Pediatric Patient Centered Medical Home

1. Pediatric Patient Centered Medical Home LEADERSHIP EDUCATION IN NEURODEVELOPMENTAL DISABILITIES (LEND) GROUP March 2013 Patti Barovechio MN BSN CCM CPUR CSHS Statewide Care Coordinator Supervisor DHH/Office of Public Health

2. OBJECTIVES • Examine the essential characteristics of a Pediatric Patient Centered Medical Home (PCMH) • Define Children with Special Health Care Needs (CSHCN) • Brief review of national/state initiatives and Medicaid reform in Louisiana related to MH’s • Discuss the essential role of care coordination and planned transitions for CSHCN • Review the Tiger Care PCMH Care Coordinator Model

3. Pediatric Patient Centered Medical Home Coordinating Care Carrie is a 3 year old who is new to Louisiana presents to a local clinic. She has Down Syndrome and has had heart surgery in the past. She has never been in our school system or in Early Head Start. Her vision is suspect, as she holds everything up close and cocks her head to the side. She is pleasant, outgoing and does not usually have temper tantrums. Her speech is difficult to understand. She walks with an unsteady gait and has decreased muscle tone. She has had no therapies to date. She takes no medications. Carrie has no insurance and Mom is concerned.

4. AAP Pediatric Patient Centered MH-History – Pediatric Medical Home • 1967 AAP Medical Home (center of medical record) • 1992 AAP Medical Home (MH) Policy Statement • 2000 Future of Pediatric Education (FOPE) II Report • 2007 AAP, AAFP, ACP, AOA “Joint Principles” Patient Centered Primary Care Collaborative • 2008 NCQA PCMH Certification – AAP input

5. Patient Centered Medical Home (PCMH)-Medical Home Current Trends • Healthy People 2010 - expanded for 2020 Goals • 2010 Patient Protection and Affordable Care Act • MH Medicaid reform in 25 States • MH Model Evolving → research/demonstration projects ongoing

6. Children with Special Health Care Needs (CSHCN) • “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and • who also require health and related services of a type oramount beyond that required by children generally” (McPherson et al., 1998 Adopted by AAP, MCHB, HRSA, US DHH)

7. Children with Special Health Care Needs CSHCN or CYSHCN • Advances in medical technology → increased life expectancy for children with severe/chronic health conditions → move from institutionalized care • CSHCN also includes ADHD, Asthma, ASD… • CYSHCN ↑ risk for chronic physical, developmental, behavioral or emotional conditions • Multiple-complex needs requiring coordinated resources/specialist care

8. Children with Special Health Care Needs (CSHCN)- Health Care Challenges • Scheduling and Coordinating care for a CSHCN a challenging task… • LA 28.7% of family members report reducing or quitting work → places additional financial burden on the family (CSHCN Survey 2009/10) Compared to Children without special health care needs… ANNUALLY MORE THAN: 2 X’s the number PCP visits 7 X’s non-physician visits 5 X’s the Prescriptions 4 X’s the hospitalizations 7 X’s as many hospital days (Newacheck & Kim S Achieves Pediatric Adolescent Medicine Jan 2005)

9. National Survey of Children with Special Health Care Needs2009/2010 Conducted by the CDC National 15.1% CSHCN ~ 11,203,616 16.9% of families living UNDER the FPL Louisiana 18.6% CSHCN ~ 207,840 20.9% of families living UNDER the FPL

10. National Survey Data- CSHCN • Large sample size-powerful study Independent random samples all 50 states 196,159 households screened/ ID CSHCN Minimum 750 CSHCN interviews in each state State and local area integrated telephone survey • Reliable data: www.childhealthdata.org • Strategic planning for population care needs

11. Pediatric Patient Centered MH-Benefits/Goals – Medical Home • Community level primary care → eliminate disparities link to resources Reduce ER visits Decrease long-term disability → Increase independence • Transition services → support life-long active participation in health maintenance activities Effective/Efficient Care = $ Control $ = Sustainable Health Care

12. Pediatric Patient Centered MH-AAP Defining Characteristics • Family centered • Accessible • Continuous • Coordinated • Comprehensive • Compassionate • Culturally effective

13. Pediatric Patient Centered MH-Family Centered • Consistent PCP provider → partnership with patient/family • Patient/Family/Physician → mutual responsibility & trust • Family center of strength/support → expert in child’s care • Clear/unbiased/complete information shared with family • Family/youth →care coordination

14. Pediatric Patient Centered MH - Accessible • Community location • Linked to public transport (where available) • Physically accessible - ADA • Expanded hours-open scheduling • Phone access/technology use • Insurance/Medicaid accepted

15. Pediatric Patient Centered MHContinuous • Ongoing relationship with PCP • Assistance through transitions • Primary Care Physician participates to fullest extent possible with inpatient/specialty care

16. Pediatric Patient Centered MH–Comprehensive • Preventative/Primary/Tertiary health care Access to full compliment of sub-specialist Diagnostics • Periodic Screenings/Early Intervention • Patient/Family needs identified/addressed Medical Family/Community Educational Psychosocial Developmental

17. Pediatric Patient Centered MH-Coordinated • Plan of care developed by PCP/Patient/Family Families Helping Families* • Care Coordinator schedule/link/follow-up • Disseminate care plan emergency care plan

18. Pediatric Patient Centered MH-Compassionate • Concern for the well-being of the patient/family • Expressed in verbal/non-verbal interactions • Efforts made to understand/empathize with feelings/perspectives of family/child or youth

19. Pediatric Patient Centered MH Culturally Effective • Family/patient Cultural background recognized/valued/respected • All efforts made to ensure patient/family understand result of medical encounter and care plan *translators – spoken and sign language

20. Pediatric Patient Centered MH-Transitions from Youth to Adult • Got Transition - National initiative www.gottransition.org • Initiate at 12-14 years • Transition issues → Care Coordination Essential Health/wellness Education/vocational planning Guardianship and legal/financial issues Community supports/recreation Health insurance Transportation

21. Pediatric Patient Centered Medical HomeTransition Health Care Parent/Youth Information Excerpts • Take charge of your health information • Do you know what medicines you are taking and WHY? If NO – ASK! • Call your drugstore for your own medicines. The phone number is on the bottle… • Be your own health care advocate • Do you know what your health issues are? • Do you know the danger signs that mean that YOU need emergency help very soon or NOW!... • Plan for transfer to a doctor who treats adults • Talk to your doctor about how and when you should start seeing a doctor who treats adults. • Ask your doctor about any resources they know that might be helpful for you… • Plan for independence: • Know what you feel comfortable doing on your own and what new skills you want to have to experience new events on your own. What are the social skills that adults have? Make a list & talk with your family and doctor. • What health insurance plan will you have when you’re 18 or 26?...

22. Pediatric Patient Centered Medical Home Developmental and Behavioral Disorder Screening • Comprehensive Care –Screening Early detection=early intervention=improved outcomes • 2006 AAP Policy Statement → Developmental surveillance with every preventative care visit throughout childhood • Screen all patients at 9-18-24 (30) -36 months and any time a patient’s surveillance yields concern Reliable/Valid/Sensitive instruments ASQ and MCHAT

23. Patient Centered Medical Home-Medical Home Model of Care - Louisiana • Louisiana Health Care Reform Act 2007 • Louisiana Health Care Quality Forum (LHCQF) • Expand health insurance coverage in the state • HIT plan to support healthcare practices

24. Pediatric Patient Centered Medical HomeLouisianaMedicaid • Kidmed-Community Care Network • Bayou Health Plans – Managed Health Care Pre-Paid Plans – capitated managed care model, traditional risk-based - fee for service Shared Plans – enhanced primary care case management plan, monthly per-member fee for care management services-opportunity for providers to share in cost savings • 5 Plan Options ‘Your Health/Your Choice’ • Bayou Health Statewide June 2012

25. Pediatric Patient Centered MH-Tiger Care Pediatric PCMH Model Background • LSU Peds/CHNO joint clinic opened March 2004 • Care Coordinator (CC) position funded by CSHS • Faculty/staff trained in AAP MH • Resident outpatient training/med student rotations • Study – Tiger Care CC Medical Home Model

26. Pediatric Patient Centered MHTiger Care Study Objective Assess for significant changes in family satisfaction among families of CSHCN before and after care coordination MH Family Index → measured receipt of MH services Determine the effect of a nurse care coordinator on the ability of the clinic to meet MH criteria MH Index → measure of clinics ability to meet MH criteria

27. Pediatric Patient Centered MHTiger Care Model- Care Coordinator Role • Screen/identify CSHCN • WrittenCare Plan complex CSHCN • Assist families/patients • Community program access • Families Helping Families • School Board/Eval/IEP • Support youth transitions initiative • MH Meetings • Track/trend population data → QI

28. Katrina

29. Pediatric Patient Centered MH-Tiger Care Post-Katrina • Katrina destroyed clinic August 2005 • Study data destroyed • Clinic reopened March 2006 • Care Coordinator hired • MH Study resumed

30. Care coordination in a medical home in post-Katrina New Orleans: lessons learned Susan J Berry MD MPH Eleanor Soltau RN CCM Nicole E Richmond MPH R Lyn Kieltyka PhD Tri Tran MD MPH Published in the Journal of Maternal Child Health –August 2011

31. Tiger Care Study Pre-Post Care CoordinatorPre-Post Katrina Clinic Population Comparison

32. Pre-Post Katrina ComparisonCharacteristics of Family Survey Participants

33. MH Family Index Result – Tiger StudyFamily Perception of Physician #1 Physicians are accessible to the family and child as needed #3a My doctor communicates well with me #3b My doctor communicates well with my child #5 My doctor asks how my child’s condition affects our family #6 My doctor listens to my concerns and questions

34. MH Family Index – Tiger StudyFamily Perception of Care Coordination #9 I receive a copy of my child’s plan whenever it is changed #10a My doctor/office staff follow through with the care plans #10b My doctor/office staff change the care plan as needed #11a My doctor has CC who helps me with referrals/payment/follow-up #11d My doctor has CC who helps everyone communicate with each other

35. MH Family Index –Tiger StudyFamily Perception of Practice #2a Staff knows who we are when we call the office. #12 When I ask, my doctor/office staff explain my child’s condition to school personnel/child care providers #14 Staff know my child’s conditions and things that concern us #15 Office staff connect me with educational/family advocacy organizations #16 My doctor assists me in finding adult healthcare services for my child

36. Medical Home Index

37. Tiger Care CanalMH Index Result Comparison 2010-11-12

43. Patient Centered Medical Home-EBPDemonstration Sampling Pediatric Alliance for Coordinated Care-Boston 6 Pediatric Practices Increased parent satisfaction Decreased caregiver missed work Decrease in burden of care Geisinger Health System-Pennsylvania Multi-dimensional MH Model 11 Primary Care Practices In-patient admissions reduced 18% Re-admissions reduced 36% Community Care of North Carolina Medicaid sponsored initiative 40% decrease in hospitalizations for asthma and 16% decrease ED visit rate Colorado Medicaid and SCHIP Medicaid sponsored initiative PCMH children decreased median annual costs ($2,275) compared to non-enrolled ($3,404)

44. Care Coordination - Carrie is a 3 year old who is new to Louisiana presents to a local clinic. She has Down Syndrome and has had heart surgery in the past. She has never been in our school system or in Early Head Start. Her vision is suspect, as she holds everything up close and cocks her head to the side. She is pleasant, outgoing and does not usually have temper tantrums. Her speech is difficult to understand. She walks with an unsteady gait and has decreased muscle tone. She has had no therapies to date. She takes no medications. Carrie has no insurance and Mom is concerned.

45. Pediatric Patient Centered Medical Home Care Coordination • PCP /family develop plan of care Prior to Cardiology referral obtain medical records → released? Team reviews medical records No meds – medication reconciliation with records Check for date of last eye exam • Vision & Developmental screens • Head Start or region school board for eval/IEP • CC resource for insurance access – eligible for SSI disability? • Speech, PT, OT • Developmentalist • Dental • Families Helping Families • Office of Citizens with Developmental Disabilities(OCDD)

46. Take Away Points • PCMH evidence supports → effective/efficient model for health care delivery • Medical Home → Improves patient outcomes • Care Coordination and planned transitions essential for CSHCN • Tiger Care Medical Home Care Coordinator Model • Replicated (+) outcomes in over 12 practices • Care Coordinator Model = Proven Effective

47. “We must become the change we want to see in the world.” Mahatma Gandhi (1869-1948) A wise man once said...

48. CHILDRENS SPECIAL HEALTH SERVICES Questions/Collaboration/Information: Patti Barovechio MN, BSN, CCM Statewide Care Coordinator Supervisor CSHS 504-568-5026

49. References/Resources/Links • AAP Medical Home http://www.medicalhomeinfo.org • Center for Medical Home Improvement http://www.medicalhomeimprovement.org • Data Resource Center for Child & Adolescent Health http://www.childhealthdata.org • Got Transitions: www.gottransition.org • National Committee for Quality Assurance (NCQA): http://www.ncqa.org • Patient Centered Primary Care Collaborative: http://www.pcpcc.net • State of Louisiana, CSHS program web site http://www.cshs.dhh.la.gov • US Department of Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB):http://mchb.hrsa.gov