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The Medical Home Leadership Network: Family, Health Care and Community Collaboration for Children with Special Health Care Needs. Kate Orville, MPH Co-Director Washington State Medical Home Leadership Network Center on Human Development & Disability University of Washington

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slide1

The Medical Home Leadership Network: Family, Health Care and Community Collaboration for Children with Special Health Care Needs

Kate Orville, MPH

Co-Director

Washington State

Medical Home Leadership Network

Center on Human Development & Disability

University of Washington

----------------------------------------

January 23, 2004

Community Health Plan of Washington

2004 Clinical Operations Meeting

overview
Overview
  • What is a medical home?
  • The Medical Home Leadership Network
  • Community medical home team activities
  • How to get involved
what is a medical home
What is a Medical Home?

NOT a building

but way of providing health care services that are:

  • Family-centered
  • Coordinated
  • Comprehensive
  • Continuous
  • Accessible
  • Compassionate & Culturally Sensitive
in a medical home
In a Medical Home…
  • Children and their families receive the care that they need from a physician or other primary health care provider whom they know and trust.
  • The pediatric health care professionals and parents act as partners to identify and access all the medical and non- medical services needed to help children and their families achieve their maximum potential.
medical home basics
Medical Home Basics
  • Primary care and acute care
  • Links/collaboration/referral with specialty care
  • Maintenance of comprehensive central record of info about child
  • Links to community programs
  • Care coordination
  • Assistance with transition
the family perspective
The Family Perspective
  • “A 24/7 relationship with my physician and/or office staff who know my child and know her needs– who I can call any hour of the day, who are responsible, who listen and who care, who help me to feel competent about my knowledge and expertise when it comes to her care, who always ask “What can I do for you today?”.
  • -- Mom of child with special needs
slide7
While all children can benefit from a medical home, it is particularly important for children with special health care needs and their families
children with special health care needs
Children with Special Health Care Needs

“Children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”

Adopted by the AAP (October 1998). McPherson M, Arango P,

Fox HB, A new definition of children with special health care

needs. Pediatrics 1998; 102:137-140

it takes a village to build a medical home
It Takes a Village to Build a Medical Home
  • Families and primary health care providers don’t have to do everything themselves
  • Office staff, community partners, specialists, and health care administrators are available to help…
medical home and the chronic care model
Medical Home and the Chronic Care Model
  • Active, empowered patient/family
  • Proactive practice team
  • Supportive health care organization (information systems to ID patients, provide clinical support, reminders, incentives etc.)
  • Links to and collaboration with community services and supports (family-to family support, public health etc)
how do we achieve a medical home for every child by 2010
How Do We Achieve a Medical Home for Every Child by 2010?
  • MCHB/AAP: Need for state-based, systematic approach
  • National Medical Home Mentorship Network
  • Washington State Medical Home Plan -Title V, WCAAP, Families,MHLN
wa state medical home goals
WA State Medical Home Goals
  • Families, providers, insurers, policymakers and others will understand and endorse the medical home concept
  • Health care providers will have the skills and knowledge to provide medical homes
  • Families will have the skills and knowledge to provide medical homes
medical home leadership network
Medical Home Leadership Network
  • Statewide network of families and professionals who promote the availability and accessibility of medical homes for children and youth with special needs in their communities
  • Supported by DOH MCHB CSHCN Program and US MCHB since 1994
  • Large, active advisory board
  • Housed at UW Center on Human Development & Disability- Dr. Forrest C. Bennett, MHLN Director
slide14

MHLN Teams

Volunteer

Interdisciplinary- PHN, FRC, MD, Family+

Community-based

Strengthen and leverage existing networks and activities

slide15

Washington State

Medical Home Leadership Network Teams

PEND

OREILLE

WHATCOM

FERRY

OKANOGAN

SAN JUAN

SKAGIT

STEVENS

SNOHOMISH

CLALLAM

CHELAN

ISLAND

DOUGLAS

SPOKANE

JEFFERSON

LINCOLN

KITSAP

KING

MASON

GRAYS

HARBOR

GRANT

ADAMS

KITTITAS

PIERCE

WHITMAN

THURSTON

FRANKLIN

GARFIELD

PACIFIC

YAKIMA

LEWIS

COLUMBIA

WAHKIAKUM

BENTON

COWLITZ

WALLA

WALLA

ASOTIN

SKAMANIA

KLICKITAT

Regional Resource Teams

(by MD team member)

CHPW Member Center

CHPW Affiliate Center

Non-CHPW affiliate

CLARK

Regions

Northwest

Central

East

King & Pierce

Southwest

mhln team members
MHLN Team Members :
  • Promote the medical home concept and strategies to support medical homes
  • Are well-informed, experienced resources for community colleagues
  • Collaborate with other interested groups and provide technical assistance and consultation as time permits
mhln teams with support of project staff
MHLN Teams, with Support of Project Staff:
  • Recruit team members
  • Identify one or more barriers to medical homes to address
  • Develop plan
  • Identify needed technical assistance
  • Implement plan
  • Monitor activities
  • Report at annual conference
yakima team activities
Yakima Team Activities
  • MHLN team active in development of Children’s Village – CV set up on medical home principles
  • Presentations to local PCPs
  • Family focus group on medical homes
  • Co-developed medical home brochure in English and Spanish
  • Local autism diagnostic team
  • Early hearing and screening outreach
kitsap county team activities
Kitsap County Team Activities
  • Development of local resource packets for services for CSHCN
  • Presentations to community primary care providers on community resources
adams county team activities
Adams County Team Activities
  • “Child Health Notes”
  • Chart review of client charts at quarterly MH team meetings
  • Presentations for parents and for physicians on medical homes
  • Physician collaborating with CHPW on piloting new CSHCN program
  • Presentation at AAP/Shriners “Every Child Deserves a Medical Home”
add l team activities
Add’l Team Activities
  • Pilot parent advisory group in MD’s practice (Skagit)
  • Down syndrome & EI presentation (Stevens)
  • Newborn Hearing Screening Follow Up (Walla Walla, Yakima, Kitsap)
  • Increase EI referrals for children with speech/language or autism concerns (Snohomish)
  • Develop rotating list of pediatricians to accept CSHCN with no PCP (Clark)
  • ID #s CSHCN by diagnosis in the county (Cowlitz)
team collaboration benefits 1999 evaluation
Team Collaboration Benefits (1999 evaluation)
  • Greater awareness of and use of community resources
    • “It’s increased my access and it’s increased my referral a lot, probably close to 100%” (MD)
    • “I feel more organized and competent that I know where to direct people” (MD)
benefits cont
Greater access to MD community (PHNs, FRCs)

Increased referrals (PHNs, FRCs)

Enhanced credibility (all)

Access to information & grant opportunities (all)

Expanded sense of community and momentum (all)

Benefits cont.
doh cshcn program support for collaboration between medical home contractors examples
DOH CSHCN Program Support for Collaboration between Medical Home Contractors - Examples
  • Medical Home Toolkit & County Resource Lists (CCSN)
  • Collaboration between family and professional organizations
  • Adolescent Health Transition Notebook
  • CHDD/CTU, Children’s Hospital, and Mary Bridge
    • increase own “medical homeness”
    • then share lessons learned with other tertiary care centers
upcoming activities
Upcoming Activities
  • Continue to identify and promote simple key activities and strategies to providers and families:
    • Care notebooks/organizers for families
    • Parent Advisory Groups
    • Care plans/written instructions for families

How to make medical homes work for families from diverse backgrounds?

more activities
More activities
  • Medical Home Website- links to:
    • community resources,
    • diagnosis specific care guidelines
    • patient handouts,
    • tips on setting up a family-friendly practice etc…
  • Collaborate with health care plans to pilot ideas – teams very interested
  • Develop new grants
  • Annual Medical Home conference
interested in getting involved
Interested in Getting Involved?
  • Contact your nearest local MHLN team www.medicalhome.org, under “community teams”
  • Talk to Dawn Davis, CHPW 206-613-8917
  • Kate Orville, WA Medical Home Leadership Network, University of Washington orville@u.washington.edu,206-685-1279
  • WA CSHCN Program reps Leslie Carroll and Stacey DeFries
  • See national medical home website: www.medicalhomeinfo.org