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The Medical Home in Pediatric Practice. Medical Home Conference Washington State May 30, 2007. EMRs and Care Plans. A High-Performing System for Well-Child Care: A Vision for the Future*. ‘…an ideal system would be characterized by : Advanced access to services Team-based care

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the medical home in pediatric practice

The Medical Home in Pediatric Practice

Medical Home Conference

Washington State

May 30, 2007

EMRs and Care Plans

a high performing system for well child care a vision for the future
A High-Performing System for Well-Child Care: A Vision for the Future*

‘…an ideal system would be characterized by:

  • Advanced access to services
  • Team-based care
  • Individualized developmental and behavioral screening
  • Cultural beliefs and practices accommodated
  • Care coordination through a medical home
  • Knowledge transfer and electronic health records
  • Health care financing

*Bergman D, Plsek P, Saunders M. CMWF Report, October 2006.

slide3

In a nutshell, what is your vision of an ideal system of well-child care?

David Bergman, M.D.

  • First, we have to have some sense of biopsychosocial risk. A lot of this can be determined at birth: Is the child born premature? Does the baby have a congenital defect? Is the family situation chaotic? These are all risk factors. We then have toassign the content of care according to the level of risk. High-risk kids need more visits with a different mix of health care professionals.
  • In terms of financing, we need to align incentives to more appropriately reimburse for kids with special health care needs. This can be done through tiered capitation—defining kids at a level of biopsychosocial risk and assigning a capitated rate.
  • Leveraging new technologies is also key.
a high performing system for well child care a vision for the future1
A High-Performing System for Well-Child Care: A Vision for the Future*
  • Advanced access to services - Secure messaging
  • Team-based care - Develop comprehensive plan, including education and socialization
  • Care coordination through a medical home
  • Knowledge transfer and electronichealth records
  • Health care financing - Reimbursement for non-physician members of health care teams (Care coordinators)
  • Individualized developmental and behavioral screening (Vanderbilt in EMR – MBCH, On-line form completion, e.g. ASQ)
  • Cultural beliefs and practices accommodated (Parent information sheets, screening tools)
slide5
EMRs
  • Scope:
    • Practice-based
      • Othello: Columbia Basin Health Association [CHARTLOGIC*],
      • Spokane: Olson Pediatrics
    • Hospital-based/System-based
      • Mary Bridge - EPIC (with SmartSet subprogram – ADHD Module)
      • Group Health Cooperative
    • Community-wide
      • Kittitas
      • Whatcom
  • Patient accessibility
    • PHRs - test results, visit summaries, input health information
    • Email communication
    • Information resources
    • Other
emrs discussion points
EMRs – Discussion Points
  • Pediatric-specific record issues/CSHCN-specific record issues (Needs/hopes/problems)
    • Provider viewpoint
      • Individual patient
      • Diagnosis specific management
    • Family/Child viewpoint (?cultural, PHRs, email interface, adult child with DD,etc.)
    • Health plan issues
      • ID CSHCN
      • Data pulls for
        • Patient care issues (often by diagnostic group)
        • Contract/reimbursement documentation
olson pediatrics
Olson Pediatrics
  • Spokane Medical Community
  • One Pediatrician
  • Three Mid-level providers
  • Office Staff of 10 FTE’s
  • Approx. 9,000 patients
  • 1212 CYSHCN
data collection
Data Collection
  • Data person
  • FACCT survey criteria – CSHCN Screener (5 item, parent-survey based tool)
  • Excel spreadsheet/Access
  • Disease-specific data collection
  • Insurance plans
care plans
Care Plans
  • Who creates them? What do they look like?
    • Health plan
    • PCP
    • Family
  • What else is needed?
  • Sample forms
  • Leveraging personnel and time
  • (Coding and Reimbursement)
care plans1
Care Plans

Examples:

    • Jack Stephens
    • Jean Popalisky
      • Health plan
      • Primary care office
    • CCSN website – Family
    • Notebook - other examples
  • Resources:
    • WA medical home site
    • National medical home site
    • HRTW site