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Newport County CATCH/ Medical Home Initiative

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  • 1. Newport CountyNewport County Community Access to Child HealthCommunity Access to Child Health (CATCH)(CATCH) Creating Medical Homes forCreating Medical Homes for all Children in Newportall Children in Newport County, RICounty, RI Newport, Middletown, Portsmouth, Tiverton,Newport, Middletown, Portsmouth, Tiverton, Little Compton, JamestownLittle Compton, Jamestown
  • 2. 2 Beginning IdeasBeginning Ideas  Newport County CATCH grew out ofNewport County CATCH grew out of the commitment to child well-being* ofthe commitment to child well-being* of thethe Newport Partnership forNewport Partnership for Families (NPFF)Families (NPFF), an existing, an existing community collaboration representingcommunity collaboration representing over 35 human service agencies,over 35 human service agencies, businesses and other organizations inbusinesses and other organizations in NewportNewport * Child well-being is one of four priority* Child well-being is one of four priority areas measured by the NPPFareas measured by the NPPF
  • 3. 3 Initial StepsInitial Steps  Step 1Step 1: Received a planning grant based: Received a planning grant based on the NPFF’s identification of accesson the NPFF’s identification of access barriers to healthcare for young children.barriers to healthcare for young children.  Step 2Step 2: Conducted outreach to the: Conducted outreach to the community to assess the quality of Medicalcommunity to assess the quality of Medical Homes and training needs required to careHomes and training needs required to care for Children with Special Health Care Needsfor Children with Special Health Care Needs (CSHCN)(CSHCN)
  • 4. 4 Newport County CATCHNewport County CATCH Purpose:Purpose:  The primary purpose of the NewportThe primary purpose of the Newport County CATCH/Medical Home InitiativeCounty CATCH/Medical Home Initiative is to facilitate the creation of medicalis to facilitate the creation of medical homes for all children in Newporthomes for all children in Newport County. Medical homes will posses theCounty. Medical homes will posses the seven common elements as defined byseven common elements as defined by the American Academy of Pediatricsthe American Academy of Pediatrics (AAP)(AAP)
  • 5. 5 Newport County CATCHNewport County CATCH Goals:Goals: 1.1. Develop and implement a careDevelop and implement a care coordination systemcoordination system to support theto support the medical homemedical home 2.2. Identify andIdentify and reduce barriersreduce barriers to medicalto medical homes.homes. 3.3. ProvideProvide medical homemedical home trainingtraining toto parents, medical and human serviceparents, medical and human service providersproviders 4.4. EvaluateEvaluate the impact of our interventionsthe impact of our interventions 5.5. Implement systems toImplement systems to sustainsustain and ensureand ensure quality medical homes for all children.quality medical homes for all children.
  • 6. 6 Newport County CATCHNewport County CATCH FundingFunding  Current funding for Newport CountyCurrent funding for Newport County CATCH is provided by:CATCH is provided by: – Newport HospitalNewport Hospital – RI DOH, Division of Family HealthRI DOH, Division of Family Health
  • 7. 7 Newport CATCHNewport CATCH Organizational StructureOrganizational Structure CATCH Steering Committee James Sattel Newport CATCH Coordinator Medical Home Training Work Group Care Coordination Work Group Barriers to Medical Homes Work Group
  • 8. 8 Function DescriptionFunction Description GroupGroup FunctionFunction SteeringSteering CommitteeCommittee Provides oversight and feedbackProvides oversight and feedback to the work group action plans.to the work group action plans. WorkWork GroupsGroups Form work group objectives andForm work group objectives and strategies and provide medicalstrategies and provide medical home training.home training. ProjectProject CoordinatorCoordinator Supports the advisory committeeSupports the advisory committee and work groups; producesand work groups; produces reports; and is a single point ofreports; and is a single point of contact for providers and familiescontact for providers and families
  • 9. 9 Newport County CATCHNewport County CATCH Medical Home AdvisoryMedical Home Advisory CommitteeCommittee  CEDDARsCEDDARs  Covering Kids and FamiliesCovering Kids and Families  Early InterventionEarly Intervention  East Bay Community Action Program (EBCAP)East Bay Community Action Program (EBCAP)  Family Practice PhysiciansFamily Practice Physicians  Head StartHead Start  Health PlansHealth Plans  Newport & Middletown Public Schools FamilyNewport & Middletown Public Schools Family Center/COZCenter/COZ  Newport Partnership for FamiliesNewport Partnership for Families  Newport County Health AdvocatesNewport County Health Advocates
  • 10. 10 Newport County CATCHNewport County CATCH Medical Home AdvisoryMedical Home Advisory CommitteeCommittee  Newport County Community Mental Health Center’sNewport County Community Mental Health Center’s Child Intensive Services (CIS) and Child and AdolescentChild Intensive Services (CIS) and Child and Adolescent Services Program (CASP)Services Program (CASP)  Newport HospitalNewport Hospital  ParentsParents  Pediatric Practice Enhancement Project (PPEP) ParentPediatric Practice Enhancement Project (PPEP) Parent Consultant (PC)Consultant (PC)  PediatriciansPediatricians  Rhode Island Department of HealthRhode Island Department of Health  Rhode Island Health Center AssociationRhode Island Health Center Association  Special Education DepartmentsSpecial Education Departments  Visiting Nurse Service of Newport and Bristol CountiesVisiting Nurse Service of Newport and Bristol Counties
  • 11. 11 Traditional Pediatric Delivery SystemTraditional Pediatric Delivery System Fragmented, Hard to Navigate, Episodic,Fragmented, Hard to Navigate, Episodic, ExpensiveExpensive Recreation Child Outreach Special Education Schools Sub-specialists Emergency Care Early Intervention Family Pediatrician/ Family Practitioner Community Support Groups/Resources Mental Health Health Plans Transportation Family Services Home Care Rehab Services
  • 12. 12 NHPRI Head Start/Child Care Special Education Schools Sub-specialists Mental Health Services Early Intervention EBCAP RIPIN/Family Voices CEDDAR Newport Hospital FRCs/FSCs Child Outreach Home Care Rehab Services Medical Home -Physician -Family (PPEP) Parent Consultant Aquidneck Medical Associates Comprehensive/CoordinatedComprehensive/Coordinated Family - Centered Medical HomeFamily - Centered Medical Home
  • 13. 13 Physician PracticePhysician Practice Training TeamTraining Team  Objectives:Objectives: To develop and offerTo develop and offer current, meaningful, and community-current, meaningful, and community- focused medical home trainings forfocused medical home trainings for pediatricians and family practitionerspediatricians and family practitioners and their staffand their staff  To establish a single point of contact asTo establish a single point of contact as a resource for quality improvementa resource for quality improvement (CATCH Coordinator)(CATCH Coordinator)
  • 14. 14 Physician PracticePhysician Practice Training TeamTraining Team  Action StepAction Step: Developed a curriculum which: Developed a curriculum which includesincludes – The history of Newport County CATCHThe history of Newport County CATCH – Community assessment methodology andCommunity assessment methodology and findingsfindings – Common elements of a medical homeCommon elements of a medical home – Cost benefits of operating a medical home,Cost benefits of operating a medical home, particularly for utilizing care coordinationparticularly for utilizing care coordination servicesservices – Codes for extended careCodes for extended care – Medical Home indicators (for self-evaluation)Medical Home indicators (for self-evaluation) – Strategies for medical home improvementStrategies for medical home improvement
  • 15. 15 Community AgenciesCommunity Agencies Training TeamTraining Team  Objective 1Objective 1: Share care coordination: Share care coordination information with the communityinformation with the community through medical home trainings, singlethrough medical home trainings, single point of contact and through thepoint of contact and through the development of a medical homedevelopment of a medical home
  • 16. 16 Community AgenciesCommunity Agencies Training TeamTraining Team  Action StepAction Step: Provided medical home: Provided medical home training to approximately forty five healthtraining to approximately forty five health care coordinators* at agencies throughoutcare coordinators* at agencies throughout Newport County.Newport County. * Agency care coordinators include family* Agency care coordinators include family service coordinators, mental health workers,service coordinators, mental health workers, nurse/educators, health advocates, casenurse/educators, health advocates, case managers, social workers, physicians andmanagers, social workers, physicians and practice staffpractice staff (any provider that links(any provider that links families to community services)families to community services)
  • 17. 17 Community AgenciesCommunity Agencies Training TeamTraining Team  Objective 2Objective 2 : Identify and document all: Identify and document all sources of care coordination supportsources of care coordination support Such as PPEP, CEDARR , East Bay CommunitySuch as PPEP, CEDARR , East Bay Community Action Program, Child and Family Services, NewportAction Program, Child and Family Services, Newport County Mental Health Center, NHPRI CaseCounty Mental Health Center, NHPRI Case Management, Housing Authority, Family ServiceManagement, Housing Authority, Family Service Coordinators, COZ Centers, Visiting Nurse Service ofCoordinators, COZ Centers, Visiting Nurse Service of Newport and Bristol Counties, Head Start, EarlyNewport and Bristol Counties, Head Start, Early Intervention, Newport and Regional SpecialIntervention, Newport and Regional Special Education, Dr. Martin Luther King Jr. Center, CODACEducation, Dr. Martin Luther King Jr. Center, CODAC
  • 18. 18 Community AgenciesCommunity Agencies Training TeamTraining Team  Action StepAction Step: Developed a comprehensive: Developed a comprehensive list of agencies that provide carelist of agencies that provide care coordination by disseminating a carecoordination by disseminating a care coordination services surveycoordination services survey .. – Based on returned surveys, developed aBased on returned surveys, developed a Pediatric Care Coordination DirectoryPediatric Care Coordination Directory that defines the scope of carethat defines the scope of care coordination provided by each agencycoordination provided by each agency (40 Agencies Represented)(40 Agencies Represented) – Distributed over 120 Directories toDistributed over 120 Directories to agencies and physician practices as partagencies and physician practices as part of Medical Home Trainingsof Medical Home Trainings
  • 19. 19 Community AgenciesCommunity Agencies Training TeamTraining Team  Objective 3Objective 3: Assist in orienting PC’s: Assist in orienting PC’s to community care coordinationto community care coordination services and through the PPEPservices and through the PPEP provides Newport County CATCH withprovides Newport County CATCH with feedback about gaps or delays infeedback about gaps or delays in service deliveryservice delivery
  • 20. 20 Family Training TeamFamily Training Team  Action Step 1Action Step 1 : Developed a family: Developed a family questionnaire to capture current andquestionnaire to capture current and specific problems regarding barriers tospecific problems regarding barriers to medical homes and to define themedical homes and to define the educational needs of the families.educational needs of the families.
  • 21. 21 Family Training TeamFamily Training Team  Action Step 2Action Step 2: Provided medical home: Provided medical home education for families through focus groups.education for families through focus groups. – Educated over 400 parents on medical homeEducated over 400 parents on medical home concepts during focus groups.concepts during focus groups. – The 400 parents represented parents served byThe 400 parents represented parents served by support groups, Head Start, Even Start, thesupport groups, Head Start, Even Start, the Newport Hospital Birthing Center, mental healthNewport Hospital Birthing Center, mental health parent groups, and the Newport County Regionalparent groups, and the Newport County Regional Special Education Advisory Committee, etc.Special Education Advisory Committee, etc. – Families are instructed on how to advocate forFamilies are instructed on how to advocate for their child and how to make maximum benefit oftheir child and how to make maximum benefit of the visit to the medical homethe visit to the medical home
  • 22. 22 Barriers WorkgroupBarriers Workgroup  Objective:Objective: Identify andIdentify and addressaddress barriers to usebarriers to use of medicalof medical homes,homes, including:including: 1.1. TransportationTransportation 2.2. LanguageLanguage 3.3. Health InsuranceHealth Insurance Jim's Email.lnk
  • 23. 23 Barriers WorkgroupBarriers Workgroup  Survey findings onSurvey findings on transportationtransportation:: – No bus service on Memorial Blvd. whichNo bus service on Memorial Blvd. which is the location of the largest pediatricis the location of the largest pediatric practice in Newport Countypractice in Newport County – Confusion over RIte Care transportationConfusion over RIte Care transportation benefits.benefits. – Bus routes are unclear.Bus routes are unclear.
  • 24. 24 Barriers WorkgroupBarriers Workgroup  Transportation Actions TakenTransportation Actions Taken :: – Partnered with RIPTA to create a medicalPartnered with RIPTA to create a medical home bus route map to be distributed athome bus route map to be distributed at the birthing center, physicians offices,the birthing center, physicians offices, and to parents in medical trainings.and to parents in medical trainings. – DHS provided CATCH with anDHS provided CATCH with an explanation of transportation benefitsexplanation of transportation benefits which will be distributed to parents andwhich will be distributed to parents and providers.providers.
  • 25. 25 Barriers WorkgroupBarriers Workgroup  Survey findings on language &Survey findings on language & cultureculture:: – Parents don’t understand medical jargon.Parents don’t understand medical jargon. – Lack of written bilingual information.Lack of written bilingual information. – Parents find it difficult to tell the doctorParents find it difficult to tell the doctor they don’t understand their instructions.they don’t understand their instructions. – Cultural sensitivity is lost if a differentCultural sensitivity is lost if a different doctor is seen at each visit.doctor is seen at each visit.
  • 26. 26 Barriers WorkgroupBarriers Workgroup  Language recommendations made:Language recommendations made: – Raise awareness of RIte Care interpretation/Raise awareness of RIte Care interpretation/ translation benefits.translation benefits. – Create flyers in multiple languages describingCreate flyers in multiple languages describing the above benefit to distribute to parents atthe above benefit to distribute to parents at medical home trainings.medical home trainings. – Encourage physicians to assess their practice’sEncourage physicians to assess their practice’s need for interpreters.need for interpreters. – Ask physicians what bi-lingual information wouldAsk physicians what bi-lingual information would be useful for the practice and help them get it.be useful for the practice and help them get it.
  • 27. 27 Barriers Work GroupBarriers Work Group Health InsuranceHealth Insurance  Identify locations where families presentIdentify locations where families present without insurance i.e. Newport Departmentwithout insurance i.e. Newport Department of Labor and Training, Housing Authorityof Labor and Training, Housing Authority Intake Offices, Urgent Care Facilities, E.R.Intake Offices, Urgent Care Facilities, E.R. etc.etc.  Collaborate with Covering Kids to provideCollaborate with Covering Kids to provide community education concerning RItecommunity education concerning RIte Care/RIte Share benefits, eligibilityCare/RIte Share benefits, eligibility guidelines and enrollment proceduresguidelines and enrollment procedures
  • 28. 28 Newport County CATCHNewport County CATCH  Overall Lessons LearnedOverall Lessons Learned :: 1.1. Simplify medical home jargon. Make it RelevantSimplify medical home jargon. Make it Relevant 2.2. One-on-one visits with organizations work best.One-on-one visits with organizations work best. Use visits to learn of services that are or are notUse visits to learn of services that are or are not available in the communityavailable in the community 3.3. Plug into existing community organizationPlug into existing community organization networks, develop collaborationsnetworks, develop collaborations 4.4. Help stakeholders understand how they benefitHelp stakeholders understand how they benefit from medical homes.from medical homes. 5.5. Tailor medical home trainings to your audience ieTailor medical home trainings to your audience ie families, human service agencies, PCP’sfamilies, human service agencies, PCP’s 6.6. Family input is critical in the developmentFamily input is critical in the development of curriculums and training strategiesof curriculums and training strategies
  • 29. 29 Future InitiativesFuture Initiatives  Collaborate with the PPEP to define accessCollaborate with the PPEP to define access barriers and capacity issues & continuebarriers and capacity issues & continue collaborative problem solving with providers andcollaborative problem solving with providers and familiesfamilies  Collaborate with the RI Lung Association,Collaborate with the RI Lung Association, Hasbro Children's Hospital and Newport HospitalHasbro Children's Hospital and Newport Hospital to implement community needs assessment andto implement community needs assessment and training for asthmatraining for asthma  Develop Neighborhood Training Teams inDevelop Neighborhood Training Teams in collaboration with the Newport Housing Authoritycollaboration with the Newport Housing Authority
  • 30. 30 Future InitiativesFuture Initiatives  Provide medical home training to school educators,Provide medical home training to school educators, FSC(s) and health advocates as part of the TrainFSC(s) and health advocates as part of the Train the Trainer Initiativethe Trainer Initiative  Collaborate with mental health and specialCollaborate with mental health and special education services to integrate care into theeducation services to integrate care into the medical Homemedical Home  Develop a Newport County Medical Home web-siteDevelop a Newport County Medical Home web-site for families and providersfor families and providers  Maintain and build upon established medical homeMaintain and build upon established medical home services and productsservices and products  Obtain funding to sustain Newport CountyObtain funding to sustain Newport County CATCH/Medical Home InitiativeCATCH/Medical Home Initiative
  • 31. 31 Newport County CATCHNewport County CATCH For more information contact:For more information contact: James SattelJames Sattel Newport County CATCH /Medical HomeNewport County CATCH /Medical Home Initiative CoordinatorInitiative Coordinator 435 Broadway435 Broadway Newport, RI. 02840Newport, RI. 02840 (401) 847‑2100; ext 223(401) 847‑2100; ext 223 jsattel@ebcap.orgjsattel@ebcap.org
  • 32. 32 Newport County CATCHNewport County CATCH  Question and Answer TimeQuestion and Answer Time

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