UCEDDs and Family Medicine: The New Jersey and Arizona

Experience in Providing a Primary Care Health Home Model for Adults

AUCD

December 4, 2012

A University for Excellence in Developmental Disabilities Education, Research, and Service

Health Disparities and People with Disabilities

People with disabilities have greater needs for medical care than those without disabilities. They are more likely to be at poverty level (7.7% non disabled vs 25.9% people with severe disabilities)

(U.S. Census Americans with Disabilities: 2002 Report)

Less likely to exercise or obtain preventive care. (Armour BS, Campbell VA, Crews JE, Malarcher A, Maurice E, Richard RA. State-level prevalence of cigarette smoking and treatment advice, by disability status, United States, 2004. Prev Chronic Dis 2007;4(4).).

Outline • Introductions, Health Disparities for Adults with

Disabilities & Patient Centered Medical Home • The New Jersey Experience: The Boggs Center • The Arizona experience: The Sonoran UCEDD • Family medicine: the possibilities and promise • The challenges of providing care to adults in this

environment

Joint Principles of the Patient Centered Medical Home

Personal Physician Physician-Directed Medical Practice Whole Person Orientation Care is Coordinated and Integrated Quality and Safety Enhanced Access to Care Payment Recognizes the Added Value of PCMH

Patient Centered Medical Home

• American Academy of Family Physicians (AAFP) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Osteopathic Association (AOA)

• Joint Principles of the Patient-Centered Medical Home March 2007

1 8000 7000 26 6000 5000 51 4000

18 19 20 21 22

Specialist Physicians per 10,000 Population

RELATIONSHIP of HEALTHCARE QUALITY and MEDICARE SPENDING to the SPECIALIST

PHYSICIAN WORKFORCE

Annual Spending

per Beneficiary

(Dollars)

Overall Quality of Healthcare

Rank by State

(Smaller

numbers indicate higher quality)

Source: Baicker et al. Health Affairs. April 7, 2004. Dartmouth Center for Evaluative Clinical Science Medicare Claims Data and Area Resource File, 2003.

Practice Characteristics Associated With Improved Health Outcomes

• First Contact Care • Patient-focused Care over time • Comprehensive Care • Coordinated Care • Family Orientation • Community Orientation

Starfield. JAMA, 1991;266:2268-71 Starfield. Lancet, 1994:344:1129-34 Starfield, et al. Oxford University Press, 1998 Or. Health Care Mortality Across OECD Countries, 2001 Shi, et al. Health Services Research, 2002;37:529-550 Macinko, et al. Health Services Research, 2003;38:831-865

The Primary Health Care Project

The Boggs Center UCEDD The Department of Family Medicine

The Family Practice Center

The Primary Health Care Project

• 1987 Robert Wood Johnson Foundation grant

• Address challenge of access to primary care for adults with chronic disabilities

• Complexity & time consuming nature of coordination biggest obstacle to providing care

• Family medicine as a discipline-world view

Resource Unit at Family Practice Center

• Family Practice Center- ambulatory care training site for Family Medicine Residents

• Integration into a large primary care practice

• Created a Resource Unit for care coordination

• Originally utilized a state operated Medicaid HMO

Program Elements

• Faculty and resident physicians have adult patients with id/dd on patient panel

• Resource Unit provides care coordination • Teaching of residents

– Precepting – Resource Unit supports & models interaction – Didactics

Resource Unit Patients with DD • Patients with disabilities throughout the practice • 16 Family Medicine Faculty Physicians

– 6 to 8 RU patients on their panel • 15 Family Medicine Resident Physicians

– 6 to 9 pts; assigned midway through 1st year • Medicaid; 4 MCOs; some Medicare • 135 RU patients

– Age range: early 20s to 78 yrs oldest – Long established; care > 22 years

• Challenge of adult onset diseases- no family hx

Goal 2 – Health and Wellness

• Improving the health of Arizonans with developmental disabilities by promoting wellness and health lifestyles and expanding competent health care services for people with developmental disabilities, particularly individuals from ethnic or racial minority groups and border communities.

Sonoran UCEDD Projects

• Medical Home for Youth and Adults • Project Search AZ • Aging and Transitions Project • Housing • ArtWorks • Person Centered Planning for Youth

The University of Arizona UCEDD Experience

Enhanced access to care

Care continuity Practice-based team

care Comprehensive care Coordinated care Population management Patient self-

management Health IT

Evidence-based Care plans Patient-centered care Shared decision-

making Cultural competency Quality measurement

and improvement Patient feedback New payment systems

• Medical home model clinic for adults with DD, including young adults transitioning from pediatric care and the children's rehabilitative services system (Title V)

• in the Family Medicine South Campus Clinic – Teaching clinic – High minority and underserved population – next to the University Medical Center South

Family Medicine Clinic

• 24 family medicine resident physicians • 10 faculty physicians • One nurse practitioner • One MSW/Coordinator • One PhD psychologist • Psychology interns • Psychiatric residents

Survey Approved by Human Subjects Implemented Fall 2009 Anonymous Length: Approximately 10-minutes to

complete, open and closed questions Setting: Academic Family Medicine

Residency Clinics Subjects: Clinic staff, nurses, family

medicine residents/fellows, teaching faculty (N=63)

Responders (N=63)

• Resident/Fellow (15) • Physician Faculty/Attending (12) • Nursing: RN, LPN (16) • Office/Clinic Staff (13) • Other: Student Intern (2), Social Worker

(1), PCA (1), CNA (1) • No response (2)

I am knowledgeable about community resources for adults with DD

I would like to know more about: Community resources (housing, employment,

LTC planning, caregiving, case management)*

Issues related to aging: cognitive capacity Health issues for prevention How medical needs might differ How to approach certain topics with persons

with DD and their family Improve communication

Teaching of residents and staff

• Initially two resident presentations per year on residency teaching days, now will occur monthly

• Staffing patients with residents by lead physician

• Two initial staff presentations. • Medical home patient(s) help teach • A medical home patient sits on our

UCEDD’s CAC

http://www.fcm.arizona.edu/so

noran-ucedd/thoughts

• Videos by people with disabilities on their health care experiences

All Scripts Resources

• Common Conditions and Orders • Medical Necessity Letters • Other resources for state services

Care Coordination: the CRS transition team

• New care coordinator specific to the medical home project

• One lead physician • Early introductory meetings with CRS • Care coordinator facilitates first visit,

assures transfer of records

Care Coordination

• Warm handoff’s from physician to care coordinator and from care coordinator to physician

• Chart review for preventive examinations and referral followup

• Outreach for flu season • Assist with access to community

services and medical referrals

Patient/Family Satisfaction

FY

2011 2010 2009 2008

# Patients

67 51 32 23

Total Respondents

21 21 8

N/A

Response Rate

31% 41% 25% N/A

Highly Satisfied

14 (67%) 11 (52%) 8 (100%)

N/A

Satisfied

3 (14%) 7 (33%)

0 N/A

Somewhat Satisfied

4 (19%) 3 (14%)

0 N/A

Not Satisfied At All

0 0 0

N/A

Addition of health indicators to annual survey

(Age 50 and older) screening for colorectal cancer within the past year.

How would you describe your health? Do you have a primary care doctor? Have you ever had a vaccination for pneumonia? Have you had a complete annual physical exam in the past year? Have you had a flu vaccination within the past 12 months? Have you had a hearing test within the past 5 years? Have you had a vision screening within the past year? Do you routinely engage in moderate physical activity? (Women 18 years and over) Have you had a Pap test screening in the

past year? (Women over 40 years old) Have you had a mammogram within the

past 2 years?

Room Design

Demonstration/Prep Kitchen, Classroom, and Exercise Room

Opportunities in Family Medicine

• Family Centered • Community Responsive • Training requirements include

– Development – Family Systems – Community Health – Behavioral Health

NJ Opportunities & Challenges • Aging population- lack of family history • Life span care- transition to adult care models • Working within a Medicaid Managed Care environment,

including financial & practice models • Difficulty in securing time in the residency curriculum • Evaluation & research:

– Longitudinal patient data ( 20+ yrs for some) – Longitudinal training data (’95 62% grads provided care to pwds

in practice) – Health outcomes

• Future: MLTSS?

AZ Opportunities & Challenges

• The Affordable Care Act • Integrations with Medicaid Behavioral

Services • Collaboration with our College of

Agriculture and Life Sciences • Funding of Team-based care • Dental Care

Thank you!

deborah.spitalnik@umdnj.edu bassford@email.arizona.edu