plan, monthly per-member fee for care management services-opportunity for providers to share in cost savings

• 5 Plan Options ‘Your Health/Your Choice’

• Bayou Health Statewide June 2012

Pediatric Patient Centered MH-Tiger Care Pediatric PCMH Model Background

• LSU Peds/CHNO joint clinic opened March 2004

• Care Coordinator (CC) position funded by CSHS

• Faculty/staff trained in AAP MH

• Resident outpatient training/med student rotations

• Study – Tiger Care CC Medical Home Model

Pediatric Patient Centered MHTiger Care Study Objective

Assess for significant changes in family satisfaction among families of CSHCN before and after care coordination

MH Family Index → measured receipt of MH services

Determine the effect of a nurse care coordinator on the ability of the clinic to meet MH criteria MH Index → measure of clinics ability to meet MH criteria

Pediatric Patient Centered MHTiger Care Model- Care Coordinator Role

• Screen/identify CSHCN

• Written Care Plan complex CSHCN

• Assist families/patients▫ Community program access▫ Families Helping Families▫ School Board/Eval/IEP

• Support youth transitions initiative

• MH Meetings

• Track/trend population data → QI

Katrina

Pediatric Patient Centered MH-Tiger Care Post-Katrina

• Katrina destroyed clinic August 2005

• Study data destroyed

• Clinic reopened March 2006

• Care Coordinator hired

• MH Study resumed

Care coordination in a medical home in post-Katrina New Orleans: lessons learned

Susan J Berry MD MPHEleanor Soltau RN CCMNicole E Richmond MPH

R Lyn Kieltyka PhDTri Tran MD MPH

Published in the Journal of Maternal Child Health –August 2011

Tiger Care Study Pre-Post Care CoordinatorPre-Post Katrina Clinic Population Comparison

Tiger Care Clinic: Pre KatrinaPre RN CC

n=68

Post KatrinaPost RN CC

n=92

Race: African AmericanCaucasian

92% 8%

94%5%

Sex: Male 73% 65%

% Clinic Population Medicaid

91% 93%

% Clinic CSHCN Medicaid

Unavailable 98%

Pre-Post Katrina ComparisonCharacteristics of Family Survey Participants

Tiger Clinic Pre KatrinaPre RN CC

Post Katrina

Post RN CCAverage age 7 years

(range 0-16 yrs)6 years

(range 0-20 yrs)

Top 4 Primary Diagnoses:

Asthma ADHD Dev. Delay CP

38%11%6% 7%

27%19%10% 8%

MH Family Index Result – Tiger StudyFamily Perception of Physician

#1 #3a #3b #5 #60

20

40

60

80

100

Pre

PostPer

cen

t (%

)

#1 Physicians are accessible to the family and child as needed#3a My doctor communicates well with me#3b My doctor communicates well with my child#5 My doctor asks how my child’s condition affects our family#6 My doctor listens to my concerns and questions

MH Family Index – Tiger StudyFamily Perception of Care Coordination

#9 I receive a copy of my child’s plan whenever it is changed#10a My doctor/office staff follow through with the care plans #10b My doctor/office staff change the care plan as needed#11a My doctor has CC who helps me with referrals/payment/follow-

up#11d My doctor has CC who helps everyone communicate with each

other

#9 #10a #10b #11a #11d0

20406080

100

Pre Post

Pe

rce

nt

(%)

MH Family Index –Tiger StudyFamily Perception of Practice

#2a Staff knows who we are when we call the office.#12 When I ask, my doctor/office staff explain my child’s condition to

school personnel/child care providers#14 Staff know my child’s conditions and things that concern us#15 Office staff connect me with educational/family advocacy organizations#16 My doctor assists me in finding adult healthcare services for my child

#2a #12 #14 #15 #160

20

40

60

80

100

Pre Post

Perc

en

t (%

)

Medical Home IndexDomain Themes

Organizational Capacity

mission, communication, access/medical records, environment, family feedback, cultural competence, staff education.

Chronic Condition Management

Identify CSHS, continuity of care across settings, cooperative management with specialists, transition to adult services, family support

Care Coordination

role definition, family involvement, child and family education, assessment of needs and plan of care, resource information and referrals, advocacy

Community Outreach

community assessment of needs of CSHCN, community outreach to agencies and schools

Data Management electronic data support, data retrieval capacity

Quality improvement

quality standards (structures), quality activities (processes)

Tiger Care CanalMH Index Result Comparison 2010-11-12

2 P 2 P 2 P 2 P 2 P 2 P 2 P 2 P 2 P 2 P

2 C 2 C

3 P

2 C

3 P

2 C 2 C

3 P

2 C 2 C2 C

3 P 3 P 3 P3 P

2 P

3 C

3 P2 C

3 P

MH Index- SV COMPARISON OF DOMAIN LEVEL BY SURVEY YEAR

MH 2010 LEVEL

MH 2011 LEVEL

MH 2012

April 2010 n=8April 2011 n=7March 2012 n=4

LEVEL 2 PARTIAL

LEVEL 3 COMPLETE

LEVEL 3 PARTIAL

Tiger Care ModelUNIVERSITY MEDICAL CENTER PEDIATRICS LAFAYETTE

MEDICAL HOME CAPACITY SCORES

BASELINE MHI SEPT 2010

FOLLOW-UP MHI FEB 2011

FAMIL

Y

CULTURAL C

OM

PETENCE

CYSHCN ID

ENTIF

IED

CARE CONTIN

UITY

COOPERATIIV

E MANAGEM

ENT

TRANSITIO

N

CARE COORDIN

ATION

CARE PLAN

CYSHCN C

OM

MUNIT

Y ASSESS...

QUALIT

Y STANDARDS

2 P 2 P 2 P 2 P 2 P 2 P 2 P 2 P 2 P 2 P

2 C

3 C

3 P

2 C

3 C

2 C 2 C

3 C

2 C 2 C

Tiger Care ModelTIGERCARE KENNER

MEDICAL HOME CAPACITY SCORES

MH 2010 LEVELMH 2011 LEVEL

Sample Size: 3Date: April 2010 & 2011

FAMILY

FEED

BACK

CULTURAL C

OMPE

TNEC

E

ID S

HCN

CARE CONTI

NUITY

COOPERATI

VE MGT

BTW P

CP & S

PECIA

LISTS

TRANSI

TION

CARE COORDIN

ATION

CARE PL

ANS

COMMUNIT

Y NEE

DS

QUALITY

STA

NDARDS

Tiger Care ModelLSU Bogalusa Medical Center

MEDICAL HOME CAPACITY SCORES

SEPT. 2010

MAR. 2011

APR. 2012

Level 3

Level 1

Level 2

FAMIL

Y FEEDBACK

CULTURAL C

OM

PETENCE

IDEN

TIFY S

HCN

CARE CONTIN

UIT

Y

COOPERATIV

E MAN

AGEMEN

T

TRANSIT

ION

CARE COORDIN

ATION

CARE PLAN

S

COM

MUN

ITY N

EEDS

QUALIT

Y STANDARDS

Tiger Care ModelTulane Children's Health Project

MEDICAL HOME CAPACITY SCORES

2010 Baseline

2011 Fol-low-up

Level 3 Complete

Level 2 Com-plete

Level 1 Com-plete

LSU MIDCITY BATON ROUGEMEDICAL HOME CAPACITY COMPARISON

20072008200920112012

LEVEL 1

LEVEL 3

LEVEL 2

LEVEL 4

Patient Centered Medical Home-EBPDemonstration Sampling

Pediatric Alliance for Coordinated Care-Boston 6 Pediatric Practices Increased parent satisfaction Decreased caregiver missed work Decrease in burden of care

Geisinger Health System-Pennsylvania Multi-dimensional MH Model 11 Primary Care Practices In-patient admissions reduced 18% Re-admissions reduced 36%

Community Care of North Carolina Medicaid sponsored initiative 40% decrease in hospitalizations for asthma and 16% decrease ED visit rate

Colorado Medicaid and SCHIP Medicaid sponsored initiative PCMH children decreased median annual costs ($2,275) compared to non-enrolled ($3,404)

Care Coordination -

Carrie is a 3 year old who is new to Louisiana presents to a local clinic. She has Down Syndrome and has had heart surgery in the past. She has never been in our school system or in Early Head Start. Her vision is suspect, as she holds everything up close and cocks her head to the side. She is pleasant, outgoing and does not usually have temper tantrums. Her speech is difficult to understand. She walks with an unsteady gait and has decreased muscle tone. She has had no therapies to date. She takes no medications. Carrie has no insurance and Mom is concerned.

Pediatric Patient Centered Medical Home Care Coordination

• PCP /family develop plan of care Prior to Cardiology referral obtain medical records → released? Team reviews medical records No meds – medication reconciliation with records Check for date of last eye exam

• Vision & Developmental screens • Head Start or region school board for eval/IEP• CC resource for insurance access – eligible for SSI disability?• Speech, PT, OT • Developmentalist• Dental• Families Helping Families• Office of Citizens with Developmental Disabilities(OCDD)

Take Away Points

• PCMH evidence supports → effective/efficient model for health care delivery

• Medical Home → Improves patient outcomes

• Care Coordination and planned transitions essential for CSHCN

• Tiger Care Medical Home Care Coordinator Model▫ Replicated (+) outcomes in over 12 practices▫ Care Coordinator Model = Proven Effective

“We must become the change we want to see in the world.”

Mahatma Gandhi (1869-1948)

A wise man once said...

CHILDRENS SPECIAL HEALTH SERVICES

Questions/Collaboration/Information:

Patti Barovechio MN, BSN, CCMStatewide Care Coordinator Supervisor

CSHS504-568-5026

References/Resources/Links• AAP Medical Home http://www.medicalhomeinfo.org • Center for Medical Home Improvement

http://www.medicalhomeimprovement.org • Data Resource Center for Child & Adolescent Health

http://www.childhealthdata.org • Got Transitions: www.gottransition.org • National Committee for Quality Assurance (NCQA):

http://www.ncqa.org • Patient Centered Primary Care Collaborative: http://www.pcpcc.net • State of Louisiana, CSHS program web site

http://www.cshs.dhh.la.gov• US Department of Health Resources and Services

Administration, Maternal and Child Health Bureau (MCHB): http://mchb.hrsa.gov