Disclosure

2. Disclosure None of the speakers, planners, nor anyone in control of content for today’s Medical Home Demonstration Project Learning Session has any relevant financial relationships to disclose.

3. Medical Home Demonstration How do you define “medical home”? If we’re going to demonstrate it, we’d better know what it means!

4. Medical Home, the model The American Academy of Pediatrics (AAP) defined it as care that is Accessible Continuous Comprehensive Family-centered Coordinated Compassionate Culturally effective

5. Medical Home, the model In 2007, the AAP and 3 other primary care professional organizations signed the Joint Principles of the Patient-Centered Medical Home, focused on Personal physician Physician-directed medical practice Whole person orientation Care that is coordinated and/or integrated Quality and safety Enhanced access Payment

6. Medical Home, the model The Center for Medical Home Improvement defines it through their Medical Home Index, measuring 4 levels of performance in 25 themes over 6 domains, including Organizational Capacity Chronic Condition Management Care Coordination Community Outreach Data Management Quality Improvement/Change

7. Medical Home, the model The National Committee on Quality Assurance (NCQA) recognizes Medical Homes based on capacity and efforts to Enhance Access & Continuity Identify & Manage Patient Populations Plan & Manage Care Provide Self-Care Support & Utilize Community Resources Track & Coordinate Care Measure & Improve Performance

8. Medical Home, our initial foci Quality improvement (QI) • Develop and integrate practice systems to support and sustain ongoing QI • Build ‘medical home teams’ • supported by UPIQ Practice Coach • facilitated by Medical Home Coordinators (MHCs) • advised and assisted by Family Partners • all guided and supported by UPIQ/CHIC leadership

9. Medical Home, our initial foci Continuity of care • Improve continuity through team approaches, electronic communication/records access • Develop and share chronic care plans across specialties, disciplines, and settings

10. Medical Home, our initial foci Care coordination • Actively coordinate care across specialties, disciplines, and settings • MHCs will lead and mentor staff in developing care coordination skills and systems

11. Medical Home, our initial foci Collaborative care • Primary and subspecialty care collaboration for patients with chronic/complex conditions • Eliminate duplicative/unnecessary care; assure timely access to appropriate care

12. Medical Home, our initial foci Patient-/Family-centered care • Integrate parent/family/consumer perspectives into practice planning and QI activities • Enhance partnerships with families, esp. those with children with chronic conditions • Family Partners will advise the practice and help families connect with services and supports

13. Medical Home, our initial foci Evidence-based practice • Consistent use of validated screening tools • Implement guidelines for care of chronic conditions, genetic conditions, etc. • Use measures/data to guide QI efforts (using existing electronic tools when possible)

14. Medical Home, our initial foci Population-based approach • Use registries of patients with chronic conditions to support proactive care and follow-up • Track all patients for completion of planned/needed preventive and screening services • Empower parents/patients through education and access to accurate/useful information

15. Medical Home, our initial foci Access to care • Improved/accommodative scheduling (open access, extended hours, etc.) • Enhanced phone access, electronic visits (e-visits); reduce ‘unnecessary’ visits • Planned chronic care visits, extended visits for patients when they need them

16. Medical Home, our initial foci Innovation • Support practices in generating ideas and in implementing and measuring them using QI/PDSA (plan-do-study-act) approaches • Report and disseminate successes and lessons • Still working on funding from the Utah Health System Reform Task Force’s multi-payer demonstration group