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Patient Centered Medical Home – Kids

Patient Centered Medical Home – Kids. Thursday, February 6, 2014 7:30-9:00 a.m. 301 Metro Center Blvd., Warwick, RI Patricia Flanagan, MD, FAAP, Co-Chair Elizabeth Lange, MD, FAAP, Co-Chair. Selection Sub-Committee. Charge:

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Patient Centered Medical Home – Kids

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  1. Patient Centered Medical Home – Kids Thursday, February 6, 2014 7:30-9:00 a.m. 301 Metro Center Blvd., Warwick, RI Patricia Flanagan, MD, FAAP, Co-Chair Elizabeth Lange, MD, FAAP, Co-Chair

  2. Selection Sub-Committee Charge: • Develop criteria for selection of initial pilot PCMH-Kids practices • Develop application and scoring process for practice selection • Develop outreach strategy to insure eligible practices are informed • Recommend selection process to Planning Committee/Conveners • With staff support, conduct selection process, score applications, and make recommendations to Conveners • Develop timeline for the application and selection process.

  3. Selection Sub-Committee Members(10) • Dr. Elizabeth Lange, Waterman Pediatrics, Co-Chair‎ • Dr. Renee Rulin, Unitedhealth Care, Co-Chair • Dr. Ailis Clyne, Baldhill Pediatrics • Andrea Galgay, RI Blue Cross/Blue Shield ‎ • Blythe Berger, Department of Health • Deb Florio, Office of Health and Human Services • Dr. Deidre Gifford, Office of Health and Human Services • Mary Evans, RI Health Centers Association ‎ • Dr. Stephen Davis, Neighborhood Health of RI ‎ • Tina Spears, Rhode Island Parent Information Network

  4. Selection Sub-Committee Summary of Call 1/22/14: • Population focus: focus on high utilizers, which are often CSHCN, Medicaid, Cedar. But way to put in application is murky. Leadership will take and think about • Goal of PMCH-Kids: To improve the pediatric practice to make them more able to accept these populations. If we improve practices we will improve care. Goal is transformation. • Need a clear definition of children with special health care needs • Get at this through an essay question: what do you currently do for care coordination and behavioral health? What are your barriers? • Want a mix of practices: high-achieving as well as practices who want to change, but don’t have the resources. Will consider using the pre-reqs from CSI Adults. Believe requiring EHR is necessary for this round (can take a practice 6-12 months to implement EHR, additional time to produce reports. This would affect the PMCH-Kids timeline.) • Also want to look at cultural diversity (i.e. languages spoken) • Next conference call: February 19 7:30-8:30am

  5. Measures Sub-Committee Charge: • Review available data on quality, health disparities, disease prevalence, utilization and cost of healthcare for children in RI • Review standardized measures of pediatric healthcare quality, including those used in other pediatric PCMH programs • Review available measures for feasibility of collection and alignment with other RI programs • Recommend set of quality, patient experience and utilization measures to Stakeholder coalition for inclusion in contract

  6. Measures Sub-Committee Current Members (23) • Dr. Patricia Flanagan, Lifespan Co-Chair • Ronald Seifer, Bradley Co-Chair • Stacey Aguiar, Department of Health • Blythe Berger, Department of Health • Dr. Elizabeth Lange, Waterman Pediatrics • Dr. William Hollinshead, RIAAP • Dr. Betty Vohr, Woman & Infants Hospital • Carrie Feliz, Providence Public Schools • Dr. Dinusha Dietrich, Smithfield Pediatrics • Dr. Deidre Gifford, Office of Health and Human Services • Dr. Keivan Ettefagh, Aquidneck Medical Associates • Dr. Marco Ferretti, East Bay Pediatrics • Dr. Nicole Gergen, Hasbro Children’s Hospital • Dr. Joanna Brown, Lifespan • Junhie Oh, Department of Health • Dr. Nathan Beraha, Anchor Pediatrics • Peter Hollmann, Blue Cross Blue Shield Rhode Island • Dr. Jose Polanco, Blackstone Valley Community Health Center • Dr. Shirley Spater Freedman, Samuels Sinclair Dental Center • Judi Stevenson Garcia, Rhode Island Department of Education • Debra Hurwitz, CSI Adults • Rebecca Labeau, • D Bergh,

  7. Measures Sub-Committee Summary of Call 1/27/14: • The goal of the Measures Sub-Committee is to select measures that will drive outcomes and change in practices. Come up with ideas, as a group, on how children are different and think about how to build the child into the medical home. • Reviewed charge. No further edits needed at this point. • Reviewed current measures in specific areas: dental, developmental, behavioral, social emotional and school settings. • Next meeting will be a discussion of specific measures: complex care coordination (CEDARR & foster care), family engagement, equity and transition. • Next conference call: March 6, 2014 from 7:30-8:30 am

  8. CSI-RI Community Health Teams • Part of our strategic to create two community health teams (CHT) • South County (serves 9 CSI Practices) and Pawtucket (serves 8 CSI Practices) • Teams will incorporate a community health worker-a person to connect patients to community resources • Teams will also incorporate a behavioral health care manager • CHT will work with the primary care provider and nurse care manager as part of the team to coordinate care and manage the patient • Focus on high-risk patients as identified by the health plans

  9. CSI-RI Integrated Behavioral Health Workgroup • Goals: to eliminate disparity in health care outcomes for people with mental health conditions, prove communication and coordination, leverage existing resources • Focus areas of medical conditions: Diabetes, COPD, and CHF • Focus areas of behavioral health: depression, anxiety, and substance abuse • What needs to happen for goals to be reached: • Clear consensus definition of behavioral health • Develop and test potential models of intervention (compacts, CHT, consultative model, co-location, integration) • Define data needs and metrics • Payment system that supports integrated behavioral health • Current work: inventory CSI practices and response to Senator Miller and Representative Bennett’s Joint Commission to Study Integrated Behavioral Health

  10. Race to the Top • Survey of Wellbeing in Young Children (SWYC) • Developmental milestones • Social/emotional development • Family risk factors • Autism-specific screening at 18 & 24 months • Collaboration Efforts • Rhode Island Department of Education • Healthcentric Advisors • American Academy of Pediatrics • Executive Office of Health and Human Services • DRAFT Resource Grid

  11. Questions

  12. Contact Information Patricia Flanagan MD, FAAP, Co-Chair pflanagan@lifespan.org 401-444-7987 Elizabeth Lange MD, FAAP, Co-Chair elizlange@cox.net 401-751-8683

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