The Medical Home Model: Caring for Children with Special Health Care Needs

1
The Medical Home Model Caring for Children with
Special Health Care Needs
Home Is Where the Heart Is

• State, Healthcare Providers and Families as
  Partners

2
The National Initiative for Childrens Healthcare
Quality
3
NICHQs Mission

• To eliminate the gap between what is and what
  can be in health care for all children.

4
About NICHQ

• NICHQ is an action oriented organization
  dedicated exclusively to improving the quality of
  childrens health care
• NICHQ is a resource for health care and
  improvement organizations, foundations, and
  government agencies seeking to improve care for
  children
• NICHQ is a national organization
• Home Office Cambridge, MA
• National cadre of key advisors
• Geographically distributed staff

5
NICHQs Success Will Be Gauged By Whether

• Children achieve
• Their greatest potential with
• No needless harminjury, pain, suffering, death
• Families
• Are optimally able to provide for, promote, and
  support their child
• Communities
• Are best able to support healthy children and
  families
• Society
• Achieves these results with
• Equality
• No waste

6
What we doChange Practice to Improve Care and
Outcomes

• Innovate
• Discover, invent, and share good ideasready for
  use in childrens health care
• Demonstrate
• Undertake targeted initiatives to demonstrate the
  feasibility of improving care and outcomes
• Accelerate Adoption
• Work with health care delivery organizations,
  families, government, and others so that better
  models are widely and rapidly adopted

7
NICHQs Bold Improvement Agenda

• Prevent Childhood Obesity
• Provide Seamless, Evidence Based, Family Centered
  Care for Children with Chronic Conditions
• Purge Harm from Childrens Health Care
• Promote Equity in Care

8
Our Services

• Training and Transforming Care
• Learning Collaboratives In person and across
  distance
• Action Networks and Spread Initiatives
  Accelerating learning, spreading better care
• Annual Childrens Forum
• Toolkits
• Jump Start and Jump Ahead Introductory and
  Advanced QI Methods and Tools for Childrens
  Health Care
• Setting the National Agenda for Change
• Federal and State Childrens Quality Policy
• Measurement
• Improvement
• Health Information Technology
• Payment
• Creating and Sustaining Improvement Resources
• Local, State, Regional and Federal programs to
  sustain change

9
7th Annual Forum March 19-21, 2008 Miami,
Florida Intercontinental Hotel
10
Our Partners

• Health Care Improvement Organizations
• Institute for Healthcare Improvement
• Improving Chronic Illness Care Program
• Center for Health Care Strategies
• Family Voices, Spina Bifida Association, CHADD,
  Epilepsy Foundation
• Child and Adolescent Health Measurement
  Initiative
• Foundations
• David and Lucile Packard Foundation
• Robert Wood Johnson Foundation
• Commonwealth Fund
• California Endowment and Health Care Foundations
• Government
• State NY, California, VT Departments of Health
• Federal Maternal and Child Health Bureau, AHRQ,
  CMS

11
Together we can make health care better for every
child!
12
Before we begin.

• This is really hard work complexabstract
• Remind you (and me) why we are doing this
• Patient 1 Infant with complex genetic disorder,
  skin breakdown, severe developmental delay,
  Cambodian refugee family, non-English speaking.
  Foster care.
• Patient 2 Girl with dozens of surgeries for
  complex congenital anomalies, failure to thrive,
  mild developmental delay, maternal substance
  abuse.
• Create a system where any parent, any child, and
  society knows that that child and family will get
  the right care, the right way, the right time to
  efficiently and effectively achieve the best
  outcome

13
Objectives

• Describe core elements necessary for
• full implementation
• spread of the medical home model
• Share how
• Maternal Child Health Bureau (MCHB),
• Title V
• primary care and
• specialty clinicians have worked/can work
  successfully to implement the medical home

14
A Medical Home is

• Accessible
• Family Centered
• Continuous
• Comprehensive
• Coordinated
• Horizontal
• Vertical
• Longitudinal
• Compassionate
• Culturally Effective

15
Defining medical homebasic, good, better, great

• A medical home is a community-based primary care
  setting which provides and coordinates high
  quality, planned
• family-centered health promotion
• chronic condition management

16
The Patient/Family the Community-Based
Medical Home at the crossroads, integrating

• Vertically Among health care systems/specialists
  /PCPs/others
• Horizontally Among supportive community
  agencies/schools

Health Care
Longitudinally.
Community Supports
Medical Home
17
Why Medical Home Spread Slow

• Lack of awareness
• Limited operationalization
• Pragmatic barriers
• Time
• Knowledge
• Role definition
• Reimbursement
• Limited skills in the methodology of changing
  practice behavior.
• Are there any other obstacles to spread?

18
Hypothesis

• Application of four key concepts
• Medical Home/Care Model for Child Health
• Collaborative Model
• Model for Improvement
• Model for Spread
• Together with support from a capable
  regional/state/local resource (Title V)
• Will result in acceleration of spread of Medical
  Home

19
Care Model for Child Health in a Medical Home
Supportive, Integrated Community
Informed, Activated Patient/Family
Prepared, Proactive Practice Team
Prepared, Proactive Practice Team
20
Model for Improvement
What are we trying to
Aim
accomplish?
How will we know that a
Measures
change is an improvement?
What change can we make that
Ideas
will result in improvement?
Act
Plan
Study
Do
From Associates in Process Improvement
21
IHI Breakthrough Series(12 month time frame)
Participants (10-100 teams)
Select Topic (develop mission)
Prework
Develop Framework Changes Measures
Dissemination Holding the Gains Publications Congr
ess etc.
P
P
P
A
D
A
D
A
D
Expert Meeting
S
S
S
LS 2
LS 1
LS 3
Planning Group
AP1
AP2
AP3
Supports Email Phone Conferences Visits
Monthly Team Reports
LS Learning Session AP Action Period
Parent Training
Parent Training
Parent Training
Title V Training
Title V Training
Title V Training
22
Modifications to BTS Design

• Participants
• State Title V Programs, each of whom recruited
• 2-3 Primary Care Practice Teams
• MHLC II Broader State Team AAP/AAFP, Medicaid,
  Parent
• Faculty
• Clinical, Title V, and Parent Chair
• Teams
• Physician, Staff (Nurse/Care Coordinator), Parent
• Topic
• Medical Home, aka, Chronic Care Model for CYSHCN
• Added emphasis on Cultural Competency (MHLC II)

23
IHI Framework for Spread
Leadership -Topic is a key strategic
initiative -Goals and incentives/policies
aligned -Executive sponsor assigned -Day-to-day
managers identified -Aim developed
Set-up -Adopter audiences -Successful sites
-Key partners
-Infrastructure supports to enable
adoption -Initial spread strategy (leverage
system structure)
Social System -Early adopters -Key
messengers -Communities
-Technical support -Transition issues
Better Ideas -Develop the case -Describe the
ideas

Communication (awareness technical)
24
Participant States

• MHLC I
• Connecticut
• Colorado
• Florida
• Ohio
• Oklahoma
• Louisiana
• Michigan
• North Carolina
• New York
• Utah
• Virginia
• Wisconsin

• MHLC II
• DC
• West Virginia
• Vermont
• Illinois
• Maine
• Maryland
• Minnesota
• Texas
• Pennsylvania
• practice team, but no State Agency

25
Aim Medical Home Learning Collaboratives

• To improve care for children with special health
  care needs/youth by implementing the Medical Home
  concept
• To foster substantial relationships between Title
  V programs and their states primary care
  community, enabling Title V to
• Support improvement in practices and
• Spread improvement across their State

26
Participants Teams-Practices

• 3 Teams from each State
• 43 Community Based, Group Practice
• 22 Community Hospital or Network Group Practice
  (e.g., Marshfield Clinic, Bassett Health)
• 25 Academic Primary Care Sites
• 9 Solo Practice
• Team Members
• Physician, nurse/other office staff/care
  coordinator, parent partner

27
Measures

• ED visits
• Unplanned Hospitalization rates
• Family worry
• Front office satisfaction
• Medical Home Index
• Care Plans
• Practice Satisfaction

28
Medical Home Learning Collaborative IMedical
Home Index Pre and Post Measures
29
Medical Home Learning Collaborative IIMedical
Home Index Pre and Post Measures
30
Results MHLC I
31
Results-MHLC II
32
ResultsMHLC II
33
Qualitative Results Title V

• Most valuable activities and insights
• Conduct walk-through of practices
• Connect teams to state resources
• Assist with care coordination
• Outreach to broad variety of audiences
• Practices need help working with families
• Positive impact on how to implement change and
  promote adoption of new models
• Additional support, training, infrastructure
  needed
• Spread Challenging
• Tool developed
• Internal collaboratives successful and ongoing

34
Qualitative Results-Parents

• Parents can be very effective in this process
  because they can counter assumptions health care
  providers make about the way things work"
• "There are things I can do, like pre-register my
  child for appointments...my pediatric clinic and
  the hospital are willing to do many things to
  make things better for my family. I never would
  have known what to ask for, as a new parent,
  before the medical home training"

35
Qualitative Results-Practices

• The MHLC "helped the practice focus on achievable
  steps to initiate a true medical home
• "the small changes have made a world of
  difference in our practice...
• Specific changes (self-report)
• 70 streamlining access
• 64 have designated care coordinator
• 63 working with community agencies
• 60 partnering with families
• 50 using some form of registry
• Simplification, prioritization needed

36
Why Medical Home Spread Slow

• Lack of awareness
• Not Directly Addressed, Other (ACP, NCQA) Efforts
• Limited operationalization
• Better, but still complex
• Pragmatic barriers
• TimeEinstein rules!
• Knowledge--Yes
• Role definition--Yes
• ReimbursementIn part. See NCQA/PC Medical Home
• Limited skills in the methodology of changing
  practice behavior--Yes

37
Hypothesis

• Application of four key concepts
• Medical Home/Care Model for Child Health
  Simplify
• Collaborative Model
• Model for Improvement
• Model for Spread Not well adopted/applied
• Together with support from a capable
  regional/state/local resource (Title V)
• Partners necessary (not sufficient)
• Trainingdata, coaching, practice issues
• Resources and priorities
• Will result in acceleration of spread of Medical
  Home

38
Step By Step Approach with Simplified Medical
Home Model

• A Guide to Assisting Practices to Implement
  Medical Home
• 1 Engage parents as partners at practice level
• 2 Identify, categorize complexity, and create a
  registry of CYSHCN
• 3 Use planned encounters
• 4 Develop strategy and identify specific roles
  for care coordination and communication at the
  practice level

39
Spread FrameworkIn Words

• Leadership Setting the agenda and assigning
  responsibility for spread
• Set-Up for Spread Identifying the target
  population and the initial strategy to reach all
  sites in the target population with the new ideas
  
• Better Ideas A description of the new ideas and
  evidence to make the case to others
• Communication Methods to share awareness and
  technical information about the new ideas
• Social System Understanding the relationships
  among the people who will be adopting the new
  ideas
• Knowledge Management Observing and using the
  best methods for spread as they emerge from the
  practice of the organization
• Measurement and Feedback Collecting and using
  data about process and outcomes to better monitor
  and make adjustments to the strategy

40
Revised Spread Planner

• Spread Planner for Medical HomeA Tool for Title
  V and Other State Level Leaders
• Leadership
• To what extent is spread of the Medical Home
  model a strategic objective of the key leadership
  organizations in your state (i.e., Title V, AAP,
  and Family Voices)?
• Are the goals/incentives of other key
  stakeholders within the state aligned with
  Medical Home spread?
• Is there support for Medical Home implementation
  at a policy level?
• How has the recent focus on medical home affected
  your efforts?

41
Joint Principles of the Patient-Centered Medical
Home

• The Patient-Centered Medical Home (PC-MH) is an
  approach to providing comprehensive primary care
  for children, youth and adults. The PC-MH is a
  health care setting that facilitates partnerships
  between individual patients, and their personal
  physicians, and when appropriate the patients
  family.

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

42
Joint Principles of the Patient-Centered Medical
Home

• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated
• Quality and safety
• Enhanced access
• Payment

43
National Committee for Quality Assurance (NCQA)
Physician Practice Connections

• Practice Requirements
• For Certification

Source 2006 National Committee for Quality
Assurance
44
NCQA PPC Standards Intent

• 1. Access and Communication
• The practice provides patient access during and
  after regular business hours, and communicates
  with patients effectively
• 2. Patient Tracking and Registry Functions
• The practice has readily accessible, clinically
  useful information on patients that enables it to
  treat patients comprehensively and systematically
• 3. Care Management
• The practice maintains continuous relationships
  with patients by implementing evidence-based
  guidelines and applying them to the identified
  needs of individual patients over time and with
  the intensity needed by the patients

45
NCQA PPC

• 4. Patient Self-Management Support
• The practice collaborates with patients to pursue
  their goals for optimal achievable health
• 5. Electronic Prescribing
• The practice seeks to reduce medical errors and
  improve efficiency by eliminating handwritten
  prescriptions and by using drug safety checks and
  cost information when prescribing
• 6. Test Tracking
• The practice works to improve effectiveness of
  care, patient safety and efficiency by using
  timely information on all tests and results

46
NCQA PPC

• 7. Referral Tracking
• The practice seeks to improve effectiveness,
  timeliness and coordination of care by following
  through on consultations with other
  practitioners.
• 8. Performance Reporting and Improvement
• The practice seeks to improve effectiveness,
  efficiency, timeliness and other aspects of
  quality by measuring and reporting performance,
  comparing itself to national benchmarks, giving
  physicians regular feedback and taking actions to
  improve
• 9. Interoperability
• The practice maximizes use of electronic
  communication to improve timeliness,
  effectiveness, efficiency and coordination of care

47
Better ideas

• Can you make the case for adoption of the Medical
  Home model?
• Set Up
• What is your implementation plan for spread?
• How will you attract new adopters (e.g., use a
  broad based communication campaign, identify and
  use opinion leaders, share comparative data)?
• What technology will you need (registries, web
  sites)?
• Who are the key messengers?

48
Measurement and Social System

• How will you measure improvement at the practice
  level?
• How will you measure improvement at the State
  level?
• How will you provide feedback?
• Social System
• Are there vehicles to link stakeholders at State
  and local level?

49
Other Health System Components

• Vertical Coordination Primary and Specialty Care
• Case example Children with Epilepsy
• Horizontal Coordination Community/Public Health
  Resources
• Case example Handoffs between newborn hearing
  screening, specialty care, primary care, and
  early intervention

50
Ten Rules for Redesign

• Care is based on continuous healing relationships
• Care is customized according to patient needs and
  values
• The patient is the source of control
• Knowledge is shared and information flows freely
• Decision making is evidence-based
• Safety is a system property
• Transparency is necessary
• Needs are anticipated
• Waste is continuously decreased
• Cooperation among clinicians is a priority
• Institute of Medicine, Crossing the Quality Chasm
  (2001)

51
Design principles of the Hearing Screening
Learning Collaborative

• Newborn and family at center family source of
  control
• All stakeholders at same table information
  shared freely, cooperation, transparency
• Create sense that all in same system
• Focus on idealized system design - safety
• Used reliability principles -safety
• Prevent initial failure
• Identify failure and mitigate
• Critical failure mode functions, redesign
• Focus on handovers and interface of care system
  -cooperation
• Develop integral role of PCP/Medical Home and
  notion of co-management continuous healing
  relationships

52
Design of change package

• Expert panel preferred change package according
  to chronology of care
• Phases of process
• Preparation and planning
• Screening
• Confirmation of diagnosis
• Treatment/amplification
• Enrollment in Early Intervention
• State infrastructure development

53
Key change concepts

• Standardization
• Scripts for failed screen
• Fax-back forms to enhance communication
• Process of referral to specialists
• Consideration of failed newborn screen as
  critical test result
• Consider people as in the same system
• Listen to the customers
• Reduce wait time (for an appointment)
• Give people access to information

54
Measurement strategy

• of newborns who do not pass with verified PCP
  in hospital record
• of newborns with results of newborn screening
  available for first newborn visit
• of infants who did not pass the screening
  phase who get a complete audiologic evaluation by
  3 months of age
• Mean age of infants at completion of audiologic
  evaluation
• Time to third available new appointment with
  the audiologists (in days)
• of infants with abnormal audiologic evaluation
  with notification of PCP/MH within 2 days
• of infants with PHL who are offered
  amplification/treatment by 3 months of age
• of infants with PHL with an initial IFSP by 6
  months
• of infants who did not pass unable to find
  through outreach by 3 months of age

55
Parent experience of care measures

• Developed by parent partners
• of parents who were told and got a copy of the
  results of the newborn screen
• of PCPs who had the results of the newborn
  screen available at the time of the first newborn
  visit
• of parents who always were able to get the
  help they needed for questions related to their
  infants hearing loss
• of parents who always were able to get
  specific information they needed

56
Lessons Learned

• Improving handovers with standardized
  communication tools enhances information transfer
  across the system
• Conversations about roles, responsibilities and
  accountability for care management improves care
  processes for clinicians and families
• Partnering with families in the design and
  improvement processes accelerates improvement
• Simple ideas work work out processes on paper
  while developing larger data systems
• Fax back forms
• Identification of roles and responsibilities
• Structure of the state system matters

57
Lessons learned (cont.)

• Identifying a system failure as early as possible
  helps reduce delays and loss to follow up
• Use every failure as an opportunity to learn
  about your system
• Standardizing processes and providing redundancy
  in birth hospitals helps to locate parents after
  discharge
• Changes to the appointment system for the
  diagnostic evaluation improves completion rates
• All parts of the system should emphasize the
  importance of establishing early communication
  approaches with the infant while in the decision
  process about communication options

58
Percent of newborns who do not pass with
verified PCP in hospital record
59
Percent of newborns who do not pass the
hospital based hearing screening with multiple
contacts on the screening form for follow-up
60
Time to third available new appointment for
ENT/ORL
61
Awareness and Access to Care for Children and
Youth with Epilepsy--Aim

• To improve systems of care for children and youth
  with epilepsy, especially those residing in
  medically underserved areas.
• To design care for children and youth with
  epilepsy to be timely, effective, safe, patient-
  and family-centered, and equitable.
• To apply the model and lessons that proved
  successful in the first Medical Home Learning
  Collaborative to the care of children with the
  specific condition of epilepsy.

62
Highlights

• Application of Advanced Access concept to
  specialty care
• Service Level Agreements, Practice Redesign
• Engagement of parents in learning collaborative
  process (see video)
• Increased use of home medication lists, attention
  to comprehensive care

63
Aim

• Improve the health and well being of Children and
  Youth with Special Health Care Needs (CYSHCN) and
  their families through building the capacity of
  state Title V programsin concert with other
  state based partnersto create and sustain
  effective community based systems of care

64
Defining System of Care

• a family-centered coordinated network of
  community-based services designed to promote the
  healthy development and well being of children
  and their families.

65
A well-functioning system of services will
coordinate and integrate the full range of needed
child and family services, among them health
care, education, and social services, with the
goal of optimizing outcomes for the children and
families it serves Perrin at al. Through any
door
66
Specific Aim

• With a focus on transforming the health care
  component of the system of care by
• Spread of the medical home and
• Strengthening co-management relationships between
  the medical home and specialty care (vertical
  coordination)

67
Three Phases

• Planned innovation program
• Implementation
• Reflection

68
Planned Innovation

• Identify successful state level strategies of
  enhancing health care and other community
  services
• Synthesize a new framework
• Assess validity of framework through expert
  review and (limited) field testing.

69
Implementation

• Two sequential learning collaboratives
• Each focusing on two categorical programs--
  Epilepsy and Newborn Hearing Screening -- while
  working with State Title V Leadership on applying
  the system framework.
• State Teams
• Practice Teams (Epilepsy, Hearing Screening)

70
Reflection

• Analysis of results
• Synthesis
• Recommendations for further action
• Preparation of dissemination materials

71
Focus of innovation

• Approaches that work
• System creation
• Supporting primary care, specialty care, public
  health system capabilityenabling spread
• Addresses financing, quality, population health
  simultaneously
• Within and outside of Title V

72
Help Me Grow- (Connecticut)

• Child Health Provider
• Language/Behavior/Parenting Concerns
• 1-800-Help Me Grow
• Referrals Language Eval Play and Support
  Groups
• Two Week Follow-Up Contact Enrolled
• Feedback to Child Health Provider

73
Design Process

• Desired performance characteristics
• Identification potential sites/programs/systems
• Screening, visits, summary
• Synthesis
• Expert review
• Test
• Revise
• Roll out

74
What do you think?

• How should Title V support improvement in
  clinical care?
• Direct coaching and support at practice level?
• Partnership in establishing regional support
  services?
• Provision of core resources (developmental
  screening, data systems, care coordination
  training and support)
• What are the most effective approaches to
  supporting better care that you have seen? Most
  innovative?
• How have changes in programs and policies (SCHIP,
  Medical Home, others) influenced your thinking?

75
IHIs Triple Aim Optimize the Health System
Across Three Dimensions
76
System Components IHI Triple Aim

• Individuals and families
• Partnership, Joint planning, Patient controlled
  record
• Redesign of primary care services and
  structures
• Team, vertical coordination
• Population health management
• Useful segmentation , health info, public
  health 
• Cost control platform
• System integration
• Developing workforce, Strategic planning
• Execution, including spread, of strategic
  initiatives