Disclosures

1. Medical Home in Pediatrics: The HOW TO Webinar Seriesbrought to you by the National Center for Medical Home Implementation How To Use Data to Improve Care DeliveryChristina Bethell, Ph.D., M.P.H., M.B.A. Child and Adolescent Health Measurement Initiative RJ Gillespie, MD, MHPE, FAAP Oregon Pediatric Improvement PartnershipApril 25, 2013

2. Disclosures We have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3. Webinar Objectives By the end of this webinar, the participant will be able to: Review the updated state profiles and additional resources on the Medical Home Data Portal Illustrate the practical use of state-level data sets to improve care equity, access and quality for children and families Explain how to effectively work with state-level data to advance the medical home model

4. History of Medical Home Measure • American Academy of Pediatrics (AAP) published the first policy statement on medical home in 1992 followed by updates in 2002 and 2008. • U.S. Department of Health and Human Services’ included medical home as a Healthy People 2010 and 2020 goal and objective. • Federal Maternal and Child Health Bureau identified medical home as one of the 18 national performance standards established for state Title V programs

5. Many PCMH recognition tools exist today; Content domains overlap This figure was adapted from the Urban Institute (March 2012), full report available at http://www.urban.org/uploadedpdf/412338-patient-centered-medical-home-rec-tools.pdf.

6. The NCQA PCMH 2011 Overall Standards Encompass the Following Content Domains*: • AAP Domains of Medical Home • Accessible • Family-Centered • Continuous • Comprehensive • Coordinated • Compassionate • Culturally Effective NCQA PCMH Standards • Enhance Access and Continuity • Identify and Manage Patient Populations • Plan and Manage Care • Provide Self-Care Support and Community Resources • Track and Coordinate Care • Measure and Improve Performance Items that are highlighted indicate similar domains for NCQA PCMH Standards and APP Domains of Medical Home.

7. Overview of Medical Home Measure The Child and Adolescent Health Measurement Initiative (CAHMI) led the development and testing of the Medical Home Measure for the Maternal and Child Health Bureau • Beginning in 2001, CAHMI coordinated a national measurement effort to design and test options for measuring Medical Home for 2003 National Survey of Children’s Health—building on prior work to measure MH in the 2001 NS-CSHCN. • This 2003 NSCH measure was “provider focused” and revised to be more “systems focused” for the 2005/06 NS-CSHCN • Current measure has been used in 2005/06 & 2009/10 NS-CSHCN and 2007 & 2011/12 NSCH • Measure is endorsed by the National Quality Forum (NQF) • Measure explicitly build on CAHMI work to design and test the initial CAHPS CCC, which addressed many MH components (see Pediatrics 2004 article) • “Best Possible” MH measure has also been constructed for the Medical Expenditures Panel Survey • All measures lack a comprehensive focus on patient engagement and continuity (for a reason!) and lack more robust care coordination measures • All measures face issues related to a provider, team and systems notion of MH

8. Overview of Medical Home Measure In order to meet medical home criteria, parent must report: • Child has a Personal Doctor or Nurse (PDN) • Child has a Usual Source of Care (USC) • Child usually or always experiences positive communication with providers (FCC) Child does not have problems getting needed referrals • When parents perceive it is needed, child receives help with care coordination When needed, parents are very or always satisfied with doctor-to-doctor and doctor-to-school communication

10. Why Use a Patient-Reported Measure? • The goal of a medical home is • “not a building, house, or hospital, but rather an approach to providing continuous and comprehensive primary pediatric care from infancy through young adulthood, with availability 24 hours a day, 7 days a week, from a pediatrician or physician whom families trust.” • Infrastructure of a practice can facilitate this care delivery, but ultimately the focus should be on the patient experience. • Having medical home friendly policies and procedures in place is very important. However, only patients and families can report on the continuous and comprehensive health care they received from a provider that they trust—the “medical homeness” of that care.

11. The Story We Want to Tell! Patient Experience of Care Provided Versus Patient “Satisfaction” MOV and PHDS Data: Comparison Analysis Source: 2004 CAHMI PHDS Data, Kaiser Permanente Northwest (N=2,116); 2004 Art of Medicine/MOV Anticipatory Guidance & Parental Education

12. State and National-Level Policy Making • The NSCH and NS-CSHCN provide standardized data at the national and state-level • Compare performance across geographic locations • Compare performance across key socio-demographic subgroups, including insurance type, race/ethnicity, household income, household education, complexity of needs • Trending of medical home measure across survey years to examine impact of state-level medical home implementation • The NSCH and NS-CSHCN include measures of health insurance status, health care utilization, impact on child and impact on the family • Provide comprehensive understanding of the impact and key factors associated with meeting medical home criteria

13. State Application Illustration The American Academy of Pediatrics' (AAP) description of a "medical home" lists seven defining components: accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective. DATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs

14. Data Application Example: Interplay between Medical Home, Parent Work Force Participation and Transition Services Association between “transition services” and parent employment

15. Exploring the Medical Home Data Portal www.medicalhomedata.org

16. Exploring the Medical Home Data Portal

17. Exploring the Medical Home Data Portal

18. Exploring the Medical Home Data Portal

19. Exploring the Medical Home Data Portal

20. Exploring the Medical Home Data Portal TOP 5 STATES BOTTOM 5 STATES

21. Exploring the Medical Home Data Portal TOP 5 STATES BOTTOM 5 STATES

23. Exploring the Medical Home Data Portal • Additional Content Available to Learn About Medical Home Measurement and Implementation • Search for More Medical Home Data • Learn about the Medical Home • Medical Home Measurement in States • Medical Home Measurement in Practices • Medical Home: New Opportunities for Implementation Through Health Care Reform • Medical Home: Data in Action! • Medical Home Measurement for Families

24. Exploring the Medical Home Data Portal

25. Exploring the Medical Home Data Portal

26. Data In Action! • National and state-level organizations utilize the medical home measure as tools to educate, build partnerships, and provide evaluation of health care service delivery for subpopulations of children.

27. Data In Action! • Practices are extremely busy with limited resources • Need policies and incentives to begin implementation • Need to create a demand and incentive for practices to implement the medical home model • Framing medical home as a protection of a child’s health trajectory • Affordable Care Act Section 2703 provide additional compensation to health care providers if child meets chronic condition requirements • Education of families about the potential impact of medical home on child and family  Create demand for enhanced service delivery • Conversation begins at a higher level, including System Administrators • The medical home profiles are intended to be easily accessible tools to start the conversation about the importance of medical home and current performance within your state.

28. RJ Gillespie, MD, MHPE, FAAP Medical Director, Oregon Pediatric Improvement Partnership

29. Practice Perspective • Disconnect between what measures are useful at a practice level and what measures are collected by the state, health plans, and public reporting entities • Applying standardized measures to a practice may not get you to the core issues within a practice that need change • Complex system change within a practice (such as medical home transformation) usually doesn’t budge standardized measures like CHIPRA core set • Complex system change means complex measurement to assess that change

30. What is Sensemaking? • “Sensemaking is the process through which the fluid, multilayered world is given order, within which people can orient themselves, find purpose, and take effective action. Organizations don’t discover sense, they create it.” --Don Berwick, MD • When it comes to quality measures, sensemaking is the process of creating a story about data to give that data meaning within a clinical context. • Once you can give the data meaning within a practice, an action plan becomes a simple next step.

31. Example: Patient survey data • One of our early quality initiatives was to implement a patient survey that assessed the clinical content of well child visits. • Network of providers utilized the online Promoting Healthy Development Survey developed by the CAHMI. • Previous data we were getting only spoke to frequency of service, but didn’t help us understand the content of visits. • HEDIS Measures: did well child care occur on schedule? • The PHDS, which looks at the content of well child visits, provided us ideas for areas of improvement.

32. Opportunity for Improvement: Assessing forParentalDepression Source: 2008-2009 CAHMI Online PHDS Data

33. Relationship between children with depressed parents and other child/family factors Source: 2008-2009 CAHMI Online PHDS Data

34. An Opportunity for Improvement: Peripartum Depression • Common narrative in primary care pediatrics: “I don’t need a screening tool to identify mothers who are depressed – I can see it in their faces.” • 12% of parents of children under a year of age were experiencing depression. • Only 24% of these parents were asked about the presence of symptoms. • The new narrative, based on sensemaking: “Maternal depression has negative consequences for our patients. We need to do universal screening for postpartum depression.” Source: Promoting Health Development Survey, CAHMI, 2008-9.

35. Maternal Depression Screening:Our first few PDSA Cycles Source: Independent chart review, The Children’s Clinic, Portland, OR. 2011-12.

36. More Sensemaking • Our detection rate at two weeks is higher than at other ages – why? • Are we picking up normal baby blues instead of actual postpartum depression? • Our referral rate at six months is 100% - why? • The literature indicates that 6 months is a spike in the incidence of postpartum anxiety. • Our overall detection rates are still lower than expected prevalence – why? • Is there a problem with the screening tool itself? • Next cycle is to add the question: Do you look happier on the outside than you feel on the inside?

37. Sensemaking of Bigger Datasets • In order to understand what needs to change within a practice, often need to look at data sources outside of what can be collected within a practice. • When looking at larger datasets for a region, state or the nation… • Does this information reflect what I think it going on in my practice? • Does this information need to be acted upon? • Does this information imply a course of action?

40. Care Coordination • Does this information reflect what I think it going on in my practice? • Very few practices that I’ve worked with have care coordinators or any formal care coordination program. • Does this information need to be acted upon? • CYSHCN without effective care coordination have problems accessing specialists, over-utilize emergency rooms and have frequent readmissions to the hospital. • Does this information imply a course of action? • Practice-based care coordination (or improved access to community-based care coordination) may be an answer to this problem.

41. Medical Home – AAP definition Accessible Family-Centered Continuous Comprehensive Coordinated Compassionate Culturally Effective

42. So how does one measure all this? How do you know that practice transformation efforts are working?

43. Oregon’s Medical Home Learning Collaboratives • While medical home principles are generally agreed upon, how to get there is highly debated • Wide variation in clinic capacity for change, experience with quality improvement, and needs for technical assistance • Currently unclear which medical home concepts lead to the greatest gains in patient outcomes • Eight practices currently participating in a 2 ½ year learning collaborative dedicated to implementing and measuring medical home • Second learning collaborative of five more practices are working on faster implementation of core principles

44. Practice-based Steps for Care Coordination • Standardized methods for identifying CYSHCN • Before care coordination can be delivered, you have to know who needs the help • Use of complexity scales • Further refines who needs help, and what type of help is necessary • Implementation of shared care plans • Goals for self-management and patient education

45. Definition of practice-based care coordination Within the medical home is a direct, family/youth-centered, team oriented, outcomes focused process designed to: • Facilitate the provision of comprehensive health promotion and chronic condition care; • Ensure a locus of ongoing, proactive, planned care activities; • Build and use effective communication strategies among family, the medical home, schools, specialists, and community professionals and community connections; and • Help improve, measure, monitor and sustain quality outcomes (clinical, functional, satisfaction and cost) Source: J McAllister and C Cooley

46. Adaptive Reserve • What’s predictive of medical home transformation is the characteristics of the practice themselves…specifically adaptive reserve • The ability of a practice to be resilient, to bend, and thrive survive under force. Facilitates adaptation during times of dramatic change. • So how do you measure Adaptive Reserve? What are the most critical components associated with practices’ ability to change?

47. Factors that Contribute to Ability to Change • EMR “Maturity” • Ability to mine data and manipulate EMR to create decision support structures • Size • Relates to staff support, ability to implement broad practice change • Previous QI experience • Participation in learning collaboratives • Enduring structures within a practice dedicated to quality improvement, interpretation of measures

48. Measuring Medical Home • Medical home attestation • Description of core medical home operational structures • Medical Home Index • Delivery of core medical home services to CYSHCN, including care coordination services • Family involvement in clinical QI processes • Patient Surveys – CAHPS-CG PCMH • Access to medical home services • Developmental promotion • Self-management support

49. Questions? Please submit your questions in the Question Box window!

50. We’re Here to Help You! Have a question about medical home? Contact us! Medical_home@aap.org800/433-9016 ext 7605