The Pediatric Medical Home: Building a Strong Foundation

R.J. Gillespie, MD, MHPE, FAAPMedical Director

Oregon Pediatric Improvement Partnership

Roadmap

• BEING a medical home– What does it look like?

• BECOMING a medical home– How does my practice

get there?

Medical Home Fervor

What’s actually happening…

Factors Influencing Health StatusMedical Care: 10%

Environment: 20%

Genetics: 20%Behavior /Lifestyle: 50%

BEING A MEDICAL HOME

A Medical Home

• Is a community-based primary care setting which provides and coordinates high quality, planned, family-centered health promotion and prevention, acute illness care, and chronic condition management — across the lifespan.

Medical Home – AAP definition

AccessibleFamily-Centered

ContinuousComprehensive

CoordinatedCompassionate

Culturally Effective

Primary Medical Home ModelPreventive Care

• Well visits• Screening for

risk factors• Health

promotion & Anticipatory Guidance

• Immunizations

Chronic Condition Management

• Identification & Monitoring

• Care plans / care coordination

• Co-management with specialists

Acute Illnesses

• Telephone triage and advice

• Office visits• Coordination

with ER / Urgent Care

• Coordination with hospitals

General Activities of the Medical Home

• Anticipatory guidance – prevention and developmental promotion

• Identification of risk factors – physical, mental, social• Understanding family strengths and protective factors• Helping families set goals and priorities for self-management• Management / referral to medical and community resources• Ensuring follow-up – was the patient able to follow

recommendations, complete referrals?• Planning for future encounters ahead of time (instead of

reacting to problems as they are presented)

Delivery of Patient & Family-Centered Care Coordination Services

Lessons of the National MHLC

• If you do nothing else…– Identify your population of CSHCN– Develop the capacity for practice-based care

coordination and the use of care plans– Gain family participation/feedback

From Carl Cooley’s presentation to the T-CHIC Annual Meeting, June 2012

• In order to improve care for CYSHCN…you have to know who they are

• Identifying CYSHCN is different than identifying adults with special health care needs– chronic conditions vary considerably in severity, degree of

impairment and service needs– a complete condition list would be unwieldy and include many

children who do not require special services– a functional status approach would not capture children who

function well but need special services to maintain function– the inherent difficulties in measuring functioning of very young

children and infants

Why worry about identifying CYSHCN?

How Identification is Done

• Three general techniques:– Provider “gestalt”– Running diagnostic codes– Using a consequences-based screener like the

CAHMI screener• Most practices do a combination, depending

on goals and purposes for identification

Shared Care Plans…Background

“Every patient can benefit from a care plan (or medical summary) that includes all pertinent current and historic, medical, and social aspects of a child and family's needs. It also includes key interventions, each partner in care, and contact information. A provider and family may decide together to also create an action plan, which lists imminent next health care steps while detailing who is responsible for each referral, test, evaluation or other follow up.”

From www.medicalhomeinfo.org

Shared Care Plans for CYSHCN

• Developed collaboratively with child and family, incorporates child and family goals

• Effective way to support self-advocacy and self-determination

• Types of care plans• Medical summary/transition summary• Emergency care plan • Working care plan or action plan• Individual Health Care Plan for educational setting

• Name, DOB• Parents/Guardians• Primary Diagnosis• Secondary diagnosis(es)• Original Date of Plan, Updated last• Main concerns/goals– Current plans/actions– Person(s) responsible– Date to be completed

• Signatures

Key Elements in Shared Care Plans

Maxims of Patient Centered Care

The needs of the patient come first

Nothing about me without me

Every patient is the only patient

From: D. Berwick. What ‘Patient-Centered’ Should Mean: Confessions of an Extremist. Health Affairs, 28, no.4 (2009): w555-565.

Patient-Provider EncounterProvider Patient

Micro-systemClinic Hospital

Macro-systemHealth Plan Delivery System

Environmental ContextPolicy

Engaging families and/or youth

• In working with practices, this is difficult but meaningful in many ways

• Some ideas for how to engage families:– Recruiting families for QI teams or standing clinic committees– Focus Groups

• Recruit a group of parents to discuss specific topics• Example: focus group to review service needs for CYSHCN

– Parent Advisory Group• Can also be subject-specific, or have the agenda driven by the parents

– Survey patients and families about their experience of care• Formal surveys• Shorter surveys of topics of interest

BECOMING A MEDICAL HOME

Adaptive Reserve

• What’s predictive of medical home transformation is the characteristics of the practice themselves…specifically adaptive reserve

• The ability of a practice to be resilient, to bend, and thrive survive under force. Facilitates adaptation during times of dramatic change.

Initial Steps

• Understand your practice’s culture• Create a team• Set priorities• Decide on accountabilities• Measure your progress

As the Project Starts

• Understanding Clinic’s Change Culture• Knowing who the clinic needs to be engaged• Getting the backing of clinic leadership

Key thought: Understanding how your practice typically addresses change and decision-making will facilitate project spread.

As the Project is Underway

• Developing QI skills as a practice (aim statements, PDSA cycles)

• Engaging patients and families in QI efforts

Key thought: QI skills and knowledge can’t live in the brain of a single individual (or small group of individuals) if change is to be sustained.

As the Project Finishes

• Creating a multi-disciplinary team for ongoing QI work

• Developing a clinic-wide strategic plan for QI• Creating systems for tracking and sharing

performance measures

Key thought: Ongoing sustainability requires a permanent infrastructure for QI.

Food for thought

• Given that medical home transformation is a flexible, long-term process…

How can you build your project team and do your project-level work in a way that sustains the work beyond the timeframe of the learning collaborative?

Key Questions: Understanding Your Clinic’s Change Culture

• How are changes made in your practice?• Who holds decision-making authority in your

practice?• How can you engage other providers to

participate in changes being made?• What are the structural supports needed to

maintain continued growth as a medical home?

Simple Steps to Implement Now• Working on team identity and function

– Are you meeting regularly? Do you create an agenda? Are you dividing accountabilities?

• Finding ways to share project information, goals, aim statements with others– What are the avenues for sharing information with other

providers and staff? Are there standing meetings that you need to get yourself on the agenda for?

• Publicizing project data with other staff members, providers and patients– How is performance data shared with others in the practice?

Structural Supports

• Implementing large scale change calls for dedicated support structures– Many highly functioning medical homes have

created QI Teams and are working on a Strategic Plan for Quality

• Success increases if multiple tactics for change are used

Final Thoughts…• Start small. One small

change can make a big difference.

• Use existing medical home tools to prioritize your efforts.

• Know which patients are in most need of your help.

• Involve your patients in improving their own care as well as your practice.