Jeanne W. McAllister, Co-Director Center for Medical Home Improvement

1. Building Primary Care Medical Homes for CSHCNs & Assessing the Quality1st Annual National EHDI MeetingFebruary 11-13 Vienna, Virginia Jeanne W. McAllister, Co-Director Center for Medical Home Improvement Hood Center for Children and Families Dartmouth Medical School, Lebanon, NH Funding USMCHB

2. Center for Medical Home Improvement Mission The mission of CMHI is to establish and support networks of parent/professional teams to improve the quality of primary care medical homes for children and youth with special health care needs and their families. (2001)

4. A Medical Home • Is not so much a place… • But a structure and process of care • That emphasizes “home” as a: • Centralizing headquarters for care • Place to feel recognized, welcomed, supported • Connection to other community resources

5. Primary Care Medical Homes Agree? Disagree? • All primary care practices are medical homes • Family feedback is difficult to obtain & to hear • Care coordination activities occur in most practices • Improvement is key to building a medical home • Measurement discourages providers • Families report (CMHI) experiencing high levels of: • understanding & listening • care & respect

6. Primary Care Medical Homes Agree? Disagree? • All primary care practices are medical homes (D) • Family feedback is difficult to obtain & to hear (D) • Care coordination activities occur in most practices (A) • Improvement is key to building a medical home (A) • Measurement discourages providers (D) • Families report (CMHI) experiencing high levels of: • understanding & listening • care & respect (A)

7. Improvement Strategies in Primary Care… Why are they needed?

8. Pediatric primary care • Designed for the 80% of children who do not have special health care needs • Designed to provide well child preventive care services and acute illness management • Designed to support a single service unit: the provider – patient encounter

9. Changing a pediatric practice is like trying to change the tire on a bicycle while you are riding it

10. CMHI methodology emphasizes: • Partnerships with parents • Primary care-based care coordination • Provider leadership • Continuous improvement process • Linkages to community resources • Improved office systems that: • Identify CSHCNs • Track and monitor progress • Evaluate outcomes

11. Clinical Value Compass for Medical Home CMHI Functional:  stress/worry  school absence  dx/rx information access  family caregiving competence Clinical:  preventive services for CSCHN  illness episodes  acute encounters Satisfaction:  communication  office responsiveness  care plan/continuity  family involvement Cost:  ER, hospital visits  unnecessary specialty & office visits  lost parental work time  care coordination activities received Center for Medical Home Improvement - Outcomes, 2001

12. Not everything that can be counted counts, and not everything that counts can be counted. Albert Einstein

13. Levels of measurement • Population level measures • What percentage of CSHCNs receive care in a Medical Home? • Practice level measures • Where is the practice on the “medical homeness” continuum • Intra-practice measures • Which changes in care constitute improvements? • Data that can feed forward and feedback

14. The Medical Home IndexValidation/Classification Tool 6 Domains (25 Themes) • Organizational Capacity (7) • Chronic Condition Management (6) • Care Coordination (6) • Community Outreach (2) • Data Management (2) • Quality Improvement/Change (2)

15. Achieving “medical homeness” • MHI measures movement toward a Medical Home • Basic (good) pediatric primary care (Level 1) • Responsive pediatric primary care (Level 2) • Proactive pediatric primary care (Level 3) • Comprehensive pediatric primary care (Level 4)

16. Points: (1 2 3 4 5 6 7 8)

17. MHI results from 43 practices

18. Distribution of overall mean item scores

19. Medical Home Index - pre-improvement (1 2 3 4 5 6 7 8) (*Rated by interviewer using primary care audit responses).

20. Medical Home Index - post-improvement (1 2 3 4 5 6 7 8)

21. Medical Home Index scores2001 & 1998 (estimate)

22. The Medical Home Family Index - practice level measurement • Short family survey available in English and Spanish • Maps to the Medical Home Index • Blends parent/professional perspectives as a basis for improvement

23. Building Medical Homes -Model • Measurement/Improvement/Measurement • Learning collaborative/ network • brings energy, support and family input to primary care • contributes to their vitality • outcome of strong medical homes for children and families

25. Center for Medical Home Improvement • Improvement kit keyed to Medical Home Index • Building a Medical Home – Improvement Strategies in Primary Care for Children with Special Health Care Needs • Web site: www.medicalhomeimprovement.org • Download kit and measurement tools • Links to other resources • News • Interactive self-assessment (future) • Jeanne.W.McAllister@hitchcock.org

26. Home is the place where When you have to go there They have to take you in Robert Frost