1. Medical Home:Just What the Doctor Ordered to Fix American Healthcare? GIH TeleconferenceRichard C. Antonelli, MD, MS Associate Professor of Pediatrics Univ of Connecticut School of Medicine Senior Fellow Child Health and Development Institute September 29, 2008

2. Learning Objectives

Articulate the key components of pediatric Medical Home

Understand primary care-based pediatric care coordinationand how it is different than adult CC

Articulate a process to measure care coordination in the pediatric primary care setting

Describe the different challenges and opportunities to provide care coordination to children and youth with special health care needs

3. Care coordination is the answer! 4. Whats the question? Carolyn Clancy, MD,Director, AHRQ 5. Definition of Medical Home

Care that is:

• Accessible

• Family-centered

• Comprehensive

• Continuous

• Coordinated

• Compassionate

• Culturally-effective

6. Definition of Medical Home

And for which the primary care provider shares responsibility with the family.

AAP/ AAFP/ NAPNAP/

ACP/ AOA

7. Patient-Centered Medical Home Joint Principles Statement

Major Focus of Advocacy for All Primary Care Specialties

Relationship between PCP and patient (adult MH) versus family (pediatric MH)

Quality

Access

Equity

Financing

8. Care Model for Child Health in a Medical Home Informed, Activated Patient/Family Prepared, Proactive Practice Team Supportive,IntegratedCommunity Prepared, Proactive Practice Team Functional and Clinical Outcomes Resources and Policies Community Health System Health Care Organization (Medical Home) Delivery System Design Decision SupportClinical Information Systems Care PartnershipSupport Family -centered Coordinated and Equitable Timely & efficient Evidence-based & safe 9. What is Care Coordination?

Depends who you ask.

A process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health.

AAP 2005

10. What Is Case Management?

Began in era of managed care as mechanism of ensuring access to appropriate benefits package of services: utilization review approach.

Any effective, sustainable community-based Medical Home system must support linkages between practice-based CC and community-based CM!

11. What Constitutes CC in a Pediatric Medical Home? 12. 13. National Study of Care Coordination Measurement in Medical Homes Antonelli, Stille, and Antonelli, 2008 14. 15.

Health Outreach for Medical Equality (HOME)

Pilot Project to Assess Feasibility and Outcomes of Co-LocatedCC model in anurbanpediatric setting

CC provided by Community-based partner (Hispanic Health Council) with clinic and community-based CC

Funded by Hartford Foundation for Public Giving, Childrens Fund of CT/ Child Health and Development Institute, Conn Childrens Medical Center, and CT Medicaid agency

16. Implications for Policy and Practice

With the advent of Patient-Centered Medical Home, all primary care provider organizations are focusing on CC as critical function

Payers and purchasers are looking at P4P to incentivize CC

CC for adult chronic condition CC is very different from pediatric CC

17. Implications for Policy and Practice

Pediatric disease-specific CC (aka, chronic condition management/ CCM) should be quite implementable

However, comprehensive pediatric CC is not the same as CCM

Mechanisms of operationalizing and measuring CC functionality at MH practice level must be developed

CC as a discipline must be developed in order to achieve high performing health care system

18. Transition for Youth You think pediatrics or adult CC is difficult, what about Transitioning youth with chronic conditions from one side of the chasm to the other? 19. Outcome Realities YSHCN

90% of YSHCN reach their 21 stbirthday

Nearly 40% cannot identify a primary care physician

20% consider their pediatric specialist to be their regular physician

Significant numbers have extensive primary health concerns that are not being met

Fewer work opportunities, lower high school grad rates and high drop out from college

CHOICES Survey, 1997; NOD/Harris Poll, 2000; KY TEACH, 2002 20. What Can Be Measured re:CC?

Pediatric Medical Home

• Parent/ youth partners in QI at practice level

• Developmental and behavioral screening

• Screening for secondary disabilities (much less prevalent than adult practice)

• Presence of registry and its utilization

• Development and deployment of Care Plans (these have CPT codes already)

• Mechanism for linkage from practice-based CC to community-based CM

• Training opportunities for CCers

• ED and in-patient utilization for patients with chronic conditions

21. How Can We Improve Quality and Increase Capacity?

Co-Management as means of increasing access and quality:

Targeted Child Psychiatric Services

Connor, Antonelli, et al (Clinical Pediatrics,June, 2006)

22. What Will Incentivize Change In Primary Care?

Patient-Centered Primary Care Collaborative (PCPCC)

Medicare Medical Home Pilots (2009)

State Level Medicaid Medical Home Projects

• North Carolina

• Minnesota

NCQA

23. PCMH-PPC: NCQA, AAFP, ACP, AAP and AOA Medical Home Qualifying Criteria Linked to Reimbursement 24. NCQA 6 Pts 2 4

Standard 4: Patient Self-Management Support

Assesses language preference and other communication barriers

Actively supports patient self-management**

20 Pts 3 4 3 5 5

Standard 3:Care Management

Adopts and implements evidence-based guidelines for three conditions **

Generates reminders about preventive services for clinicians

Uses non-physician staff to manage patient care

Conducts care management, including care plans, assessing progress, addressing barriers

Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities

21 Pts 2 3 3 6 4 3

Standard 2: Patient Tracking and Registry Functions

Uses data system for basic patient information (mostly non-clinical data)

Has clinical data system with clinical data in searchable data fields

Uses the clinical data system

Uses paper or electronic-based charting tools to organize clinical information**

Uses data to identify important diagnoses and conditions in practice**

Generates lists of patients and reminds patients and clinicians of services needed (population management)

9 Pts 4 5

Standard 1: Access and Communication

Has written standards for patient access and patient communication**

Uses data to show it meets its standards for patient access and communication**

4 Pts 1 2 1

Standard 9: Advanced Electronic Communications

Availability of Interactive Website

Electronic Patient Identification

Electronic Care Management Support

15 Pts 3 3 3 3 2 1

Standard 8: Performance Reporting and Improvement

Measures clinical and/or service performance by physician or across the practice**

Survey of patients care experience

Reports performance across the practice or by physician **

Sets goals and takes action to improve performance

Produces reports using standardized measures

Transmits reports with standardized measures electronically to external entities

4 PT 4

Standard 7: Referral Tracking

Tracks referrals using paper-based or electronic system**

13 Pts 7 6

Standard 6: Test Tracking

Tracks tests and identifies abnormal results systematically**

Uses electronic systems to order and retrieve tests and flag duplicate tests

8 Pts 3 3 2

Standard 5: Electronic Prescribing

Uses electronic system to write prescriptions

Has electronic prescription writer with safety checks

Has electronic prescription writer with cost checks

25. Useful Websites

http:// www.medicalhomeinfo.org : American Academy of Pediatrics hosted site that provides many useful tools and resources for families andproviders

http:// www.medicalhomeimprovement.org :tools for assessing and improving quality of care delivery, including the Medical Home Index, and Medical Home Family Index

26. References

Antonelli, RC ,Stille, C, and Antonelli, DM, Care coordination for children and

youth with special health care needs: a descriptive, multisite study of activities,

personnel costs, and outcomes.Pediatrics. 2008 Jul;122(1):e209-16

Turchi, R, Gatto, M, and Antonelli, R, Children and Youth with Special Health

Care Needs:There is No Place Like (a Medical) Home, Curr Opin Pediatr

2007, 19: 503.

Connor, D, McLaughlin, T, Jeffers-Terry, M, OBrien, W, Stille, C, Young, L, and

Antonelli, R,TargetedChild Psychiatric Primary Clinician-Child Psychiatry

Collaborative Care, Clin Pediatr. 2006; 45:423-434.

Antonelli, R., Stille, C., Freeman, L.,Enhancing Collaboration: Roles of Primary

and Subspecialty Care Physicians in Providing a MH for CYSHCN, MCHB,

Georgetown Univ, 2005.

Stille, C and Antonelli, R, Coordination of care for children with special health

care needs,Curr Opin Pediatr 2004;16:700-705.

Antonelli, R and Antonelli, D, Providing a medical home: the cost of care

coordination services in a community-based, general pediatric practice,

Pediatrics 2004; 113:1522-1528

27. References (continued)

McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with special health care

needs.Pediatrics ,102 ,137140

Committee on Children with Disabilities, American Academy of Pediatrics. (1999). Care coordination:

Integrating health and related systems of care for children with special needs.Pediatrics ,104 (4, Part 1),

978981

Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm:

A new health system for the 21 stcentury

Friedman, Mark, Trying hard is not enough; excellent reference on Results-Based Accountability.