Children’s Medical Services SocialWorkers: Care Coordination and the

Medical Home Model in NM

Quality Improvement Initiative Maria Elena Corral, Abigail Fajardo, Janelle Groover, Jake Perret,

Brandon Proctor, Margaret White

Acknowledgements

• Envision New Mexico staff

• Children’s Medical Services staff

• Community Providers from around the state

• Families with Children with Special Health Care Needs (CYSHCN)

Outline

• IRB Process

• Stakeholders, Background, and Projected Outcomes of Study

• Qualitative Research Methodology and Interaction Data

• Recruitment, Demographics, and Themes from Community Focus Groups

• Future of the Study

• Out-takes

IRB Process

Primary Investigator: Dr. Kirsten Bennet • Study ID/HRRC#:16-279

• Exempt Protocol 45 Code of Federal Regulations, Section 46.101(b) Categories 2 and 3 • Research involving interview procedures or observation of public behavior

• Obtained through recordings

• Confidentiality of personal identifiable information maintained

• Approved 8/31/2016

Background – Why is this important?

• Children’s Medical Services – Care coordination

• Medical Home Model

• Quality improvement for NM residents

Projected outcomes

• 1) Implement positive changes in knowledge, attitudes and provider practice in care

coordination for CYSHCN by CMS social workers

• 2) Implement significant improvements in patient/family engagement in care consistent

with the American Academy of Pediatrics (AAP) Bright Futures Guidelines for evidenced-

based approaches to care coordination

• 3) Develop plans to improve:

• Primary Care Physician engagement with CMS social workers as part of the care team

•Tracking and follow up for families of CYSHCN receiving care coordination services.

Qualitative Study

• Key Literature: “Using focus groups in medical education research” - Stalmeijer,

McNauthon, & Walther

• Focus Group vs Group Interview

• Recruitment of Representative Sample

• Design of Questions

• Roles: Moderators and Observers

Methods

• Facilitate focus groups in 5 targeted communities

• Utilize World Café Model

• Analyze interaction and demographics of participants

• Condense responses into themes

• Summarize findings and define work for FY18

World Café

Research Questions

1.What are the roles and responsibilities of NM CMS social workers,

providers, community agencies, and families in the care coordination process

for children and youth with special healthcare needs?

2.How do CMS social workers coordinate care within the NM health care

system, in collaboration with providers, families, and community agencies?

3.What barriers exist within the NM health care system to implementing

effective care coordination within the medical home that is patient and

family-centered?

Interaction Data

• Consensus/Dissent

• Contribution of Participants to Discussion

• Energy of Group Discussion

• Nonverbal Body Language

• Interruptions

• Number of Words in Discussion

• Participant Interaction with Each Other

• Participant Interaction with Moderators

Las Vegas

Located 123 miles northeast from

Albuquerque on I-25. Las Vegas is in San

Miguel County (previously West and East

Las Vegas municipalities).

NM Highlands University

Large classroom, plenty room, no coffee

Recruiting

Focus Group Demographics

Focus Group Info:

(14 total participants)

57% Caucasian (8 participants) 43% Other (6 participants) ---71% Hispanic/Latino (10 participants) ---14% not Hispanic, 14% no answer (4 participants)

Ages ranged from 31-61+

Preferred Language: English (14 participants) All female

Las Vegas

Role

Community medical provider (CMP)

14

Community behavioral health professional (CBH)

1

7.14%

1

7.14%

CMS Social Worker (CMSW)

2

14.29%

CMS Administration (CMSA)

2

14.29%

Community Resource Professional (CRP)

5

35.71%

Medicaid Representative (MR)

0

0.00%

Intern (INT)

2

14.29%

Parent (PAR)

1

7.14%

Characteristics of CMS and Las Vegas CMS: 6 Counties

160 cases

---93% Medicaid, 6% private insurance,

1% undocumented, one case NMMIP

Clients from 0-21 years of age

Majority Hispanic, 5 Spanish Speaking Families

Population: 14,408 - 3,559 families

Las Vegas Demographics:

54% Caucasian

1% African American

2% Native American

.7% Asian/Pacific Islander

37% Other

5% 2 or more races

--- 83% Hispanic

24% of families (28% of pop. live

below the poverty line)

“2 of everything”

Themes Top Themes:

Access to services or providers

Communication/Collaboration

--CMS Identity

Client-Based Factors

Roles/Responsibilities:

Facilitators, resource providers/educators

Quotes/Themes that generated much consensus

Las Cruces

Road trip!

Recruiting

Over 4 weeks, >40 phone calls to 23 provider contacts

Participation based on role

Community medical provider 1 5%

CMS Social Worker 4 20%

CMS Administration 1 5%

Community Resource Professional 6 30%

Parent

40%

Total

8

20

Participant demographics

Race and ethnicity

Identified as anglo or caucasian

55%

Hispanic/Latino

85%

Prefered Language

English

80%

Spanish

10%

English and Spanish

10%

Age range Under 21 1

5.00%

21-30 0

0.00%

31-40 4

20.00%

41-50 11

55.00%

51-60 3

15.00%

Las Cruces and surrounding community

Population Las Cruces Doña Ana County New Mexico

Hispanic or Latino, percent (2015) 67.1% 48.0%

Hispanic or Latino, percent (2010) 56.8% 65.7% 46.3%

Language other than English spoken at home* 38.7% 51.1% 35.7%

With a disability, under age 65 years, 2011-

2015

7.5% 6.9% 10.1%

Setting

Comfy chairs

Good table cloths

Seasonally appropriate deco

Food and fluids

and Envision Swag!

Group interaction

Consensus/Dissent 92%

Consensus

Most Participants Contributed to Discussion

93% Yes

Family Member Active in Discussion

86% Yes

Energy of Group Discussion

61% Medium, 20% High, 12%

Low

7% Unsure

Nonverbal Body Language

87% Positive, 13% Unsure

Interruptions

95% Low, 3% Unsure, 2% Medium

Number of Words

75% High, 20% Medium, 5% Unsure

Participant Interaction with Each Other

45% High, 35% Medium, 15% Low, 5% Unsure

Participant Interaction with Moderator

45% Low, 25% Medium, 23% High, 7% Unsure

Themes

Roles and Responsibilities

CMSW and Community Resource Professionals

troubleshooter, problem solver

Parents - the leader

Family-Centered Care

Providers collaborate, partner and communicate as equals

Care Coordination

Last fail-safe, keeping kids from falling through the cracks

Magic wand solutions

Greater CMS visibility,

outreach to providers

CMS website

Social workers at IEPs

Family-Centered Care

What I Learned

What qualitative research looks like

Interview skills

Subtly steer conversations through the sneaky act of listening

Ask follow up questions that may elicit more in depth answers

Leadership from recruiting

Jake’s references

• The National Survey of Children with Special Health Care Needs Chartbook 2009–2010. (2013) U.S. Department of Health and Human Services. Health Resources and Services Administration https://mchb.hrsa.gov/cshcn0910/more/pdf/nscshcn0910.pdf

• Dona Ana County, New Mexico. Quickfacts. United States Census Bureau. https://www.census.gov/quickfacts/table/POP060210/35013,3502000,3539380,00

Dec.5th. 2016

Recruiting issues

Matt 25

• One stop community resource center

• Abandoned Memorial hospital building

• Support Groups

• Community Learning Classes

• Rainbow reading room

Demographics of the focus group

Hispanic: 54% Non-Hispanic: 45%

White: 81% Prefer not to answer: 18%

Age: 51-60 54 % 41-50 18% 31-40 9% 61+ 9%

English preferred language: 90% Unknown: 10%

Female 90% Male 10%

Currie County

Majority race: Caucasian 49%

The 2016 Community Health Needs Assessment for Curry County published by the New Mexico

Department of Health reports that Curry County is a rural county, has a health professional shortage,

and has been designated a medically underserved population area by the federal government. The

major city in Curry county is Clovis, NM.

Source: https://ibis.health.state.nm.us/

Focus Group Themes

• Lack of access to providers

• Lack of communication between providers and clients and MCO’s and clients

• Transportation to specialty care

• Out of state providers and access to medical records

• More outreach by CMS to let the community know about what they offer

In conversation with many providers after the

focus groups, and in work settings the process of

referring to Children’s Medical Services is not

clear.

• Website has confusing information about

financial eligibility for case management services.

https://nmhealth.org/about/phd/fhb/cms/cys

hcn/

• Providers are confused about why some

CYSHCN’s cannot get case management (ie:

autism)

• Providers and families are confused about the

role of the care coordinator vs the CMS social

worker.

Albuquerque

• Albuquerque, NM is the largest city in NM

• 32nd most populous city in the US

• Population was 545,852 in the 2010 Census

• Estimated up at 559,121 in 2015

Albuquerque Participant Roles and Languages:

Participant-Defined Role

•Comm. medical provider 2

•Comm. Behav. Health Professional 1

•CMS Social Worker 5

•CMS Administration 2

•Community Resource Professional 1

•Medicaid Representative 1

•Parent or family 6

Preferred Language

• English 14

• Spanish 3

• Tribal language 0

• English & Spanish 1

• English & Tribal Language 0

Albuquerque Demographics

Albuquerque Demographics

•Hispanic/Latino 46.7%

•White, not hispanic 42.1%

•Black or African American 3.3%

•Asian 2.6%

•Native American 4.6%

•Hawaiian or Pacific Islander 0.1%

•Male and Female 48.6% and 51.4%

Focus group Demographics*

• Hispanic/Latino 61.1%

• White, not hispanic 38.8%

• Black or African American 0%

• Asian 5.5%

• Native American 11.1%

• Hawaiian or Pacific Islander 0%

• Male and Female 11.1% and 88.9%

*5 of 18 participants choose not to provide demographic information

Albuquerque: Barriers and Needs Access to services or providers

Limited providers in Albuquerque:

• “It’s kind of heartbreaking to see providers leave the state, and it’s very difficult to convince others to come here.” ­

CMP

• “If I had a magic wand, I’d wave it over the legislature to have them put together a very serious plan to attract and

keep providers, all the way from medical providers to

nurse practitioners to dentists to physical therapists,

occupational therapists, speech therapists to attract and

keep them here in New Mexico.” -CMSSW

Access to transition and adult medical services:

• “So we've been in the situation when someone ages out that they're left without any services at all.” -CMSSW

• “I don't know who the adult providers are that would even take my phone call.” -CMSSW

• “It’s really difficult, because there is just a dearth. There are some specialties where there is not an adult doctor

that’s prepared to take the patient on. And then, in certain

departments, they were refusing treatment to anybody

over 18 in Peds.” -CMSSW

Albuquerque: Barriers and Needs

Culturally and linguistically competent providers

• “If they spoke Spanish...and not only speak Spanish, but to understand the culture...Navajo or whatever. To have

those providers be Navajo providers. Wouldn’t that be

amazing? That they understand the culture and they speak

the language.” -CMSSW

• “If I could do magic, I would make everyone bilingual, I would make people speak other languages that are not

common.” -Parent

• “It’s important for them to have someone, like a liaison or someone who speaks Spanish.” -CMSSW

• “Because not only do we have a huge Spanish speaking-only population, as a matter of fact, out of the, 99.6

percent of my families are all Spanish speaking only.” ­

CMSSW

• “I always run into the issue, parents can’t communicate because nobody speaks Spanish or they don’t understand

the culture” -CMSSW

• “I think it’s important for the providers to have people who speak Spanish, because sometimes, they talk to the

clients and they don’t understand English and it’s difficult

for them to communicate with us.” -CMSSW

Albuquerque: Barriers and Needs

Timely and close access to services or providers:

• “His providers are—the team, they're all in different places.” -Parent

• “I had to take my child to a urologist and it was going to take four months to get into UMH and he couldn’t wait.” ­

Parent

Financial hardship:

• “I don't have gas in my car. I can’t get my kid to thedoctor.” -Parent

• “If you don’t have the money, I’m very sorry. That’s too bad.”--CMSSW

Immigration status:

But all of mine are undocumented, every single one of my

clients is undocumented. -CSSW

Communication between medical providers and systems:

• “So it’s not just the systems not working together, it’s the larger communication.” -Parent

• “I will tell you, there are specialties at UNM that don’t send any feedback. There are many who send feedback

three to six months later.” -CMP

• “Doctors don't talk to each other. We are the communicators for everybody” -Parent

Zuni/Gallup

• Located 138 miles west of

Albuquerque on I-40, Gallup is in

McKinley County and had a

population of 21,678 at the 2010

census. A substantial percentage of

its population is Native American

with residents from the Navajo,

Hopi, and Zuni tribes.

Gallup Area vs. Focus Group Demographics

McKinley Co. Population 2010

(76,708 residents)

Native American: 77.5%

Hispanic or Latino: 13.8%

Caucasian: 9.3%

African American: 1.1%

Asian American: 0.9%

Focus Group Ethnicity/Race

Hispanic/Latino 3 30%

Not Hispanic/Latino 5 50%

Prefer not to answer 1 10%

Anglo/Caucasian 2 20%

Asian 1 10%

Native Am/Am Indian 3 30%

Prefer not to answer 3 30%

Gallup Focus Group Participants: Role & Language

Participant-Defined Role

• Comm. medical provider 4

• Comm. behavioral hlth professn’l 0

• CMS Social Worker 3

• CMS Administration 2

• Community Resource Professional 0

• Medicaid Representative 0

• Parent 1

Preferred Language

• English 6

• Spanish 1

• Tribal language 0

• English & Spanish 1

• English & Tribal Language 1

Gallup CMS Population Served: Age & Language Preference

Age of Clients 2/1/17

• 0-12 mos 1

• 1-5 years 8

• 6-11 years 14

• 12-21 years 19

• >21 years 1

Language Preference 2/2/17

• 26 English Primary Language

• 3 “other” language preferences • 1 Spanish

• 17 no primary language provided

• 5 English as second language

Focus Group Findings: Common Themes “To Walk the Journey with Them”

Service Providers

Availability of clinics

/medical providers

mentioned as an issue

as at other sites

Transportation

Remote nature of the site

and time and distance to

the major metro area for

services also mentioned

as a challenge as at other

sites

Communication/Records

Communication between

providers and between

providers and patients as

well as more efficient sharing

of records were mentioned

as challenges

UNM-Gallup, Calvin Hall

Luxury transport, Chauffeur in red velvet and weird location of gas tank

Christine points out mine tailing locations

That we talked about last semester during the seminar on the Navajo Birth

Cohort Study

Set-up is key

to smooth

operation

Brandon makes

demographic fun Abbie distributes forms

Jake provides directions

with great cheer ...._

Lrr J .J

Afterward

There’s Earl’s for

food and shopping!

Sharing this Information

Future of the project

• Recommendations for improvements

• Compile data in a report

• Quality improvement initiative and implementation (Year 2) --NM Title V Maternal Child Health 5-year action plan:

(1) Families of CYSHCN partner in healthcare decision making at all levels (2) CYSHCN received coordinated care in the medical home

(3) Services for CYSHCN are organized, accessible, and user-friendly