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Medical Homes Presentation Medical Homes Presentation Presentation Transcript

  • Medical Home: Just What the Doctor Ordered to Fix American Healthcare? GIH Teleconference Richard C. Antonelli, MD, MS Associate Professor of Pediatrics Univ of Connecticut School of Medicine Senior Fellow Child Health and Development Institute September 29, 2008
  • Learning Objectives
    • Articulate the key components of pediatric Medical Home 
    • Understand primary care-based pediatric care coordination and how it is different than adult CC
    • Articulate a process to measure care coordination in the pediatric primary care setting 
    • Describe the different challenges and opportunities to provide care coordination to children and youth with special health care needs
  • “ Care coordination is the answer!”…
  • …“ What’s the question?” Carolyn Clancy, MD, Director, AHRQ
  • Definition of Medical Home
    • Care that is:
      • Accessible
      • Family-centered
      • Comprehensive
      • Continuous
      • Coordinated
      • Compassionate
      • Culturally-effective
  • Definition of Medical Home
    • And for which the primary care provider shares responsibility with the family.
    • AAP/ AAFP/ NAPNAP/
    • ACP/ AOA
  • Patient-Centered Medical Home Joint Principles Statement
    • Major Focus of Advocacy for All Primary Care Specialties
    • Relationship between PCP and patient (adult MH) versus family (pediatric MH)
    • Quality
    • Access
    • Equity
    • Financing
  • Care Model for Child Health in a Medical Home Informed, Activated Patient/Family Prepared, Proactive Practice Team Supportive, Integrated Community Prepared, Proactive Practice Team Functional and Clinical Outcomes Resources and Policies Community Health System Health Care Organization (Medical Home) Delivery System Design Decision Support Clinical Information Systems Care Partnership Support Family -centered Coordinated and Equitable Timely & efficient Evidence-based & safe
  • What is Care Coordination?
    • Depends who you ask.
    • A process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health.
    • AAP 2005
  • What Is Case Management?
    • Began in era of managed care as mechanism of ensuring access to appropriate benefits package of services: utilization review approach.
    • Any effective, sustainable community-based Medical Home system must support linkages between practice-based CC and community-based CM!
  • What Constitutes CC in a Pediatric Medical Home?
  •  
  • National Study of Care Coordination Measurement in Medical Homes Antonelli, Stille, and Antonelli, 2008
  •  
    • Health Outreach for Medical Equality (HOME)
    • Pilot Project to Assess Feasibility and Outcomes of Co-Located CC model in an urban pediatric setting
    • CC provided by Community-based partner (Hispanic Health Council) with clinic and community-based CC
    • Funded by Hartford Foundation for Public Giving, Children’s Fund of CT/ Child Health and Development Institute, Conn Children’s Medical Center, and CT Medicaid agency
  • Implications for Policy and Practice
    • With the advent of Patient-Centered Medical Home, all primary care provider organizations are focusing on CC as critical function
    • Payers and purchasers are looking at P4P to incentivize CC
    • CC for adult chronic condition CC is very different from pediatric CC
  • Implications for Policy and Practice
    • Pediatric disease-specific CC (aka, chronic condition management/ CCM) should be quite implementable
    • However, comprehensive pediatric CC is not the same as CCM
    • Mechanisms of operationalizing and measuring CC functionality at MH practice level must be developed
    • CC as a discipline must be developed in order to achieve high performing health care system
  • Transition for Youth You think pediatrics or adult CC is difficult, what about Transitioning youth with chronic conditions from one side of the chasm to the other?
  • Outcome Realities YSHCN
    • 90% of YSHCN reach their 21 st birthday
    • Nearly 40% cannot identify a primary care physician
    • 20% consider their pediatric specialist to be their ‘regular’ physician
    • Significant numbers have extensive primary health concerns that are not being met
    • Fewer work opportunities, lower high school grad rates and high drop out from college
    CHOICES Survey, 1997; NOD/Harris Poll, 2000; KY TEACH, 2002
  • What Can Be Measured re: CC?
    • Pediatric Medical Home
      • Parent/ youth partners in QI at practice level
      • Developmental and behavioral screening
      • Screening for secondary disabilities (much less prevalent than adult practice)
      • Presence of registry and its utilization
      • Development and deployment of Care Plans (these have CPT codes already)
      • Mechanism for linkage from practice-based CC to community-based CM
      • Training opportunities for CC’ers
      • ED and in-patient utilization for patients with chronic conditions
  • How Can We Improve Quality and Increase Capacity?
    • Co-Management as means of increasing access and quality:
    • Targeted Child Psychiatric Services
    • Connor, Antonelli, et al (Clinical Pediatrics, June, 2006)
  • What Will Incentivize Change In Primary Care?
    • Patient-Centered Primary Care Collaborative (PCPCC)
    • Medicare Medical Home Pilots (2009)
    • State Level Medicaid Medical Home Projects
      • North Carolina
      • Minnesota
    • NCQA
  • PCMH-PPC: NCQA, AAFP, ACP, AAP and AOA Medical Home Qualifying Criteria Linked to Reimbursement
  • NCQA 6 Pts 2 4
    • Standard 4: Patient Self-Management Support
    • Assesses language preference and other communication barriers
    • Actively supports patient self-management**
    20 Pts 3 4 3 5 5
    • Standard 3: Care Management
    • Adopts and implements evidence-based guidelines for three conditions **
    • Generates reminders about preventive services for clinicians
    • Uses non-physician staff to manage patient care
    • Conducts care management, including care plans, assessing progress, addressing barriers
    • Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities
    21 Pts 2 3 3 6 4 3
    • Standard 2: Patient Tracking and Registry Functions
    • Uses data system for basic patient information (mostly non-clinical data)
    • Has clinical data system with clinical data in searchable data fields
    • Uses the clinical data system
    • Uses paper or electronic-based charting tools to organize clinical information**
    • Uses data to identify important diagnoses and conditions in practice**
    • Generates lists of patients and reminds patients and clinicians of services needed (population management)
    9 Pts 4 5
    • Standard 1: Access and Communication
    • Has written standards for patient access and patient communication**
    • Uses data to show it meets its standards for patient access and communication**
    4 Pts 1 2 1
    • Standard 9: Advanced Electronic Communications
    • Availability of Interactive Website
    • Electronic Patient Identification
    • Electronic Care Management Support
    15 Pts 3 3 3 3 2 1
    • Standard 8: Performance Reporting and Improvement
    • Measures clinical and/or service performance by physician or across the practice**
    • Survey of patients’ care experience
    • Reports performance across the practice or by physician **
    • Sets goals and takes action to improve performance
    • Produces reports using standardized measures
    • Transmits reports with standardized measures electronically to external entities
    4 PT 4
    • Standard 7: Referral Tracking
    • Tracks referrals using paper-based or electronic system**
    13 Pts 7 6
    • Standard 6: Test Tracking
    • Tracks tests and identifies abnormal results systematically**
    • Uses electronic systems to order and retrieve tests and flag duplicate tests
    8 Pts 3 3 2
    • Standard 5: Electronic Prescribing
    • Uses electronic system to write prescriptions
    • Has electronic prescription writer with safety checks
    • Has electronic prescription writer with cost checks
  • Useful Websites
    • http:// www.medicalhomeinfo.org : American Academy of Pediatrics hosted site that provides many useful tools and resources for families and providers 
    • http:// www.medicalhomeimprovement.org : tools for assessing and improving quality of care delivery, including the Medical Home Index, and Medical Home Family Index
  • References
    • Antonelli, RC , Stille, C, and Antonelli, DM, Care coordination for children and
    • youth with special health care needs: a descriptive, multisite study of activities,
    • personnel costs, and outcomes. Pediatrics. 2008 Jul;122(1):e209-16
    • Turchi, R, Gatto, M, and Antonelli, R, Children and Youth with Special Health
    • Care Needs: There is No Place Like (a Medical) Home, Curr Opin Pediatr
    • 2007, 19: 503.
    • Connor, D, McLaughlin, T, Jeffers-Terry, M, O’Brien, W, Stille, C, Young, L, and
    • Antonelli, R, Targeted Child Psychiatric Primary Clinician-Child Psychiatry
    • Collaborative Care, Clin Pediatr. 2006; 45:423-434.
    • Antonelli, R., Stille, C., Freeman, L.,Enhancing Collaboration: Roles of Primary
    • and Subspecialty Care Physicians in Providing a MH for CYSHCN, MCHB,
    • Georgetown Univ, 2005.
    • Stille, C and Antonelli, R, Coordination of care for children with special health
    • care needs, Curr Opin Pediatr 2004;16:700-705.
    • Antonelli, R and Antonelli, D, Providing a medical home: the cost of care
    • coordination services in a community-based, general pediatric practice,
    • Pediatrics 2004; 113:1522-1528
  • References (continued)
    • McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with special health care
    • needs. Pediatrics , 102 ,137–140
    • Committee on Children with Disabilities, American Academy of Pediatrics. (1999). Care coordination:
    • Integrating health and related systems of care for children with special needs. Pediatrics , 104 (4, Part 1),
    • 978–981
    • Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm:
    • A new health system for the 21 st century
    • Friedman, Mark, “Trying hard is not enough”; excellent reference on “Results-Based Accountability”.