“building your own pediatric medical home for cshcn”
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“Building Your Own Pediatric Medical Home for CSHCN”. Jennifer Lail, M.D. Jacksonville, FL October 16, 2010. With Help From:. Blue Cross Blue Shield of NC Foundation Division of Medical Assistance of NC, Quality Management Dept. NC Title V Program Joseph, Christina and Teresa. - PowerPoint PPT PresentationTRANSCRIPT
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“Building Your Own Pediatric
Medical Home for CSHCN”
Jennifer Lail, M.D. Jacksonville, FL
October 16, 2010
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With Help From:
Blue Cross Blue Shield of NC Foundation
Division of Medical Assistance of NC, Quality Management Dept.
NC Title V Program Joseph, Christina
and Teresa
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Disclosures “I have no relevant financial
relationships with the manufacturer(s) of any commercial products and/or provider of commercial services discussed in this CME activity.”
“I do not intend to discuss an unapproved or investigative use of a commercial product/device in my presentation.”
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Objectives
Identify Medical Home adaptations to pediatric practice that support patient-centered care for all, esp.
CYSHCN
Discuss how patient-centered and planned care promotes communication between patients and multiple providers and facilitates all medical transitions
Understand new initiatives that link Medical Home practices to reimbursement
“I want to try that!” ideas
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What is a Medical Home? “The Medical Home is the model for 21st
century primary care, with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated and family-centered manner.”
-American Academy of Pediatrics www.pediatricmedhome.org/
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“Crossing the Quality Chasm: A New Health System for the 21st Century”
-New Performance Expectations for care that is:
PATIENT-CENTERED SAFE EFFECTIVE TIMELY EFFICIENT EQUITABLE
-Institute of Medicine, Committee on
Quality of Health Care in America, 2001
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Quality Chasm Rules for Practice Redesign 1. Care is based on continuous healing relationships
2. Care is customized according to patient needs and values.
3. The patient is the source of control.
4. Knowledge is shared and information flows freely.
5. Decision making is evidence-based.
6. Safety is a system property.
7. Transparency is necessary.
8. Needs are anticipated.
9. Waste is continuously decreased.
10. Cooperation among clinicians is a priority.
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“System Changes? I have patients to see!”
One in 5 families has a CSHCN
Survival/Longevity among CSHCN is increasing
Design is for 1 problem in 10 minutes
Retail-based Clinics erode our acute care base
Reimbursement will be linked to system change
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Welcome to Our Medical Home!
Suburban Private Practice, 2 offices, self-owned
Duke University and University of NC Medical Centers within 15 miles
12 MD providers, 9 F.T.E.
74% Managed Care
13% Self Pay (incl. HSA) 13% Medicaid + SCHIP
>30 year history of collaboration with both medical centers
Office hours 365 d/year
Evening/weekend office hours
Nighttime Nurse triage and daytime Advice Nurses
Transition to EMR in fall 2007
Around 50,000 visits/year at 2 sites; 12,233 physicals
See til 21, 43% in registry are 12 and older
Age 12-21 = 24% of 2009 physicals; 4% > age 18
27% CSHCN in registry are Medicaid-insured
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Imagine: Staff recognizing a parent when
appt. is made Adequate time scheduled for that child Specialist’s records in your hands prior to the visit,
including lab and X-ray results Parent concerns identified before the visit; multiple
tasks completed Lab slips ready, and EMLA cream on child prior to
visit Help by your staff for families with referrals,
resources, equipment Followup to assure completion of tasks
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Essential Components of a Medical Home System
Relationships/RespectReady AccessRegistry and RecordsResourcesReimbursementRecruitment
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Relationships Youth and family Supportive staff Care coordinators Specialty Providers
and their staff Schools Insurers Community Providers
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Ready Access
Accept Medicaid, many insurers
Evening, Weekend and Holiday office hours
24-hour advice nurses Care til age 21 Translation Phone Privacy protection for
Teens ADA accessible physical
plant Handicapped parking
spaces Identified Adult
Providers
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Registry & Care Coordination Program
“The Left Ventricle of the Medical Home”
Identifies who needs more help
Separate from Advice Nurses
Direct Phone Extension Brochures and Business
Cards Care Coordinators Link to
Other Care Coordinators!
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Care Coordinators: -Maintain registry of 1434 pts.; data entry, annual purge, data enquiries
-Referrals: 1690 in 2008, 1800 in 2009-contact parent-assure referral data is at specialist
-obtain and scan notes from specialist appt.-referrals directly from parent after familiar with CC system
-Pre-Visit Contacts: 298 in 2008, 473 in 2009 -Transition Care:
-Hospital and ED fup, locating records, calling family, scan to EMR-Newborn entry to practice; discharge summary, NBS results-New pts: obtain old med records, PVC’s with families-Capture of episodic care and return to care system-Bridge of information for parents between school/Medical Home
-Pre-authorizations-radiology procedures-insurance authorizations for specialists
-Medical Necessities:-durable med. eqpt-mattress/pillow covers-Bipap machinery-authorizations for CAP-C, CAP MR/DD
-Medicaid Interface:-capture of episodic care-collaboration with Medicaid Case Managers-Followup on missed primary and specialty appts.
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Registry: Knowing Who Needs Care
Maintained by Care Coordinators
Notebooks Excel Access EMR
Alerts schedulers to need for more time
Assures key data to specialist for consult
Track referrals and specialist reports
Prompt Pre-visit contacts
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Risk Stratification = Complexity Scores More time? Communication
devices? Technological
support? Translator? Pre-Visit
Contact?
REGISTER YOUR PATIENT WITH SPECIAL HEALTH CARE NEEDS-completed form to Peggy Name:_______________________________Race___________ Sex__________Birthdate________________Chart #________________ Insurer:________________________________ Primary CHP Provider: SBH MI CM JO AD SVH RMC KS JL RSW KM Diagnoses: 1) 2) 3) 4) CSHCN Complexity Rating
Description
Examples
1
1 chronic condition, well-controlled OR Significant PMH, quiescent or resolved
Asthma, mild per. Repaired VSD
2
1 evolving chronic condition, unstable OR 2 chronic conditions, both well-controlled
Asthma PCOS +Type 2 DM Asthma +ADHD
3
2 or more chronic conditions, with either unstable
GERD Asthma w/ER visit
4
Any tech. dependent pt. Mod./severe cognitive delays
(wheelchair, walker, GT, Trach) MR, Autism, Group Home res.
+1
Language barrier
Non-English speaker
+1
Behavioral Disorder
OCD, Anxiety in addition to above
+1
Family/Social Complications
Divorce, Horizons
Total complexity score
DO YOU WANT A PVC DONE? YES NO
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Registry-Helps Document Care
Permits data collection for negotiation with insurers
Permits recall by dx for research, parent-to-parent
Aids in NCQA certification process for PCMH
Assists with chart retro-fit for EMR
Risk-stratification for Care-Planning
Population-based care (flu, Synagis, etc.)
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Registry permits Planned CarePVC = Productive Visit
Care Coordinator identifies for
Pre-visit contact
MD visit, referrals
made, resources
found
CC helps parent with referrals, resources
CC calls parent, notes
concerns, and interim encounters
CC gathers specialty reports, assures
adeq. time
PVC, spec. data to MD for Preview
MD previews
chart, requests
more info or time
Parent calls for physical
appt. for CSHCN
“Special”
Lab and XR slips are created, EMLA cream made available
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PVC’s streamline care Parent survey of
PVC’s- 93% rate as “very helpful”
“it shows you care about my child”
“makes my visit more useful and efficient”
“less reviewing, more looking forward”
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MH Services aid Collaboration/Comanagement with
Specialists
Care coordinators as facilitators Assure that referral data sent and visit
accomplished Access to Specialist records (letter, fax-back,
electronic) Phone/email dialogue re: care Specialty followup at PCP office (weight
checks, labs) Synthesis of thought from multiple specialists
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Our Parents/Families as Resources Education!
Parent-to-Parent Collaboration
Advocacy Groups
Personal Knowledge of Local Providers and Services
Word-of-mouth referrals
Physical Plant walk-through
Boardmaker
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Community Resources Directory “answers in our pockets”
Ask MD’s to submit their favorites from all disciplines
MD’s who respond get a copy!!
Parent Partner and Care Coordinator add Local Resources
Every Fall, update from margin notes and new mailings
Pocket size fits Lab coat 5th edition now in use
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CSHCN Directory Index State Programs for CSHCN Alternative Medicine Audiology Augm. Comm./Asst.Technology Autism Baby Nurses Carseats for CSHCN Child Abuse Child Psychiatry/Psychology Community MD’s Compounding Pharmacies Dentistry Devel. Eval and Therapy Domestic Violence Early Intervention Eating Disorders G-tube and Trach care Genetic Testing Grief Counseling/Hospice Group Homes Gynecology Handicapped Parking
Health Depts. Home Health Care/Eqpt. Lactation Services Nutrition Orthotics OT/Feeding Parent-to-Parent Podiatry PT PT Sports/Injury Rare Disorders Recreation for CSHCN Rehabilitation Specialists Respite/Residential Care School Systems Social Services Smoking Cessation Speech SSI Substance Abuse Travel for CSHCN Voc. Rehab. Misc.
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Resources for Young Adult Care
Med-Peds Trained ? Family has prior
relationship? Identify by Transition
Fax-Back Transition Provider List Update List yearly Give list before Transition
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A Medical Home for CYSHCN eases transitions
Trusted relationships Established access to care Providers identified (medical
and support) Current Problem List defined Established mechanisms of
communication Resources and obstacles
identified Upcoming needs anticipated
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Reimbursement-How to Pay for Improvement
Market your Medical Home services
Optimize MD time with Care Coordination
Proper coding for care of CSHCN
Careful attention to charge capture
Contract renegotiations with insurers (data!)
Medicaid Community Care-case management fee pm/pm
NCQA- Physicians’ Practice Connection/Patient Centered Medical Home
Pay-for-Performance Programs
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Families want a Medical Home!
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Adequate time for the visit promotes appropriate coding
Remember CYSHCN visits often are 99214
Learn to use modifiers
Learn to code for time
Capture all charges Do coding reviews Code for after-hours
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Appropriate Coding for Enhanced Care
% of PF Office Visits Ideal 5% 2.4% 3.1% 4.8% 4.8%
% of EX Office Visits Ideal 60% 68.0% 68.1% 70.3% 72.3%
% of DT Office Visits Ideal 30% 27.6% 27.0% 23.2% 21.5%
% of CP Office Visits Ideal 5% 1.9% 1.7% 1.6% 1.3%
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Better Quality = Better Reimbursement Renegotiate Contracts with Data
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Big Goals— Small Steps Adequate time for care Better planned visits Better links with
specialists Help with referrals and
resources Family satisfaction Fiscal Viability Caution-Don’t wait for
consensus
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Countless Small Steps Later 4/03—10/10NICHQ Medical Home Learning Collaborative
Docs re-educated on coding for CSHCN
Title V 3 year grant
Forum with CHPA, Parents and School Admin. for CSHCN in schools
“Listening Session” with CHPA parents to identify needs
Streamlined “checkout” process
Joined NC Medicaid Managed Care Network
Computer Access for UNC, Duke
“Backlines” to Specialty Care
Identified 1500+ in registry and Office Mgmt. System
Care Coordinator from 3 hrs./wk to 2 full-time positions
5th ed. CSHCN pocket phonebook; transition referral options
93 % of Families find PVC’s helpful
Reduced ED and after-hours utilization for 4 years
Boardmaker for commun. impaired BCBS “Bridges to Excellence” P4P
program; NCQA certification; BQPP participation
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So how do we get there? Identification of problem
areas Establish explicit goal to
address Break process into tiny
steps Create tools to support
weak spots Try ONE SMALL change Measurement of
improvement (or failure!) Try another test of change
and see if you’re ready to grow that change
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BTE,
QI, PPC-PCMH, BTEBQPP, NCQA, PDSA??
Enhanced reimbursement for quality improvements
PLAN-consider a needed improvement
DO-try some SMALL changes to make it better (“test of change”)
STUDY-measure if your changes helped
ACT-refine the process to make it work even better
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IMPORTANT…
NCQA CERTIFICATION
is NOT the same as
A Patient-Centered Medical Home
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NCQA Certification Process
Pay for Performance program
Promotes processes and information systems to improve patient care
Three levels of incentive payments
Certification by NCQA for 3 years.
EVALUATES: Access and
Communication Patient Tracking and
Registry Functions Care Management Pt. Self-Management E-prescribing Test Tracking Referral Tracking Performance Reporting
and Improvement Advanced Elec.
Communication
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BQPP - demands NCQA certification
Enhanced reimb. on E&M codes to max of 176% of Medicare
Measures: Clinical Quality Outcomes (NCQA cert.) Administrative Efficiency Patient Experience with Care
2 levels of reimb. increase 15% over standard 30% over standard
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“When you stop getting better, you stop being good”---Wyatt Taylor
“Changing a Pediatric practice is like changing the tire on your bike while you’re riding it” --- Carl Cooley
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“My family, with all its challenges, is a success story, but part of that success is because we have
had a Medical Home”… Libby
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Relationships/Respect Ready access Registry and care coordination Resources Reimbursement RECRUITMENT??
WHAT DO YOU WANT TO TRY?