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The Medical Home on Steroids: Caring for Children with Medical Complexity. Dennis Z. Kuo , MD, MHS Assistant Professor of Pediatrics, UAMS Denny Society 2011 Triennial Meeting September 23, 2011. Disclosures.

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the medical home on steroids caring for children with medical complexity

The Medical Home on Steroids:Caring for Children with Medical Complexity

Dennis Z. Kuo, MD, MHS

Assistant Professor of Pediatrics, UAMS

Denny Society 2011 Triennial Meeting

September 23, 2011

  • Dennis Z. Kuo, MD, MHS has no financial relationships or commercial interests to disclose
  • No off-label use of medications or therapeutic devices will be discussed
alex name is changed
Alex (name is changed)
  • Alex is a 3 month old child you have seen since birth. In the nursery, you noticed dysmorphicfacies, low tone, undescended testes, and a heart murmur. He developed heart failure shortly after and required surgery to repair a large VSD.
  • Today, you suspect craniosynostosis on exam. He is developmentally delayed and small for age.
  • What specialists does he need?
  • Therapists?
  • What is the role of the PCP?
  • Define medical complexity
  • Define the ideal model of care
  • Discuss the role of the medical home (with or without steroids) for the child with medical complexity
history of the medical home
History of the Medical Home
  • 1967: AAP – central source of records
  • 1978-9: efforts in NC and HI to meet health needs through community-based primary care
  • 1992: first AAP policy statement (update 2002)
  • 1994: Medical Home Training Program – MCHB
  • 1999: National Center
  • 2006: PCMH Joint Statement
  • 2009: ACA – multiple provisions (Health Homes, CMMI, etc)
  • Medical Home is rooted in community-based primary care, particularly for children with special health care needs

Sia (2004)

medical complexity
Medical Complexity
  • Medically fragile, medically complex, etc
  • 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

Srivastava 2005; Cohen 2011, Pediatrics

why consider these children separately
Why consider these children separately?

Kuo et al (2011) Arch PediatrAdol Med, in press

bending the cost curve
Bending the cost curve
  • Medicaid projected growth rate: 8.8%
  • 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
    • Most are children with medical complexity
  • Willie Sutton

Shortell (2009), JAMA; Kenney (2009), Health Affairs; Neff (2004);

Berry (2011) unpublished, by permission

chronic care model addressing needs of children with medical complexity
Chronic Care Model: Addressing needs of children with medical complexity

Antonelli R (2005). Adapted from Bodenheimer (2002)

the medical home clinic
The Medical Home Clinic
  • Comprehensive care assisting PCPs
    • Team-based care: physician, nurse, social work, nutrition, psychology, speech
    • Medical needs: nutrition, dysphagia, respiratory
    • Care coordination and oversight with specialty colleagues at ACH
  • Infants and children with at least 2 complex medical conditions that require care by at least two subspecialty clinics
overall costs adjusted vs predicted and 95 confidence intervals
Overall Costs: Adjusted vs Predicted and 95% Confidence Intervals
  • Pre-Post Analysis
  • Pre Medical Home average costs per child
  • per month = $4,678
  • Post Medical Home average costs per child
  • per month = $3,427
  • Pre – Post = -1,251, p < 0.001

Casey et al (2011) Arch PediatAdol Med

  • Financially difficult to sustain
    • Gordon: deficit of $400K in 2005
  • Services located at tertiary care centers
  • Capacity
    • MHCL enrollment: 450
    • ~3700 children with medical complexity in Arkansas
co management the medical home on steroids
Co-management:The medical home on steroids
  • Multiple health care professionals partner with families to provide a consistent direction of care
    • Integrates all components of care
    • Reinforces the active role of the PCP/Medical Home
  • Can we bring comprehensive care services to the community setting?


physician practices
Physician practices

Kuo et al. ClinPediatr (2011)

implementing co management
Implementing co-management
  • Is the Medical Home communicating with other service providers?
  • Are the roles of all providers clear?
  • Are there clear protocols of care?
  • Is there patient and family engagement?
  • Are there strong community linkages?

Taylor (2011), AHRQ

  • 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
additional roles
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

Kuo (2007) Pediatrics

clear protocols of care
Clear protocols of care
  • Common medical issues
    • Swallowing/feeding/growth; maximize pulmonary function; promote development/function
  • Engage specialty providers
    • Networking most important
    • “good neighbor” referrals
  • Define your communication lines
patient and family engagement
Patient and family engagement
  • “The ultimate measure of effectiveness of health care is how patients and families experience it” (Antonelli, 2009)
  • Educate families on roles
  • Family-centered care assessment tools
  • Families as partners on committees, QI teams, learning collaboratives
community linkages
Community linkages
  • Know your resources
    • Get involved with statewide initiatives, AAP, etc
    • Develop relationships with local family-to-family health information center, other groups
  • Other folks to engage: care managers, social work, tertiary care centers
ongoing projects
Ongoing projects
  • Learning collaboratives
    • Supported by HRSA D70 System of Care grant
  • Co-management protocols for complex neonates
    • Evaluate health care outcomes
  • Quality improvement
    • Implement practice changes
    • Carrot: get MOC Part 4 approval…hopefully
  • Children with medical complexity: high resource utilizers, multiple specialty needs, technology dependence
  • Comprehensive care and care coordination can reduce hospitalizations and overall costs
  • The Medical Home on steroids
    • Defined roles with colleagues
    • Care protocols
    • Patient and family engagement
    • Community linkages
  • Research continues
  • Health care reform???