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Creating an Environment of Change:

Creating an Environment of Change:. A Medical Home Approach Sharon Fleischfresser, M.D., M.P.H. Medical Director, Wisconsin Children with Special Health Care Needs Program AMCHP Conference February 20, 2005. Medical Home for CSHCN.

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Creating an Environment of Change:

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  1. Creating an Environment of Change: A Medical Home Approach Sharon Fleischfresser, M.D., M.P.H. Medical Director, Wisconsin Children with Special Health Care Needs Program AMCHP Conference February 20, 2005

  2. Medical Home for CSHCN A Medical Home is an approach to providing health care services in a high-quality and cost-effective manner. In the Medical Home pediatric health care professionals and parents act as partners in the medical home to identify and access all the medical and non-medical services needed to help children and families achieve their maximum potential.

  3. Medical Home Background • National initiative supported by Family Voices, the Maternal & Child Health Bureau (MCHB), American Academy of Pediatrics, and others • Performance measure for State Title V CSHCN Programs

  4. Wisconsin’s Vision • Every child with special health care needs will have access to a medical and dental home • Access to the system is seamless and care is coordinated and integrated • Families and providers work in partnership • Providers have the skills and resources to provide needed services

  5. Setting the Stage: Partnerships • Participation in the Maternal Child Health Bureau (MCHB)/American Academy of Pediatrics (AAP) Medical Home Mentorship Meeting - January 2002 • Collaboration with MCH Advisory Committee, Wisconsin AAP and Academy of Family Physicians, parent advocacy groups including Family Voices • Participation in National Medical Home Learning Collaborative

  6. National Medical Home Learning Collaborative • Sponsored by National Initiative for Child Healthcare Quality (NICHQ) in collaboration with Center for Medical Home and the MCHB • Wisconsin is one of eleven states selected to participate in the first cycle • Goal: improve care for CSHCN by making changes in primary care service delivery and state programs

  7. National Medical Home Learning Collaborative • 3 primary care practice teams • Each practice team: parent of a CYSHCN, primary care physician, nurse/care coordinator • Diverse in practice type, population served, and geographic location • 1 CSHCN State Program Team • CSHCN Medical Director, Health Educator, Medicaid Medical Director, Lead for care coordination services at Children’s Hospital of Wisconsin

  8. Medical Home Learning Collaborative Fond du Lac Regional Clinic Participating Practices Marshfield Clinic, Chippewa • Northpoint Pediatrics, Milwaukee

  9. Wisconsin Team Retreat:Planning for Replication Lessons Learned: • Learning Collaborative provides framework to support change • Establish additional parent partners within practice teams • Teams need regular contact and skilled facilitation of team meetings • Practices need guidance regarding available state programs and community resources • Practices need technical assistance related to reimbursement strategies, transition planning

  10. The Wisconsin Replication • Implement 2004 MHLC replication with 10 primary care practices statewide • Title V Central Office and Children’s Hospital of Wisconsin work with Title V Regional CSHCN Centers in implementing replication with pediatric practices and family practitioners • Each practice team has a trained “medical home facilitator” from the Regional CSHCN Center • Identification of areas for quality improvement using the Medical Home Index (baseline score) • Regional CSHCN Centers will connect practice teams to resources

  11. Participating Practices Medical Home Learning Collaborative Regional CSHCN Centers

  12. Wisconsin Medical Home Learning Collaborative Implementation • Learning Session 1: MH Basics, Family Support and Quality improvement – Plan, Do, Study, Act • Learning Session 2: Financing • Learning Session 3: Transitions • Between Session work

  13. Focus of Practice Change • Family Support Activities (focus groups, family surveys, creation of Parent Advisory Committee) • Identification of CSHCN within the practice • Development of medical care plans (Emergency care, after hour coverage)

  14. Office scheduling accommodations Parent input in practice renovation Office staff training Creation of “Roadmaps to Resources” Family Nights Care plan part of a system wide electronic medical record Care coordinator within the practice Emergency plans in ER, school and practice Create Transition Team Practice Changes

  15. Measurement: MH Indexes

  16. Wisconsin Title V - Impact of MHLC • Stronger relationship with Title V Regional CSHCN Centers, Title V Central Office, and Primary Care Community • Primary Care Practices now formally implementing Medical Home • Community, Health Care, and Family Partners statewide trained on concepts of Medical Home • State partners, including Medicaid, Early Intervention and others now ongoing participants in Medical Home process

  17. Next Steps…. • All practice teams agree to continue participating in the WI MHLC • Team focus continues on identification, care planning and family support • New focus on spread, cultural effectiveness, primary/tertiary care relationships • Ongoing outreach to partner organizations related to the Medical Home

  18. Additional Information Wisconsin CSHCN Program Sharon Fleischfresser, 608.266.3674 fleissa@dhfs.state.wi.us www.medicalhomeinfo.org www.nichq.org

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