Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Cent

1. Partnering with Patients and Families in the Medical Home2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation

2. Disclosures Neither Dr. Kuo or Dr. Sneed have any relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation.

3. Looking Back� Hopefully many of you were able to participate in this series� first webinar on April 27 where the role of the medical home in preventive and acute care was discussed by leaders of a pediatric practice in Vermont. Providing medical homes to all children and youth means providing quality preventive care, and referring to the evidence-informed Bright Futures guidelines Since preventive and acute care represents a large portion of the care that pediatric providers deliver, it is crucial to establish effective health care teams within the practice, as well as engage patients and families in order to establish family/professional partnerships During the first webinar, the history of the concept of the medical home was also discussed; from it�s first reference in the early 1960s as a central respository for medical home records for children with special health care needs �to the development of a policy statement in the 1990s, and a reaffirmation of that policy in 2008, emphasizing the medical home as the gold standard of primary care for all children and youth�medical home recognition programs and state demonstration projects have been gaining traction across the country to this day� Quality improvement strategies are integrated throughout this webinar series, and will build upon the first webinar�s description of state practice improvement partnerships, quality improvement education modules such as AAP�s EQIPP courses, Plan Do Study Act (PDSA) cycles, family advisory committees, as well as practice self-assessments. We now move along the spectrum of care and go from looking at the role of the medical home in the delivery of preventive and acute care�and now look at the role of medical home in the delivery of chronic care in a pediatric setting�Hopefully many of you were able to participate in this series� first webinar on April 27 where the role of the medical home in preventive and acute care was discussed by leaders of a pediatric practice in Vermont. Providing medical homes to all children and youth means providing quality preventive care, and referring to the evidence-informed Bright Futures guidelines Since preventive and acute care represents a large portion of the care that pediatric providers deliver, it is crucial to establish effective health care teams within the practice, as well as engage patients and families in order to establish family/professional partnerships During the first webinar, the history of the concept of the medical home was also discussed; from it�s first reference in the early 1960s as a central respository for medical home records for children with special health care needs �to the development of a policy statement in the 1990s, and a reaffirmation of that policy in 2008, emphasizing the medical home as the gold standard of primary care for all children and youth�medical home recognition programs and state demonstration projects have been gaining traction across the country to this day� Quality improvement strategies are integrated throughout this webinar series, and will build upon the first webinar�s description of state practice improvement partnerships, quality improvement education modules such as AAP�s EQIPP courses, Plan Do Study Act (PDSA) cycles, family advisory committees, as well as practice self-assessments. We now move along the spectrum of care and go from looking at the role of the medical home in the delivery of preventive and acute care�and now look at the role of medical home in the delivery of chronic care in a pediatric setting�

4. Webinar Objectives By the end of this webinar, the participant will be able to: Illustrate�the importance of building and maintaining multi-specialty teams in the provision of care for children and youth with complex chronic conditions Explore strategies for enhancing complex co-management working partnerships�between specialty and�primary care clinicians Explain how to effectively work with clinical teams and�patients/families�for successful and appropriate care transition planning from pediatric to adult care

5. Alex (name is changed) Alex is a 3 month old child you have seen since birth. In the nursery, you noticed dysmorphic facies, low tone, undescended testes, and a heart murmur. He developed heart failure shortly after and required surgery to repair a large VSD.

6. Alex�s needs What specialists does he need? Cardiology, neurosurgery, urology, GI, genetics when older: ENT, developmental, neurology What therapists does he need? Speech, swallowing, OT, PT, developmental What is the role of his primary care provider? Checkups? Nutrition? Care coordination? Immunizations? What is the role of his family? Should this have gone at the top of the list?

7. Complex Chronic Conditions �Medically fragile� or �Medical Complexity� Usually described by: Multiple subspecialists Technology dependence for basic health needs Frequent visits to tertiary care centers High prevalence of neurodevelopmental disabilities and genetic disorders

8. Why consider these children separately? Highest risk for adverse outcomes Medical, growth, developmental, social Tend to �fall through the cracks� Most challenging Most satisfying? The role of the Medical Home (on steroids?)

9. Bending the cost curve Medicaid projected growth rate: 8.8% - higher than Medicare or national health spending Bend the curve: slowing the rate of increase A small number of children are responsible for a majority of health care costs Medicaid: 10% of children = 72% of costs 0.4-1% of children = 12-15% of total costs, 20-25% of hospitalized patients, and 45-50% of hospital days

10. The high resource utilizers The vast majority of the high resource utilizers have �complex� and �chronic� conditions Children who �fall through the cracks� Majority of costs are inpatient Need to coordinate care and improve quality Integrated, organized systems Fundamental payment reform

11. Building and maintaining multi-specialty teams for children with complex chronic conditions Consider: The components of care How the components work together The role of the Medical Home How the Medical Home can initiate and lead co-management JS to comment on being a practicing physician and from her perspective, will provide experiences and tidbits on how Children�s Clinic has approached this issueJS to comment on being a practicing physician and from her perspective, will provide experiences and tidbits on how Children�s Clinic has approached this issue

12. Care components

13. The world that Alex�s parents see

14. The Chronic Care Model

15. Chronic Care Model components Care partnership support Delivery system design Decision support Clinical information systems

16. When comprehensive care works 48% decrease in the number of hospital days and a $10.7 million decrease in payments to the tertiary care center Gordon JB Pediatr Adol Med 2007 55% reduction in ED visits Klitzner TS J pediatr 2010 40% reduction in inpatient costs, 27% decrease in hospital stays Casey PH Arch Pediatr Adolesc Med 2011 DK to note that these are comprehensive care programs in tertiary care centersDK to note that these are comprehensive care programs in tertiary care centers

17. Putting it all together: Co-management Multiple health care professionals partner with families to provide a consistent direction of care For children with complex chronic conditions: Integrates all components of care Reinforces the active role of the PCP/Medical Home

18. Partners Specialty care = straightforward Does not address all needs Primary care = first point of access, immunizations, continuity Primary care sometimes not fulfilled when child has multiple visits to specialty services Assumption that needs are being met Community-based services Not always consistent Families! JS:; comment on how Children�s Clinic sees itself in the care system; what it aims to provide for children with complex/chronic conditions; what partners it has identified, and whether it chose informal or FORMAL RELATIONSHIPS (hire?) and whyJS:; comment on how Children�s Clinic sees itself in the care system; what it aims to provide for children with complex/chronic conditions; what partners it has identified, and whether it chose informal or FORMAL RELATIONSHIPS (hire?) and why

19. Primary care �Medical Home� as hub of coordination partnership More comments by JSMore comments by JS

20. Spectrum of co-management PCP as primary manager, specialist as consultant Less complex, few specialty needs Specialist as primary manager, PCP less involved Appropriate for high complexity and if comprehensive service exists at tertiary care center Co-management Medical Home has higher responsibility Medical Home acts as care coordinator Some children with complex chronic conditions have no subspecialty �home� JS: do you agree? Who do you think needs co-management? Where do you see yourself and your group?JS: do you agree? Who do you think needs co-management? Where do you see yourself and your group?

21. Making co-management work Define your roles Primary care physician has higher responsibility Specialty provider provides decision making support Primary care physician can learn to care for higher complexity over time Most PCPs welcome co-management Don�t forget families!

22. Take the initiative Recognize the components of comprehensive care that only PCP can deliver PCP determines the additional level of involvement, due to varying experience PCP can provide improved access, continuity, and care coordination for children and families Higher level of co-management likely improves care outcomes due to improved access Initiate communication with specialty colleagues Determine your roles and be specific for what you need Comfort will increase over time JS: discuss how you initiate your co-management with specialty colleagues, particularly since Jonesboro is away from tertiary care center - also discuss challenges. Do you tell the physician what you are comfortable with? Who initiates the contact (you or nurse or staff?)JS: discuss how you initiate your co-management with specialty colleagues, particularly since Jonesboro is away from tertiary care center - also discuss challenges. Do you tell the physician what you are comfortable with? Who initiates the contact (you or nurse or staff?)

23. Care partnership: Family-Centered Care Essential, yet frequently misunderstood Associated with more efficient use of health care resources for CYSHCN Principles: Partnership approach to care Respect for diversity Information sharing is open and unbiased Care plans may be negotiated JS: option to you to discuss anything here � this is a plug for the important and heightened roles that families play in this population � I am happy to take this slide JS: option to you to discuss anything here � this is a plug for the important and heightened roles that families play in this population � I am happy to take this slide

24. Delivery System Design: Define Roles Medical Home: ALWAYS good primary care First point of contact Anticipatory guidance Immunizations Care hub / care coordination Verify/Initiate Early Intervention Act as �eyes and ears� for specialty teams Remind families that you can be first point of contact

25. Additional roles With good communication with specialty colleagues, may consider: Labs Medication initiation / adjustment Referrals to community services Consider designating office staff (such as nurse) to be single point of contact Additional roles for office staff Help families define their roles Foster children/families likely require extra attention JS: important slide for you here. Your clinic operates at a very high level for such children. How did you develop the skills/expertise? And how did you structure your office? And what would you recommend for others?JS: important slide for you here. Your clinic operates at a very high level for such children. How did you develop the skills/expertise? And how did you structure your office? And what would you recommend for others?

26. Decision making support Clinical care guidelines (e.g. AAP) Be familiar with common issues of condition(s) High prevalence of neurodevelopmental disabilities Recognize that many children have feeding/growth issues, dysphagia, respiratory issues Learn from specialty colleagues Regular communication; they will teach you Eyes and ears / red flags JS: briefly follow up from what you said on previous slideJS: briefly follow up from what you said on previous slide

27. Define communication lines Keep updated and continuous care plan Consider separate forms and someone to maintain Methods of communication Email? Fax? Phone call? What will be communicated? � ask specialists Timing and frequency of communication Health care portals If all else fails, encourage family to contact you and / or schedule regular follow-up visits JS: discuss what you recommend here � what works best for youJS: discuss what you recommend here � what works best for you

28. Clinical Information Systems Track your children with special needs Particularly children with complex chronic conditions Quality of care measures Utilize communication lines, including email, fax, phone Clinical decision making tools JS: what do you recommendJS: what do you recommend

29. Conclusions Comprehensive care can improve health outcomes and reduce utilization Medical Home must take the lead to develop comprehensive care for children with complex and chronic health conditions Co-management increases PCP involvement and can lead to improved outcomes

30. Thank you! Questions?

31. Got Medical Home? Have a specific question or need regarding medical home? Contact us! Medical_home@aap.org800/433-9016 ext 7605