2014 mobile health clinics association forum- …€¦ · mobile health clinics association forum-...

MOBILE HEALTH CLINICS ASSOCIATION

FORUM- SAVANNAH GEORGIA

2014

THE FIVE PILLARS OF

HEALTH: USING MOBILE

HEALTH TO LEAD THE

MOVEMENT

Maria G. Aramburu, MD, FAAP

Division of Community Pediatrics

MedStar Georgetown University Hospital

Washington D.C

OBJECTIVES

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• Introduce the five pillars of health as an innovative model of healthcare delivery to at-risk children and their families

• Introduce the potential synergy of these five components to the promote wellness for our patients

• Review quality improvement projects in the mobile health setting

• Identify the successes and barriers to care integration in community based services

• Capture the unique opportunities for mobile health care as a platform for change in the evolving healthcare environment

DIVISION OF COMMUNITY PEDIATRICS

Our mission is based on the belief that every child, regardless of his/her financial means, deserves

high-quality,

comprehensive,

continuous care,

delivered in a respectful, caring and family centered environment—a “wellness home.”

KMMC

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KIDS MOBILE MEDICAL CLINIC/

RONALD MCDONALD CARE MOBILE

Comprehensive medical services to children and adolescents birth through 21 years old

Provided over 55,000 patients visits since 1992.

Currently providing an average of 1600 patient visits per year

Six sites in wards 4, 5, 6, and 7 of Washington DC, serving six public housing communities, two public high schools and a homeless shelter for families

Mobile unit goes out 4 days per week

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HISTORY

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1992

• Georgetown University Medical Center opened the first pediatric mobile program in the District of Columbia

• Target population: children in low income communities who were uninsured

2000

• MedStar Health purchased the clinical enterprise of GUMC and program was reestablished as Georgetown University Hospital Kids Mobile Medical Clinic

• The 1997 Authorization of State Health Insurance Program created an insurance safety net for children in the District of Columbia. This addressed a financial barrier to health care access.

• Many neighborhoods in Washington DC Wards 6,7,8 continued to be designated Health Professional Shortage areas thus creating geographic barriers to accessing health care for children

2005

• First Licensing agreement with RMHC Global Inc, Ronald McDonald House Charities of Greater Washington and MedStar Georgetown University Hospital for the Ronald McDonald Care Mobile at MGUH

• First clinic in the MedStar Health System to adopt the Electronic Health Record to improve documentation and efficiency

MGUH- KIDS MOBILE MEDICAL CLINIC


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The program may evolve, but the mission stays the same:

To remove the barriers to health care for childrenand families of the Greater Washington Regionliving in or near poverty by delivering health andwellness services directly in their neighborhoodsat no direct cost to their parents or caregivers.

MGUH- KIDS MOBILE MEDICAL CLINIC


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IMPLEMENTATION PROCESS

ASSESSMENT IMPLEMENTATION

Where are the gaps in wellness in our population

• What do our patients say?

• What local data is available?

• What are the national trends?

What services can we provide to fill these gaps in wellness?

• Evaluate current initiatives in place locally and nationally

• Evaluate our current capacity for services

• Evaluate opportunities for new programming.

Process planning

• Structure and development

Program development,

• Staffing and training

Implementation of services

• Service delivery

• Documentation of Services in the Electronic Health record

• Billing and Coding processes

• Referrals and Care Coordination

Outcomes and Evaluation

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PILLAR # 1

PHYSICAL HEALTH

PHYSICAL HEALTH-SERVICES PROVIDED

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• School/Sports/Camp/Daycare Physicals• Sick/Periodic Care• Hearing/Vision Screenings• Immunizations• Laboratory Studies• Tuberculosis Testing• Ophthalmology Exams• Specialty Referrals and Care Coordination• 24 hour On-call coverage• On-site Pharmacy

PHYSICAL HEALTH QI- ASSESSMENT

IMMUNIZATIONS We know:

There has been a greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 for diphtheria, mumps, pertussis, and tetanus.

Smallpox has been eradicated worldwide.

Declines were 80% or greater for cases and deaths of most vaccine-preventable diseases targeted since 1980 including hepatitis A, acute hepatitis B, Hib, and varicella. Declines in cases and deaths of invasive S pneumoniae were 34% and 25%, respectively.

DC Immunization Registry noted our immunization compliance at below 70%

Yet…

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DC- VFC PROGRAM- IMMUNIZATION STATISTICS

School coverage rates are bellow the target of

98%

NIS series is bellow 76% which had been

achieved in the past

High missed opportunities illustrated by gaps in

NIS coverage for selected vaccines ( HPV)

ALL VISIT IMMUNIZATION PROGRAM

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NOT A NEW IDEA…JUST A NEW IDEA FOR US

IMMUNIZATIONS

PROGRAM IMPLEMENTATION

Process Planning

Addressing Logistical challenges Two rooms

Increased time to pull records for either nurse or coordinator from DC Registry

Increased time to record immunizations in EHR

Increased time to give immunizations

Delay in patient throughout

Increased ordering demand for vaccines

Potential increased cost of private vaccine stock for uninsured

But it’s the right thing to do…

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IMPLEMENTATION

Screening for vaccine delay at every visit

Determining eligibility for VFC program

Reviewing patients before visits to ensure

adequate stock of vaccines

Increasing vaccine education to our patients

Adequate staff training and ongoing education

Elimination of missed opportunities to

vaccinate

IMMUNIZATIONS- OUTCOMES

Before May 2013

Approximately 63% of our visits included immunizations

Between May 2013 and May 2014

Instituted All Visit Immunization Program

40% sick visits were either due or overdue and got

immunized

Increase immunization compliance:

Increase from approximately 63% to 92% of patients

were up to date at the end of their visit

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PHYSICAL HEALTH ---------ASTHMA

INITIATIVE

Chronic lung disease that affects 7.0 million children (aged< 18 years)1 in the United States (U.S.), regardless of age, sex, race, or ethnicity.

Although the exact cause of asthma is unknown and it cannot be cured, it can be controlled with self-management education, appropriate medical care, and avoiding exposure to environmental triggers

ASTHMA INITIATIVE- ASSESSMENT

DC PREVALENCE OF ASTHMAPERCENTAGE OF CHILDREN WITH UNCONTROLLED ASTHMA

In 2008, an estimated

13,981 children in the

District of Columbia had

asthma.

- Child lifetime asthma

prevalence was 18.4%

- Child current asthma

prevalence was 12.6%.

EV

ALU

ATIO

N-N

ATIO

NA

L

TR

EN

DS

ASTHMA IN CHILDREN- INTERVENTION

PROGRAM

Reach out to patients with asthma: Schedule asthma control visits

Asthma action plans for every asthma patient

With EMR additions: Evaluation of severity at well- check visits

Self evaluation questionnaires between visits

Enhanced “Asthma Action Plan” visits

Providing medication and spacers to uninsured patients

Pillar #2

ORAL HEALTH

ORAL HEALTH

NEEDS ASSESSMENT

Previous research has established the effectiveness of fluoride varnish, applied 2 to 4 times per year, is effective in preventing dental caries among children. A meta-analysis of 3 studies found a 33% reduction in decayed, missing and filled primary-tooth surfaces.

Early childhood caries experience negative consequences such as pain, difficulty eating and sleeping, and diminished quality of life

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ORAL HEALTH

PROGRAM INTERVENTION

Fluoride Varnish

Program-

Ages 6 months to 3 years

10 months

Oral Health Assessment

Program

4 years to 21 years

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ORAL HEALTH

IMPLEMENTATION PROCESS

Process planning:

Establishing workflow in an already limited space

Finding a partner to work with for referrals

Program Development:

Training providers (physicians and nurses) on Fluoride varnish application through an online and in person training developed by DC Chapter of the American Academy of Pediatrics

Creating a guide for oral health services in primary care for ages 6m-3y and another for 4y-21y

Developing education materials for parents

Revising encounter forms in the electronic medical record to document services

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ORAL HEALTH

IMPLEMENTATION PROCESS CONT’D

Additional Implementation considerations:

DC Medicaid began reimbursing for Fluoride Varnish from 6months to 3 years.

- Identifying appropriate billing and ICD-9 codes to use

Ordering and paying for supplies upfront

Developing a system for tracking referrals to outside partner

Setting goals and proposed patient outcomes:

Children between 6mo to 3 years seen for a well visit will receive fluoride varnish application as part of the comprehensive well child exam

Children between 4yr and 21y will receive an oral health exam as part of the comprehensive well child exam

Increase early identification of dental caries in the primary care setting

Ensure that all children seen for prevention services have a dental home AND have had a preventive visit in the last 6 months

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PARENT EDUCATION

ELECTRONIC RECORDING

BILLING/CODING

REFERRAL PROCESS

ORAL HEALTH:EXPECTED OUTCOMES

HOW DO YOU MEASURE WHAT YOU DO?

Data Collection:Can we create a closed loop

system? We can use the EHR or Radar

for tracking structured data Number of referrals and the

outcome

Number of children provided the fluoride varnish

Risk Factors

Protective Factors

Disease indicators

Sharing of information between partners

Can we then estimate the reduction in early childhood caries we expect to see in this population?

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PILLAR # 3

NUTRITIONAL HEALTH

NUTRITION SERVICES

ASSESSING THE NEED

2011 study- cost of medical care for obesity-

related illnesses-$190 billion annually

2001 study-obese people had 67 percent

higher chance of suffering from conditions

like diabetes than similar normal weight

individuals.

Nearly 1 in 5 children under the age of 6,

either overweight or obese

23% Children in Washington DC are

overweight, with the vast majority coming

from wards 5,6,7,8

Health professionals are on the front line to

address this but… 34


Process planning:

Reviewed all patients between June 2012 and December 2013

to identify patients with BMI either overweight >85th%ile or Obese >95th%ile

Identified any other co-morbid or chronic conditions

PHYSICIAN LED FOCUS GROUP FOR PARENTS

Data collection: barriers, enabling factors, and participants’ knowledge of nutrition with the hope of influencing future intervention design

CREATION OF PARTNERSHIPS

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EXPLORING OUR PATIENTS NEEDS-NUTRITION

1%

1%

18%

19%61%

Age Distribution of Patients with

Overweight or Obesity

0 to 3

3 to 6

6 to 10

10 to 13

13 and above

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Presence of Dx of

Obesity/Overweight

Had Dx 42.1%

Did not have Dx

57.9%

EXPLORING OUR PATIENTS NEEDS-NUTRITION

0

5

10

15

20

25

30

35

40

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PROGRAM DEVELOPMENT

Train faculty, staff, students and residents on

use of Motivational Interviewing for behavior

change

Create encounter form in the electronic

medical record to document weight

management plan

Establish routine follow up visits

Telemedicine Nutrition Visits Pilot

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NUTRITION


Implementation:

PHASE I : NUTRITION CLINIC

Phase II: implementation of a comprehensive nutrition and physical activity program that addresses knowledge and access to fresh fruits and vegetables for the family and community.

Setting goals and proposed patient outcomes:

Improved understanding of the link between diet and health

Increased physical activity

More effective and educated consumers

Motivating change in patients

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PILLAR # 4

MENTAL HEALTH

MENTAL HEALTH –

ASSESSING THE NEED

AAP policy statement in 2009 Recognized the uniqueness of the primary care clinician’s role: Building resilience in all children

Promoting healthy lifestyles

preventing or mitigating mental health and substance abuse problems

identifying risk factors and emerging mental health problems in children and their families and

partnering with families, schools, agencies, and mental health specialists to plan assessment and care

In July 1st 2013 – DC Medicaid Managed Care Organizations are required to ensure annual mental health screening using approved screening tools

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MENTAL HEALTH

PROGRAM INTERVENTION

Establish Screening as

a Standard of Care and

Best Practices in

Pediatrics Mobile Care

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CHILDHOOD MENTAL HEALTH-ASSESSMENT

Importance of screening for developmental, social emotional and potential mental health problems as early as possible

Reasons to screen AAP Guidelines

DC medical Community Commitment

Access to services

Mental Health-Preschool Children Prevalence

Any anxiety-9.4%

ADHD-2-5.7%

Depression-2.1%

Any emotional disorder-10.5%

Any behavioral disorder-9%

Any disorder-16.2%

Pervasive Developmental Disorders-1/125 4year olds

MENTAL HEALTH


Process planning:

Review Literature

Assessment of ways to implement and score tools in time efficient manner

Chart Audit initially throughout the Pediatrics Department

Establishing a referral network within the team and identifying outside providers that fit our patients needs

Program Development

Department wide implementation of universal screening

Staff training and pilot implementation of screening process (learning collaborative webinars and on-site training from pediatric psychiatry providers)

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MENTAL HEALTH- IMPLEMENTATION

All visits 1-3 year olds : Ages and Stages Questionnaire- Social Emotional

Component

MCHAT

All visits 4-11 year olds : Strengths and Difficulties Questionnaire –parent

report

All Visits 11-18 year olds: Strengths and Difficulties Questionnaire self report

All visits 18-21 year olds: PHQ-9 Adolescent

MENTAL HEALTH

PROCESS IMPLEMENTATION

Implementation:

Evaluation of billing and coding for mental health screening

Developing a system for tracking referrals to outside partner

Assess implementation of tool, report of result, referral of patient and billing for services used in visit

Evaluation and outcomes

Early identification of mental health conditions Chart Audit of pre and post implementation of screening tools in

well child visits

Improved emotional markers for our patients

Increased # of visits with a mental health management plan

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PILLAR #5

SOCIAL DETERMINANTS OF HEALTH

SOCIAL DETERMINANTS OF HEALTH: ASSESSING THE NEED

Social determinants of health are conditions in the environment in which people are born, live, learn, work, play and age that affect their health, functioning, and quality of life outcomes

Recognizing the social determinants of health in a primary care setting helps to explore how programs, practices and policies affect the individual, family, and community.

We know that we can provide good health services and promote healthy lifestyles

If we don’t address some of the other disparities or access issues our patients were experiencing: they will not achieve their optimal health status

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PROGRAM IMPLEMENTATION Social work services support the creation of a social

and physical environment that promotes good

health for all

Since 1997 the mobile program has employed a full

time social worker as part of the integrated care

model. With the family, the social worker examines:

The availability of resources to meet the daily

needs of the family (housing , food, clothing

Access to health care services (including

mental health services)

Access and quality of education

Availability of community-based resource to

support safe and appropriate recreational and

leisure activities

Exposure to crime and violence (community

and in the home)

Social support

Socioeconomic condition49



Social work services on the care mobile aims to emulate the medical home model and ensures:

children receive a continuum of care to help resolve their problems and make positive life changes

that limited resources are being maximized

that care is managed and coordinated effectively and efficiently for the most complex needs of children and adolescents

that ‘silos’ of care are removed to create a coordinated system

that educational resources are available for both patients, providers and community members to improve understanding of the impact of conditions on an individual’s psychosocial functioning.

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SOCIAL DETERMINANTS OF HEALTH-

EXPECTED OUTCOMES

Using collected data, in addition to pre-assessment and post-assessment instruments, measure the successful attainment of desired outcomes which include:

A reduction of symptoms

A return to previous levels of functioning

Attainment of necessary resources

Increase understanding for people to make good decisions about their health.

Connecting families to resources that enhance quality of life

This enables us to evaluate our program intervention strategies and make appropriate adjustments to best meet the needs of our patients.

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KEY CONSIDERATIONS FOR COLLECTING DATA

AND EVALUATING EFFECTIVENESS

Practice Management Information System

Electronic Medical Record

RADAR

DC Immunization Registry

Manual data collection

Surveys

Standardized tools

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THE FIVE PILLARS OF HEALTH

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An inter-professional model that focuses on care delivery that supports wellness in all five areas:

• Physical Health

• Mental health

• Oral Health

• Nutritional Health

• Social Determinants of health

Using data and patient outcomes we expect to measure

and evaluate the synergistic effect of addressing all areas

in sync to improve patient well being

IS THERE PROOF OF A SYNERGY IN

IMPLEMENTING THE FIVE PILLARS OF HEALTH

USING MOBILE HEALTH?

Not yet, but, the conversation is beginning…

Healthy People 2020 includes Health-Related quality of

life (HRQoL) indicators to measure impact of health

status on quality of life

Patient reported Outcomes Measurement Information system

(PROMIS) Global health measures

Well-being measures- assess the positive evolution of the

individuals daily lives, the quality of their emotions, relations,

and resilience

Participation measures- reflect the individuals’ assessment of

the impact of their health on their current environment

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SUMMARY

Mobile health can be synergistic.

We aim to prevent disease and therefore

create: Wellness

A holistic approach to health will lead to health

Outcomes measures are essential to measure

if we are being effective

Constant growth is an essential component to

our commitment to excellence

THANKS

QUESTIONS?

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