Medical Home: Just What the Doctor Ordered to Fix American Healthcare?

1. 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

2. 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

3. “Care coordination is the answer!”…

4. …“What’s the question?” Carolyn Clancy, MD, Director, AHRQ

5. Definition of Medical Home • Care that is: • Accessible • Family-centered • Comprehensive • Continuous • Coordinated • Compassionate • Culturally-effective

6. Definition of Medical Home • And for which the primary care provider shares responsibility with the family. AAP/ AAFP/ NAPNAP/ ACP/ AOA

7. 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

8. Health System Community Health Care Organization (Medical Home) Resources and Policies ClinicalInformationSystems Care Partnership Support DeliverySystem Design Decision Support Timely & efficient Family -centered Evidence-based & safe Coordinated and Equitable Functional and Clinical Outcomes Care Model for Child Health in a Medical Home Supportive, Integrated Community Informed, Activated Patient/Family Prepared, Proactive Practice Team Prepared, Proactive Practice Team

9. 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

10. 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!

11. What Constitutes CC in a Pediatric Medical Home?

13. National Study of Care Coordination Measurement in Medical Homes Antonelli, Stille, and Antonelli, 2008

15. 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

16. 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

17. 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

18. 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?

19. Outcome Realities YSHCN • 90% of YSHCN reach their 21st 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

20. 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

21. 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)

22. 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

23. PCMH-PPC: NCQA, AAFP, ACP, AAP and AOAMedical Home Qualifying Criteria Linked to Reimbursement

24. NCQA

25. 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

26. 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, Providinga medical home: the cost of care coordination services in a community-based, general pediatric practice, Pediatrics 2004; 113:1522-1528

27. 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 21st century • Friedman, Mark, “Trying hard is not enough”; excellent reference on “Results-Based Accountability”.