The Operations of the Medical Home In-Depth: Developmental Screening and Care Coordination

1. The Operations of the Medical Home In-Depth: Developmental Screening and Care Coordination Hilary Gillette-Walch, RN, MPH Program Director, Cowlitz Center of Foster Care Health Phyllis M. Cavens, MD Medical Director Email: pcavens@pacifier.com Child and Adolescent Clinic, Longview, WA www.candac.com

2. Cowlitz County

3. Cowlitz County Overview • A resource-based economy with a population of 98,000 persons • High rate of unemployment in the state (over 8%) • Low rate of college education attainment among adults (2000 Census) 13% of Cowlitz adults vs. 26% of Washington State adults • High rate of women delivering without a high school education (27%) and high rates of Medicaid utilization (64%) for prenatal care and delivery (2005 birth data)

4. Objectives • Discuss the implementation of developmental screening into the pediatric practice • Review a model of care coordination, focus on children in Foster Care • As time allows, review strategies for financially supporting this work

5. The Child and Adolescent ClinicLongview, WA

6. Child and Adolescent Clinic • Pediatrician-owned practice and clinic • 10 pediatricians, 4 PNPs, 55 support staff • 20,114 patients (29% Medicaid) • 41,258 yearly visits (52% Medicaid) • 41% of annual income goes to the clinicians

7. Pediatrician & Policy Driven Family Centered Culturally Effective Compassionate Continuous Resource Driven Coordinated Comprehensive Accessible Medical Home

8. Developmental Screening • AAP 2006 Policy Statement regarding developmental screening, “It is an integral function of the primary care medical home and an appropriate responsibility of all pediatric health care professionals.” • Incorporate surveillance at every well child preventive care visit. • Early identification is critical for access to services and treatment.

9. Groundwork before Implementation • Find your physician champion • Identify one person to coordinate the process in the medical home • Partner with and utilize your local Early Intervention program – in Washington its “Infant Toddler Early Intervention Program (ITEIP)”. • http://www.dshs.wa.gov/iteip/ • Our model found that we needed some additional funding to support this work, approximately $3,000 annually

10. Clinic Budget for 2008-2009

11. Steps to Implementation • Business contract with Early Intervention provider- Neurodevelopmental center (Progress Center) • Clearly spells out how funds are to be used (if providing the ND center with funds to support their activities) without jeopardizing other grant money they may be receiving. • Indicates specific role of each agency • HIPPA clause (or make separate contract) allows for transfer of information between the agencies – specific to the screening program

12. Implementation, 2 • Identify a tool – with Clinician input • Ages and Stages Questionnaires (ASQ), Battelle Developmental Inventory Screening (BDI-ST), Bayley Infant Neurodevelopmental Screen (BINS), etc. Complete list with details is here: • http://aappolicy.aappublications.org/cgi/reprint/pediatrics;118/1/405.pdf • Determine the ages and visits when the tool will be used by your practice: • Where will it be completed? At the office? In the waiting room? At home? • Identify all staff that will be impacted by the process, create a team of staff that represent these work areas

13. Implementation, 3 • Draft a possible flow of the screening tool through your entire clinic with team members: • Who copies the screening tool? Other parent ed materials? • Who gives it to the parent? • Who scores the tool? • When does the clinician review the tool with the parent? • Who makes referrals on screens that are positive? • What information goes to the parent? • Where does the screening tool get filed? • Where are the results documented in the chart? • Who bills the insurance company for completed tools? • How will you track if the tool has been completed?

14. Parent Completes Screening Tool Flowchart Screen is Negative Staff Score tool, review narrative answers Screen is Positive RN reviews results with chart in hand. -Flags result, puts copy of tool in chart -Is child up to date on well-child exam? -Determines if the concerns have already been addressed by clinician, if yes, typically monitor future screening results. -If concern is new or no evidence that it has been addressed completely, evaluates whether a return visit is needed. -Checks with MD on some of these, if it has been some time since last visit, especially if problem severe, if rescreening might be needed, etc. Parental Concerns No Concerns (aide charts result on a worksheet in chart)

15. Implementation, 4 • Launching the project • Notify families that they are being enrolled in the screening program, give them information about the process and tool. • Identify your cohort of children to be screened, create a process for updating monthly with births, moves, deaths, etc. • Determine a process for reminder letters or calls to parents for completed tools, if desired. • Meet often in the first few weeks • Train staff, then train again

16. Implementation, 5 • Autism and ADHD evaluation: • Have tools and processes selected for staff to move to when a parent raises these diagnoses as a concern. • MCHAT gets completed by the clinician during a visit with the parent • Appointment staff: • Be ready to schedule appointments – for well child exams, hearing screening, anything that might be due - or to return for further evaluation or parent conferences.

17. Utilize the Children With Special Health Care Needs (CSHCN) Program Public Health Nurses • Meet your local staff • Get a copy of their referral form • Find out their procedures for following-up on referrals and giving feedback about services provided. • Identify the contacts for your local school district – know how they want to receive referrals for screening.

19. Results of Screening, June – Nov., 2008 (932 screenings completed of the 2,800 mailed out, there may be some children who were screened more than once in this period).

20. Follow-up on Positive Screens and Parent Concerns (n=152)

21. Cowlitz Center of Foster Care Health • The Center’s goal is to create a model medical home site specific to children in foster care which will result in improved health outcomes for participating children. • Participating children are defined as children currently in out-of-home placements through the auspices of Children’s Administration and are current patients of CAC.

22. Cowlitz Center of Foster Care Health • Using the Medical Home Care Plan as the key document for individual case information about each participating child. The purpose of Medical Home Care Plan: • A summary of key data regarding the child’s overall health especially in regards to their foster care placement. • Is a central location from which data entry can be completed to support performance measures • A place to communicate concerns, findings, and plans that the clinic has for the child • Document results of mental health screening done by Center staff and plan for follow-up.

23. Medical Home Care Plan • The Program Director and Counselor review all incoming documents and: • Use them to update the care plan • Remove duplicate files • Remove irrelevant files (fax cover sheets) • Highlight any files that might impact the ongoing medical care of the child for the pediatrician’s review • When it appears all available records have been reviewed, or as acute needs of the child dictate, will determine if case conferencing for individual child is needed with the pediatric clinician.

24. CHET Child & Adolescent Clinic Chart MMIS Medical Home Care Plan Medical Records from Children’s Administration Mental Health Records MMIS: Medicaid management information system CHET: Children’s Health Education Tracking To be determined, educational updates, conferencing with social worker, family.

25. Cowlitz Center of Foster Care Health MMIS Print out (Medicaid management information system) A listing of services paid for in last 12 months and the service provider Medical Home Care Plan • Data gleaned from this: • Frequency of all health care visits • Listing of service providers • Dental visits • Also serves a cross-check to determine that clinic’s chart is complete for all medical care, e.g., no unknown ED visits. • Data gleaned from this: • Listing of service providers • Again serves a cross-check to determine that clinic’s chart is complete for all medical care, e.g., no unknown ED visits. Medicaid Print out of all Medications

26. Cowlitz Center of Foster Care Health CHET (Child Health and Educating Tracking) system) Medical Home Care Plan • Summary of the child’s status completed after removal from biologic home: • physical/medical & dental) • Developmental • Connections (visitation plans) • educational, and • emotional/behavioral • Data gleaned from this: • Mental Health records updating the social worker on child’s progress in therapy • Results of progress center evaluations and services from other providers. Other Medical Records held by Children's Administration

27. Medical Home Care Plan Fluid document Will need to be updated often Will likely become an electronic database in the future Will probably keep changing as we gain experience using it

28. 7 Strategies to Develop a Cost-Effective Medical Home • Purpose: Locate resources and dollars (outside of the fee-for-visit system) to enable comprehensive, coordinated care and access.

29. Strategy 1: Create a 501(c)3 • Children’s Community Resources was founded to “serve the unmet medical needs of children in our county” Form a board of pediatricians and concerned parents • Purpose: to gather funds to provide medical care for needy children and to employ grant writers. • Obtain tax-exempt, non-profit status • Obtain funds from donors and grants • Facilitate Medical Home care for needy children by building partnerships

30. Strategy 2: Develop a Community Organization • Purpose: Develop a coalition of community organizations who care for children to plan, collaborate, and deliver services • Provide pediatrician leadership • Invite participation of community leaders who care for children • Write a strategic plan for the Medial Home • Commit to a family and child care charter • Develop policy and procedures. • Proceed as a collaborative care system

31. Strategy 3: Develop Cost-Effective, Coordinated Care • Purpose: Build partnerships with schools, agencies, organizations, and clinics that care for children. • Team Conferencing & Co-managed Care Plans • Mental Health • Early Intervention 0-3 • Early Learning 3-6 • Foster Care • Drug Affected Children

32. Strategy 4: Comprehensive Care • Purpose: Support partnerships, programs, services, and parent education that addresses the health care of our children. • Parent Education • Mental Health Partnerships • Telemedicine • Pediatric Subspecialists (Collect Rent) • Insurance & Care Coordinators (grant revenue)

33. Strategy 5: Affirm a Clinic Commitment to Open Access • Purpose: To recruit and retain quality pediatricians who share a commitment to the medical home system of care. • Medical Home program financing • Adequate Medicaid reimbursement ensures access • Training of clinic staff and other local agencies to enroll children directly into Medicaid • General pediatric practice with inpatient care, 24/7 care, one out of seven call • Oversight of pediatric nurse practitioners • Student loan forgiveness • Above average incomes and benefits

34. Strategy 6: Use a Business Approach to Cost Effective Care • Purpose: Develop a strategic plan and budget for each program and service. • Recall: disease and well child management • Pediatric practice oriented IT partner • Allocation of staff hours, facility use • Allocation of pediatrician time • Negotiation of contracts • Grant writing and funding • Coding and documentation

35. Strategy 7: Use Marketing to Ensure Cost Effective Care • Purpose: support a medical director, program director, and marketing consultant. • Budget 1.25% of gross income • Pediatrician medical director • Pediatrician marketing consultant • MPH program director • Brochures, newspaper ads, e-media flash ads, website • Disease management, patient binders, patient education, telemedicine

36. Quality Improvement Activities • Using the Center for Medical Home Improvement tools • Self-assessment tool – checking on our “medical home-ness” • Family survey • Weekly quality assessment meetings for clinical staff

37. Questions? • Phyllis Cavens, MD, Medical Director • Email: pcavens@pacifier.com • Phone: 360-577-1771 • Hilary Gillette-Walch, RN, MPH, Program Director, Cowlitz Center of Foster Care Health and Healthy Tomorrows Grant • Email: hgillette-walch@pacifier.com • Phone: 360-577-1771, extension 282