Richard C. Antonelli, MD, MS, FAAP Assoc Prof Pediatrics, Univ Conn SOM

1. Medical Home: Primary Care for the 21stCenturyIs This the Path to Quality and Value in Health Care?Louisiana Health Care Quality ForumMay 23, 2008 Richard C. Antonelli, MD, MS, FAAP Assoc Prof Pediatrics, Univ Conn SOM Chief of General Pediatrics Connecticut Children’s Medical Center AAP National Center for Medical Home Initiatives Project Advisory Committee

2. Every System is Perfectly Designed to Get the Results it Gets • Institute for Healthcare Improvement • National Initiative for Children’s Healthcare Quality

3. Definition of Medical Home • Care that is: • Accessible • Family-centered • Comprehensive • Continuous • Coordinated • Compassionate • Culturally-effective

4. Definition of Medical Home • And for which the primary care provider shares responsibility with the family. AAP/ AAFP/ NAPNAP/ ACP

5. Functional Definition of Medical Home • Partnership between family and providers • Commitment to continuous quality assessment and improvement • Single point of entry to a “system” of care that facilitates access to medical and non-medical resources

6. Joint Principles of the PCMHAAP, AAFP, ACP, AOA March 2007 • Whole person orientation • Personal physician • Physician directed medical practice • Care is coordinated and/or integrated • Quality and safety • Enhanced access to care • Payment to support the PC-MH

7. Issues • Can Primary Care Survive? • Capacity of current workforce • Attracting new providers to workforce • What About Quality and Value? • Do We Need Medical Home? • Highest quality with least disparity to access occurs when Medical Home available

8. What About Disparity?

9. Figure 8. Across Income Levels, African Americans Are More Likely to Have Health Problems, Even After Adjusting for Age Percent of adults ages 19–64 with health problems* * Defined as having any chronic condition or disability. Note: Percentages are age-adjusted. Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

10. Percent of adults ages 19–29 reporting the following problems in the past year because of cost: Lacking Health Insurance for Any Period Threatens Young Adults’ Access to Care, 2005 Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

11. The Result of Delayed Access? • More Expensive Care Rendered in Emergency Departments • In case of Mental Health, services “rendered” in criminal justice system

12. Figure ES-1. Nearly Half of Hispanics and One of FourAfrican Americans Were Uninsured for All or Part of 2006 Percent of adults 18–64 49* 28 26 21 18 * Compared with whites, differences remain statistically significant after adjusting for income. Source: Commonwealth Fund 2006 Health Care Quality Survey.

13. Figure ES-3. Uninsured Are Least Likely to Have a Medical Home and Many Do Not Have a Regular Source of Care Percent of adults 18–64 Note: Medical home includes having a regular provider or place of care, reporting nodifficulty contacting provider by phone or getting advice and medical care on weekendsor evenings, and always or often finding office visits well organized and running on time. * Compared with insured with income at or above 200% FPL, differences are statistically significant. Source: Commonwealth Fund 2006 Health Care Quality Survey.

14. Figure ES-4. Racial and Ethnic Differences in Getting Needed Medical Care Are Eliminated When Adults Have Medical Homes Percent of adults 18–64 reporting always getting care they need when they need it Note: Medical home includes having a regular provider or place of care, reporting nodifficulty contacting provider by phone or getting advice and medical care on weekendsor evenings, and always or often finding office visits well organized and running on time. Source: Commonwealth Fund 2006 Health Care Quality Survey.

15. CSHCN receive coordinated, ongoing, comprehensive care within a medical home 2005-2006

16. Families of CSHCN will be partners in decision-making and are satisfied with the services they receive2005-2006

17. Families of CSHCN will have adequate private and public insurance to pay for the services they need2005-2006

18. % of CSHCN whose family members cut back and/or stop working because of child's health needs2005-2006

19. What Is Important About Primary Care?

20. UK UK DK DK NTH NTH FIN FIN SP SP CAN CAN AUS NZ AUS SWE JAP SWE JAP GER US GER US BEL FR BEL FR Primary Care Score vs. Health Care Expenditures, 1997 Starfield 06/02

21. While access to insurance is an important and necessary determinant for having a Medical Home, it is not sufficient to predict quality of care or outcomes.

22. Is Medical Home Enough? • Transforming American Healthcare from a “Sector” to a “System” Requires Broad-based Re-design: • Financing • Quality measurement • Regulatory support • State and Federal policy support • Infrastructure is Medical Home

23. Priority Areas for National Action: Transforming Health Care Quality • Priorities Relating to Children and Youth • Care Coordination- across paradigms of care • Self-management/ health literacy • CSHCN • Immunizations • Depression • Medication Management Institute of Medicine

24. Health System Community Health Care Organization (Medical Home) Resources and Policies ClinicalInformationSystems Care Partnership Support DeliverySystem Design Decision Support Timely & efficient Family -centered Evidence-based & safe Coordinated and Equitable Functional and Clinical Outcomes Chronic Care Model (Wagner, et al) Supportive, Integrated Community Informed, Activated Patient/Family Prepared, Proactive Practice Team Prepared, Proactive Practice Team

25. What is Care Coordination? 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

26. Care Coordination- ACP • Ensuring communication among specialists and PCP and families • Tracking if referrals happen • System to prevent errors among multiple providers • Tracking Test Results

27. What Is the Result of CC in a Pediatric Medical Home?

29. What Can Be Measured re: CC? • Adult Medical Home • Screening rates for disease and risk factors • Screening for secondary disabilities • Presence of registry and its utilization • Development of Care Plans (these have CPT codes already) • Mechanism for linkage from practice-based CC to community-based CM • Training opportunities for CC’ers • ED and in-patient utilization for patients with chronic conditions

30. 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 CC’ers • ED and in-patient utilization for patients with chronic conditions

31. Stakeholders • Families • Employers (Leapfrog Group, National Quality Forum) • Providers • Community-Based Organizations • Payers: Medicaid and Commercial (PCPCC) • State and Federal Agencies • Legislators

32. PCMH-PPC: NCQA, AAFP, ACP, AAP and AOAMedical Home Recognition Criteria Linked to Reimbursement

33. National Noteworthy Models of Medical Home and Care Coordination • Minnesota Medicaid Transformation • North Carolina • PACE: case management/ CC for adults with chronic conditions

35. Useful Websites • http://www.medicalhomeinfo.org: American Academy of Pediatrics hosted site that provides many useful tools and resources for families and providers  • http://www.medicalhomeimprovement.org: tools for assessing and improving quality of care delivery, including the Medical Home Index, and Medical Home Family Index

36. References • McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with special health care needs. Pediatrics, 102,137–140 • U.S. Department of Health and Human Services. www.hhs.gov/newfreedom, accessed April 26, 2005 • Committee on Children with Disabilities, American Academy of Pediatrics. (2005). Care coordination policy statement

37. References (cont) • Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century • Committee on Identifying Priority Areas for Quality Improvement, Institute of Medicine. (2003). Priority areas for national action: Transforming health care quality. Adams, K. and Corrigan, J. Editors. • Providing a Medical Home:The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice, Pediatrics, Supplement, May, 2004, Antonelli, R. and Antonelli, D.