Newport County Community Access to Child Health (CATCH)

1. Newport CountyCommunity Access to Child Health(CATCH) Creating Medical Homes for all Children in Newport County, RI Newport, Middletown, Portsmouth, Tiverton, Little Compton, Jamestown

2. Beginning Ideas • Newport County CATCH grew out of the commitment to child well-being* of the Newport Partnership for Families (NPFF), an existing community collaboration representing over 35 human service agencies, businesses and other organizations in Newport * Child well-being is one of four priority areas measured by the NPPF

3. Initial Steps • Step 1: Received a planning grant based on the NPFF’s identification of access barriers to healthcare for young children. • Step 2: Conducted outreach to the community to assess the quality of Medical Homes and training needs required to care for Children with Special Health Care Needs (CSHCN)

4. Newport County CATCH Purpose: • The primary purpose of the Newport County CATCH/Medical Home Initiative is to facilitate the creation of medical homes for all children in Newport County. Medical homes will posses the seven common elements as defined by the American Academy of Pediatrics (AAP)

5. Newport County CATCH Goals: • Develop and implement a carecoordination system to support the medical home • Identify and reduce barriers to medical homes. • Provide medical hometraining to parents, medical and human service providers • Evaluate the impact of our interventions • Implement systems to sustain and ensure quality medical homes for all children.

6. Newport County CATCH Funding • Current funding for Newport County CATCH is provided by: • Newport Hospital • RI DOH, Division of Family Health

7. Newport CATCH Organizational Structure

8. Function Description

9. Newport County CATCHMedical Home Advisory Committee • CEDDARs • Covering Kids and Families • Early Intervention • East Bay Community Action Program (EBCAP) • Family Practice Physicians • Head Start • Health Plans • Newport & Middletown Public Schools Family Center/COZ • Newport Partnership for Families • Newport County Health Advocates

10. Newport County CATCHMedical Home Advisory Committee • Newport County Community Mental Health Center’s Child Intensive Services (CIS) and Child and Adolescent Services Program (CASP) • Newport Hospital • Parents • Pediatric Practice Enhancement Project (PPEP) Parent Consultant (PC) • Pediatricians • Rhode Island Department of Health • Rhode Island Health Center Association • Special Education Departments • Visiting Nurse Service of Newport and Bristol Counties

11. Traditional Pediatric Delivery SystemFragmented, Hard to Navigate, Episodic, Expensive Pediatrician/ Family Practitioner Community Support Groups/Resources Recreation Health Plans Transportation Special Education Mental Health Family Family Services Schools Early Intervention Child Outreach Sub-specialists Home Care Emergency Care Rehab Services

12. Comprehensive/Coordinated Family - Centered Medical Home CEDDAR RIPIN/Family Voices NHPRI Medical Home -Physician -Family (PPEP) Parent Consultant Aquidneck Medical Associates Newport Hospital FRCs/FSCs Special Education Child Outreach EBCAP Sub-specialists Head Start/Child Care Early Intervention Home Care Mental Health Services Schools Rehab Services

13. Physician Practice Training Team • Objectives: To develop and offer current, meaningful, and community-focused medical home trainings for pediatricians and family practitioners and their staff • To establish a single point of contact as a resource for quality improvement (CATCH Coordinator)

14. Physician PracticeTraining Team • Action Step: Developed a curriculum which includes • The history of Newport County CATCH • Community assessment methodology and findings • Common elements of a medical home • Cost benefits of operating a medical home, particularly for utilizing care coordination services • Codes for extended care • Medical Home indicators (for self-evaluation) • Strategies for medical home improvement

15. Community Agencies Training Team • Objective 1: Share care coordination information with the community through medical home trainings, single point of contact and through the development of a medical home

16. Community Agencies Training Team • Action Step: Provided medical home training to approximately forty five health care coordinators* at agencies throughout Newport County. * Agency care coordinators include family service coordinators, mental health workers, nurse/educators, health advocates, case managers, social workers, physicians and practice staff (any provider that links families to community services)

17. Community Agencies Training Team • Objective 2: Identify and document all sources of care coordination support Such as PPEP, CEDARR , East Bay Community Action Program, Child and Family Services, Newport County Mental Health Center, NHPRI Case Management, Housing Authority, Family Service Coordinators, COZ Centers, Visiting Nurse Service of Newport and Bristol Counties, Head Start, Early Intervention, Newport and Regional Special Education, Dr. Martin Luther King Jr. Center, CODAC

18. Community Agencies Training Team • Action Step: Developed a comprehensive list of agencies that provide care coordination by disseminating a care coordination services survey . • Based on returned surveys, developed a Pediatric Care Coordination Directory that defines the scope of care coordination provided by each agency (40 Agencies Represented) • Distributed over 120 Directories to agencies and physician practices as part of Medical Home Trainings

19. Community Agencies Training Team • Objective 3: Assist in orienting PC’s to community care coordination services and through the PPEP provides Newport County CATCH with feedback about gaps or delays in service delivery

20. Family Training Team • Action Step 1: Developed a family questionnaire to capture current and specific problems regarding barriers to medical homes and to define the educational needs of the families.

21. Family Training Team • Action Step 2: Provided medical home education for families through focus groups. • Educated over 400 parents on medical home concepts during focus groups. • The 400 parents represented parents served by support groups, Head Start, Even Start, the Newport Hospital Birthing Center, mental health parent groups, and the Newport County Regional Special Education Advisory Committee, etc. • Families are instructed on how to advocate for their child and how to make maximum benefit of the visit to the medical home

22. Barriers Workgroup • Objective: Identify and address barriers to use of medical homes, including: • Transportation • Language • Health Insurance

23. Barriers Workgroup • Survey findings on transportation: • No bus service on Memorial Blvd. which is the location of the largest pediatric practice in Newport County • Confusion over RIte Care transportation benefits. • Bus routes are unclear.

24. Barriers Workgroup • Transportation Actions Taken: • Partnered with RIPTA to create a medical home bus route map to be distributed at the birthing center, physicians offices, and to parents in medical trainings. • DHS provided CATCH with an explanation of transportation benefits which will be distributed to parents and providers.

25. Barriers Workgroup • Survey findings on language & culture: • Parents don’t understand medical jargon. • Lack of written bilingual information. • Parents find it difficult to tell the doctor they don’t understand their instructions. • Cultural sensitivity is lost if a different doctor is seen at each visit.

26. Barriers Workgroup • Language recommendations made: • Raise awareness of RIte Care interpretation/ translation benefits. • Create flyers in multiple languages describing the above benefit to distribute to parents at medical home trainings. • Encourage physicians to assess their practice’s need for interpreters. • Ask physicians what bi-lingual information would be useful for the practice and help them get it.

27. Barriers Work Group Health Insurance • Identify locations where families present without insurance i.e. Newport Department of Labor and Training, Housing Authority Intake Offices, Urgent Care Facilities, E.R. etc. • Collaborate with Covering Kids to provide community education concerning RIte Care/RIte Share benefits, eligibility guidelines and enrollment procedures

28. Newport County CATCH • Overall Lessons Learned: • Simplify medical home jargon. Make it Relevant • One-on-one visits with organizations work best. Use visits to learn of services that are or are not available in the community • Plug into existing community organization networks, develop collaborations • Help stakeholders understand how they benefit from medical homes. • Tailor medical home trainings to your audience ie families, human service agencies, PCP’s • Family input is critical in the development of curriculums and training strategies

29. Future Initiatives • Collaborate with the PPEP to define access barriers and capacity issues & continue collaborative problem solving with providers and families • Collaborate with the RI Lung Association, Hasbro Children's Hospital and Newport Hospital to implement community needs assessment and training for asthma • Develop Neighborhood Training Teams in collaboration with the Newport Housing Authority

30. Future Initiatives • Provide medical home training to school educators, FSC(s) and health advocates as part of the Train the Trainer Initiative • Collaborate with mental health and special education services to integrate care into the medical Home • Develop a Newport County Medical Home web-site for families and providers • Maintain and build upon established medical home services and products • Obtain funding to sustain Newport County CATCH/Medical Home Initiative

31. Newport County CATCH For more information contact: James Sattel Newport County CATCH /Medical Home Initiative Coordinator 435 Broadway Newport, RI. 02840 (401) 847‑2100; ext 223 jsattel@ebcap.org

32. Newport County CATCH • Question and Answer Time