Retrofitting the Medical Home for Children with Special

Retrofitting the Medical Home for Children with Special Health Care Needs Mara Mc. Grath, MPH Manager, Alameda County Medical Home & Help Me Grow Projects October 25, 2017

Objectives • Introduce the characteristics of a medical home • Describe the Medical Home Index • Give examples of how to strengthen the medical home infrastructure • Share outcomes of quality improvement projects • Identify barriers to shoring up the foundation • Questions and potential answers

Medical Home • Accessible: I can get care for my child 24 hours a day, 7 days a week. • Family-Centered: I am a valued and respected member of my child’s medical team. • Comprehensive: My child’s providers are familiar with who my child is and his/her health condition(s). I get the same doctor with every visit.

Medical Home • Continuous: My child’s doctor never gives up on meeting my child’s needs; this includes a “warm handoff” to adult provider • Coordinated: I can easily receive referrals to specialty care and community services when my child needs it; reports are integrated into personal health record • Compassionate: My child and I are treated with genuine concern and compassion • Culturally Sensitive, Humble and Competent

Medical Home Index • Short version has ten indicators • Three levels: (1), – Level 1: good, responsive pediatric care – Level 2: proactive care – Level 3: comprehensive care/care coordinator *Administered for baseline and then every three years

Family Feedback • • • Suggestion box Focus groups, individual interviews On-line reviews (Yelp) Annual patient satisfaction surveys Parent advisory board or process for parent input in policies/procedures

Cultural Competence As a medical provider, you: • Learn about other cultures; ask questions • Are aware of your own values and beliefs and how they help shape your actions and decisions • Respect family values and beliefs, including interest in alternative remedies; incorporate into care plan • Are nonjudgmental • Consider ways to sensitize the entire office staff about the diversity of families • Provide educational materials in multiple languages as needed, and offer translation and interpreter services • Decorate the office to reflect cultural diversity • Recognize what nonverbal behaviors are communicating to the family and vice versa

Identification of CSHCN • Track children who have involvement with Regional Center, California Children’s Services (including MTP), Special Education and Mental Health • Flag electronic health record (EHR) on facesheet or problems’ list • Search on ICD-10 diagnostic codes and/or acuity levels

Care Continuity Ø Team made up of PCP, family and staff Ø Care plans include home, school and community with visit schedules outlined and communication strategies Ø Practice back-up/cross coverage is outlined Ø Medical condition protocols or algorithms for care coordination, eg. Autism Algorithm, are developed (include goals, services, interventions and referral contacts) Ø Care coordinator relies on these protocols for direction

Cooperative Management Ø Primary Care Provider (PCP) and family set referral and communication goals for Specialty Care: time lines and how communication will be handled with all parties involved Ø Parent(s) choose to be the “driver” and partner with PCP; specialists’ role is consultation only

Supporting Transition to Adulthood Ø Establish timelines and developmental approach to health & wellness, education & vocational planning, conservatorship, and community supports & recreation Ø PCPs identify adult providers and facilitate a “welcome” visit sometimes with help from health plans

Care Coordination/ Role Definition • Provider and parents (or older child) partner to accomplish care coordination goals • Care coordination activities and services are offered by a designated care coordinator as part of the practice’s standards • Family needs/wishes drive their choice and level of practice involvement

Patient Needs Assessment/ Care Plans Ø Review and update care plans twice a year (health status, hospitalizations, medication changes, equipment needs, mental health needs) Ø Care coordinators (mostly found in specialty practices) monitor and update care plan at every visit

CSHCN Community Needs Assessment Ø Providers raise questions (eg. eligibility based on number of prescriptions) Ø Seek pertinent information from families Ø Participate in community public health effort (eg. Special Needs Committee) Ø Bring observations/data to attention of local (eg. Special Needs Committee) or State (Family Voices) policy-maker

Quality Standards • Medical practice has quality improvement mechanism for CSHCN • Integrates into regular staff meetings • Parents of patients participate in QI activities (eg. Training on transition, developmental screening, and handouts for providers’ interactions with families

Quality Improvement Projects • Sonoma County FQHC üSpecific to children with epilepsy üFederally funded üFederally qualified health center (FQHC) üMulti-disciplinary coalition(monthly) üStabilized provider assignment üSpread included nursing training

Quality Improvement Projects • Large Pediatric Practice – BPMG üSpecific to children who have CCS üIdentification of all CCS children (200) and those who would be transitioning (25) üMonthly meetings with providers and representatives from front & back office üFlag charts and add visit time üCreate transition packet and train

Quality Improvement Projects • Children’s Hospital üSpecific to children with acute needs for intensive case management üInitially, monthly meetings with CCS team and Family Navigator (no patients) üCurrently, quarterly meeting after two years üAddress care coordination challenges üEffect policy changes (billing codes and specialists in primary care)

Quality Improvement Projects • Alameda County Behavioral Health Care Services üSpinoff from Special Needs Committee üBuy in from director at ACBHCS üBetter communications between PCP and mental health providers üBilling code, conferences, website, communication tools

Barriers to Medical Home • • Ability to be reimbursed (certification) Leadership (champions) Patient collaboration/encouragement Practice environment/extended environment (eg, hospital linked to practice) Staff capacity (other QI projects, unions) An electronic health record (didn’t expect this!) Adequate time for innovation and reflection (PDSA)

Key Strategies • Whatever documents/resources that are created for families or providers should be designed for interchangeability. • Dissemination to both families and providers simultaneously is critical for increased utilization and engagement. • Keeping documents simple makes for easier translatability and readability for low literacy. • Family leaders vet all documents.

Medical Provider’s Role • • • Information on Accessing Health Coverage Knowledge of Entitlement System Alert to Changes in Legislation and Impact on Families (Regional Center) • Awareness of Resources in Family Support and Navigation • Access to Current Health Records

Wrap-Up • Pediatric providers want a care coordinator in their office • PCPs want simple and practical recommendations for changing their practice • PCPs want technical assistance that can interface with their larger systems • PCPs want seamless integration of EHR • PCPs want family participation to feel comfortable for their families

Questions? ? ? Email Mara Mc. Grath: mmcgrath@stanfordchildrens. org