Provide and Document Planned, Proactive Comprehensive Care

1. Provide and Document Planned, Proactive Comprehensive Care • Jill S. Rinehart, MD FAAP • Associate Clinical Professor Pediatrics, University of Vermont Medical School • Owner/Pediatrician • Hagan, Rinehart & Connolly Pediatricians, PLLCFlorida Pediatric Medical Home Demonstration Project Learning Session I September 23-24, 2011

2. Disclosure • I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

3. Objectives • Describe family centered tools that may be helpful in documenting care in a coordinated, proactive, preventative way • Example of Well-Child Visit • Examples of coordinated comprehensive care for CSHN

4. Medical Home Definition • Accessible • Culturally Effective • Continuous • Comprehensive • Coordinated • Compassionate • Family Centered

5. Medical Home Definition • The Medical Home is the model for 21st century primary care, with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated and family-centered manner…~National Center for Medical Home Implementation

6. What is Bright Futures? • Gold standard for pediatric care provides detailed information on well-child care for health care practitioners. • A national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community

7. Bright Futures and Medical Home “Bright Futures is an evidenced based approach to preventive health care, that is best delivered in the medical home.” Editors: Joseph F. Hagan, MD,FAAP Judy Shaw, EdD,RN, FAAP Paula Duncan MD, FAAP

8. Medical Home: Health Supervision • At any given time we have 2 distinct populations in Pediatrics: • Relatively healthy: need preventive health care, education and community support

9. Medical Home: Health Supervision • And 2) The pretty sick: who need preventive health care, education, community support AND chronic care management

10. Medical Home and Health SupervisionCoordinated, Continuous • Lacation Consultation • Nurse phone call follow up • First touchpoint with office • after infant born • Past 24 hours (stools, swallowing, engorgement) • Feeding, jaundice • Explore supports • “Baby blues”

11. Medical Home and Health SupervisionComprehensive • 11 year old boy, Bright Futures Visit • BMI: 87%, SMA II • Strengths based assessment • H-ome • E-ducation • A-ctivities • D-rugs • S-ex • S-uicide • S-afety

12. Medical Home and Health SupervisionFamily Centered, Comprehensive • Parent Concerns:Mom concerned about anxiety around swim meets and whether divorce adjustment ok • Youth Concerns:Warts-hands and fingers, biggest kid in 5th grade • Physician Concerns:Elevated BMI, needs Immunizations, puberty

13. Medical Home and Health Supervision • Strengths Based Assessment, developmental milestones of pre-adolescent • Generosity: likes younger kids, book buddy has special needs • Independence: self-reliance, supervises younger brother at Dad’s • Mastery: qualified New England’s 9 swim events • Belonging: loves school, has friends, loves Vermont

14. Medical Home and Health Supervision • Bright Future’s Evidenced Based Anticipatory Guidance: • Physical Growth/Development: puberty, BMI • Emotional Well-being: decision making, dealing with stress, mental health concerns, puberty • Risk reduction : parents know friends, limit screen time • Violence and Injury Prevention: helmet use, no guns, bullying

15. Health Supervision in the MedicalHome • Conclude with “readiness to change steps”--switch from chocolate milk to skim at school, review healthy choices for food in all settings, identify opportunity for role as a babysitter/mother’s helper in the neighborhood • Support psychotherapy around divorce issues • Immunizations: HPV, Tdap, Menactra

16. Coordinated Care • Teagan is a 2 year old with Kabuki (Make-up) Syndrome • Had a Nissen and G-Tube placed in infancy for severe aspiration, oral aversion • Late last fall, she presented with seizures associated with hypoglycemia • Difficult IV access • Sister, clown, cousin

17. Comprehensive • Pediatric Medical Home: Dr. Rinehart (HRC) • Pediatric Resident Team • Dr. Guillot Pediatric Nephrology • Dr. D’Amico Pediatric Gastroenterology • Dr. Kacer Endocrinology • Dr. Burke Pediatric Genetics • Dr. Modlinsky Anesthesia • Dr. Mingin Pediatric Urology • Dr. Hubble Pediatric ENT • Dr. Sartorelli Pedi Surgery • Dr. Hastings Pediatric Opthalmology • Dr. Bingham Pediatric Neurology • Dr. Soll Neonatology

18. Coordinated Care • PICC placed by anesthesia • Dr. Mingin renal calculi surgery • Labs coordinated by genetics, endocrine, GI, me (some first a.m., fasting, hypoglycemic,etc.)

19. Evidence for Medical Home • Comprehensive care for high-risk infants resulted in more outpatient visits, but fewer life-threatening illnesses, PICU admissions and PICU days • Broyles RS, Tyson JEH, Heyne ET, et al. “Comprehensive follow-up care and life-threatening illnesses among high-risk infants: a randomized controlled trial,” JAMA. 2000;284 (16):2070 –2076

20. Evidence for Medical Home • For children with Asthma a decreased continuity of care is shown to increase hospitalizations • Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;107 (3):524 –529

21. Comprehensive • Review of evidence base for medical home model found that 28 of 33 articles reported benefits of medical home over a range of outcomes • Homer CJ, Klatka K, Romm D, et al. “A review of the evidence for the medical home for children with special health care needs.” Pediatrics. 2008;122 (4)

22. Care Coordination • A plan of care developed by the physician, CSHN, and family • A central record with pertinent medical information kept in the primary care office • When CSHN is referred for a consultation, the medical home assists the CSHN and family in communicating clinical issues • The medical home evaluates and interprets the consultant’s recommendations for the CSHN and the family • The care plan is coordinated with other community agencies

23. Documentation • Our “Medical Home Care Plan” • “Family Snap Shot,” “Team members,”“Strengths,” as well as “Problem List,” “Medications” • Tools for Change: Care Plans

25. Medical Home Care Plan • ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣ • ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ • ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣ • ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣

26. Documentation • EHR templates match Bright Futures’ visits • Evidence based templates for standard of care for chronic conditions (Asthma, ADHD, Depression) • Pre-Visit Questionaires (see Packet for Change for BF questionaire)

27. Documentation • Family eco-map as a tool for families with children with special needs • Helps identify gaps in services • Begin to see community based patterns

28. Support Family, Friends, Groups, Advocacy FAMILY Our Medical Home Post Diagnosis 1:35 pm 2/15/01 Specialists Neurosurgery Neurology Physiatrist Endocrinology Funding Insurers Medicaid FIT CSHN MEDICALHOME PRIMARY DOCTOR CARE COORDINATOR On-Going Care Team Social Worker OT/PT/SLP Therapists Daycare Staff & Aide Respite Medicaid Aris FIT CSHN Clinics Funding Equipment

29. Eco-Map: Community Links • Know your community and its common health concerns • Parent to Parent Support Networks (Family Voices, Vermont Family Network)

31. Care Coordination • The medical home evaluates and interprets the consultant’s recommendations for the CYSHCN and the family • The care plan is coordinated with other community agencies

32. CSHN Registry at HRC • Method of “flagging” a child as needing care coordination • Indicates “more time needed:” consult MD before scheduling acute visit, or have scheduler find time spot for preventative visit • We initially had levels based on types and number of medical and or psychosocial needs, contacts per week/month, complexity of disease -medical and psychosocial • See Change Package-examples of registries and levels of care coordination

33. Comprehensive • Having a medical home is associated with increased ease of use of community services by families • Baruffi G, Miyashiro L, Prince CB, Heu P. Factors associated with ease of using community-based systems of care for CSHCN in Hawaii. Matern Child Health J. 2005;9 (suppl 2):S99

34. Comprehensive • 2 brothers live with their dad and paternal Grandma in Burlington • Scotty is 6, has CP • Sam is 7 has Autism • Chief Complaint: Truancy • Scotty unable to get a power chair because home is not accessible • Accessible “units” not possible due to Sam’s sleep dysfunction

35. Coordinated • Care Conferences: Kidsafe Collaborative, Burlington Housing Authority, Howard Center, Bridge Program, Burlington School district, Shelburne School District, psychologist, CSHN social worker, school nurses, PT, OT, SLP

36. Compassionate • BHA found a house in Shelburne, needed indoor modifications and a ramp • Generous donor--donated supplies, labor • Family moved in April • Negotiated with town Historical Preservation Society • Ramp built in August, 2011 • Power chair due September

37. Take Home Ideas • Eco-maps for families • Eco-map for community • Bright Futures Visits • Medical Home Care Plans • Practice based CSHN Registry • Care Coordination: create a system

38. Thank You to Our Parent Partners 38 Carolyn Brennan Kimberly Cookson Sandy Julius Scott Metevier Peggy Mann Rinehart Theresa Soares Kate & Michael Stein

39. Resources 39 Antonelli RC, Stille CJ,Care , Antonelli DM, “Coordination for CYSHCN: A descriptive Multisite Study of Activities, Personnel Costs, and Outcomes,” Pediatrics, July 2008 Baruffi G, Miyashiro L, Prince CB, Heu P. “Factors associated with ease of using community-based systems of care for CSHCN in Hawaii,” Maternal Child Health J, 2005 Broyles RS, Tyson JEH, Heyne ET, et al. “Comprehensive follow-up care and life-threatening illnesses among high-risk infants: a randomized controlled trial,” JAMA. 2000 Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001 Cooley C, McAllister J, “CMHI National Outcomes Study Cost/Utilization,” Pediatrics, July 2009

40. Resources 40 Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001 Hagan, J.F, Duncan, P., Shaw, J., Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, p.4 Homer CJ, Klatka K, Romm D, et al. “A review of the evidence for the medical home for children with special health care needs.” Pediatrics. 2008 MCHB/NCHS. National Survey of Children with Special Health Care Needs, 2002 National Center for Medical Home Implementation “Building Your Medical Home Toolkit,” website:http://www.pediatricmedhome.org/ Strickland, et.al.,“New Findings from the 2005-2006 NS-CSHN,” Pediatrics, June 26, 2009

41. Questions?