child medical care

1. Optimizing Health
Outcomes for Delaware’s
Children:
Pediatric Patient-Centered
Medical Home
Presentation to the Delaware Health Care
Commission
Patricia Redmond, Senior Advisor
Policy, Evaluation and Research
Nemours

2. Overview
 The Many Faces of Nemours
 The Challenge for Nemours—and the Country
 Pediatric medical home definition and plans
 Population health and primary care: what can be gained
from this marriage?
 Questions/Stay Tuned
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3. The Many Faces of Nemours
 Integrated health system with a continuum of care including:
– Clinical treatment
– Health promotion and prevention services, including
community-based
– Research
– Education
– Policy and advocacy
 Alfred I. du Pont Hospital for Children and outpatient facilities in
the Delaware Valley.
 Operating foundation dedicated to children's health & health care.
 Specialty care services in Northern/Central Florida; building new
state-of-the-art Children’s Hospital near Orlando.
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4. Challenge for Nemours—and the Country
 For the first time in our history, the United States is
raising a generation of children who may, because of
the toll of chronic disease, live sicker, shorter lives
than their parents.
 We need to respond to this reality with a
comprehensive model that integrates and coordinates
across health, education and human services
 Where is this model? Examples of change throughout
the country, but Nemours is responding in part with a
medical home model that unites primary care and
population health services
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5. The Challenge: Continued
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 Many elements of pediatric health care were designed decades
ago to treat infectious disease; they are not fully capable of
addressing current threats such as:
– Obesity
– Chronic diseases
– Mental illness
 Our existing children’s system is:
– Highly fragmented
– Highly complex for families, providers and administrators
– Financed by multiple public and private categorical funding streams
that perpetuate silos in the system

6. The “Blind Side of Health Care”
 blind side n. the part of one’s field of vision where one
is unable to see approaching risk and is particularly
vulnerable; the opposite side of where one is looking
 The current health care system has a blind side—one
which our system change efforts will attempt to
address.
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7. The “Blind Side of Health Care”
 Four months ago, the Robert Wood Johnson Foundation
released survey results that reveal physicians believe
unmet social needs are directly leading to worse health for
Americans — and that patients’ social needs are as
important to address as their medical conditions.
 These social issues are the health care system’s “blind
side.”
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8. The “Blind Side of Health Care”
 Strong evidence linking social needs to health and life
expectancy. Health care itself plays surprisingly small
role (10 percent of contributing factors) in life
expectancy.
 Social circumstances, environmental exposure and
behavior are estimated to account for 60 percent of
the risk of premature death.
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McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA
1993; 270(18):2207-12
McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to
population health promotion. Health Affairs 2002; 21(2):78-93
Slide content borrowed from Dr. Bailey 10/26/10 LDI presentation
• 40% Behavior (tobacco, alcohol,
obesity, auto safety, etc.)
• 20% Environment and social
circumstances
• 30% Genetics
• 10% Health care delivery
• In 2007, $7,123 per person spent on health
care in U.S.
• Below average life expectancy compared to
30 other developed countries
• Children: 26% of population, 13% of health
care dollars
• 15% of children have chronic diseases
accounting for 70%+ of pediatric health costs
Main Determinants of Health High Cost
Why Change the Delivery Model?

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 We are examining our own system as part of this
work. Asking:
– How do our patients access us?
– How can we do better for our patients?
– Where does the “blind side” of health care come into
play in our work?
Why Change the Delivery Model at Nemours?

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 Recent record review of the 20 most frequent users of
our Emergency Department (ED) revealed the likely
extent of social issues involved with avoidable ED
visits and hospitalizations.
 The overwhelming majority of parents in the high user
sample were between the age of 15 and 21; half self-
identified as single parents; and more than half were
first time parents.
How Do Our Patients Access Us?

12. How Do Our Patients Access Us?
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 Most of the patients presented with symptoms of
common infant and childhood illnesses during at least
one, if not several, visits. Parental-reported asthma
represented nearly half of the visits.
 For the large part, we are looking at (in this small
sample) avoidable ED visits. But avoidable HOW?

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 Just released from the Institute of Medicine (IOM):
– “The integration of primary care and public health could
enhance the capacity of both sectors to carry out their
respective missions…”
– Each has knowledge, resources and skills to enable
the other to carry out its role.
– Examples of integration, but it is not the norm.
One Solution: Primary Care and Public Health

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 Caveat: Only part of the answer. This is a multi-tiered,
big, hairy problem.
 Nemours is launching a pilot in three primary care
practice sites in which we will achieve Level 3 NCQA
recognition as a medical home and begin work to address
non-medical needs, “the blind side of health care.”
Nemours Medical Home “Plus”

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 Starting from Academy of Pediatrics definition:
– Primary care that is accessible, continuous,
comprehensive, family-centered, coordinated,
compassionate, and culturally effective to all children
and youth, including children and youth with special
health care needs.
Nemours Medical Home “Plus”

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 Launching pilot to achieve Level 3 medical home
recognition by the National Committee for Quality
Assurance (NCQA) in three of Nemours nine primary
care practices: Jessup St; Seaford; Dover.
 NCQA provides a set of standards that describe, in very
clear and specific terms, how practices may organize
care around patients, work in teams, and coordinate and
track care across time.
 Level 3 is the highest level of recognition.
Nemours Medical Home “Plus”

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 Level 3 NCQA recognition PLUS
 The creation of a medical home in which non-medical
needs and the fostering of healthier communities are
integrated into the mission of pediatric primary care
 Our guiding principle is “The Triple Aim.”
The “Plus”

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 The Triple Aim, developed by the Institute for
Healthcare Improvement and adopted by the
Department of Health and Human Services, focuses
on three aims to improve health and health care in the
United States:
– (1) enhance the patient experience (quality) of care;
– (2) improve the health of the population; and
– (3) reduce the cost of care.
Triple Aim

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 Medical home alone cannot achieve the Triple Aim.
 We need a systemic approach to address the blind
side. Medical home Plus is a beginning.
 Very intentionally a pilot: ambitious goal, test on a
smaller scale first.
Why Medical Home “Plus”

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 Pilot sites: Nemours Pediatrics practices—Jessup
Street; Dover; and Seaford.
 Three communities; very different needs. We are
targeting six zip codes—two surrounding each site.
“Hyper local.”
 NHPS will partner with community leaders to identify,
prioritize and address non-medical needs in schools,
child care, housing & other systems of targeted zip
codes.
Medical Home “Plus”

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Connecting Clinical Care and Population Health
What it Looks Like
Our Community Our Health System
Resources, Policies and System Change Health Care Organization
Informed, Activated Patient, Family
and Community Partners
Productive Interactions
& Spreading Change
Organized, Prepared, Proactive
Health Team with patient/family
Improved Health Among Patients
Improved Health for Delaware’s Children
Health Policy
Health Promotion
Practice Change
Self-Management
Support
Delivery System
Design Decision Support
Clinical
Information
Systems

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 Individual level: Decrease in ED visits for asthma
diagnosis.
 Systems level: Increase in number of school nurses
linked to Nemours Pediatrics and managing children with
asthma appropriately; increase in number of homes with
reduction in asthma triggers.
 Population level: Increase in number of children with
asthma engaged in appropriate healthy behavior, such as
physical activity. Ultimately, reduce, prevent or manage
morbidity related to asthma.
A Possible Outcome to Measure

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 Individual: Increase in number of identified
patients/families receiving non-clinical services that
improve health (e.g., parenting support).
 Systems: One or more concrete policy or practice
changes in child-serving systems as a direct result of the
model (e.g., state grant-in-aid funds used to imbed
parenting classes in communities).
 Population: Increase in the number of children
demonstrating healthy behaviors and outcomes.
Another Possible Outcome to Measure

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Optimal health for all children, with both
medical and non-medical needs
appropriately addressed.
Overall Outcome

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“To raise new questions, new possibilities, to regard
old problems from a new angle, requires creative
imagination and marks a real advance in science.”
Albert Einstein

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Questions?