Kate Orville Wendy Harris Pediatric Resident Noon Conference October 14, 2014

1. Essential Community Resources for the Pediatric Medical Home – Building a Strong Medical Neighborhood for Children with Special Needs Kate Orville Wendy Harris Pediatric Resident Noon Conference October 14, 2014

2. Kate Orville, MPH • Co-Director, WA State Medical Home Partnerships Project for CYSHCN • UW Center on Human Development & Disability • Medical Home Teams • Community Coalitions to ID children with special needs and services needed • Pediatric Resident Training

3. Wendy Harris • Early Intervention Program Manager • King County Developmental Disabilities Division

4. Why we’re here • Developmental-Behavioral Pediatric Resident rotation • Request for information about community resources earlier in training • Medical Home fuzzy concept for many, despite growing importance in health care

5. Today • The Medical Home Model • Why does it matter for families with children with special needs • What does it mean for pediatricians as primary care providers and as specialists? • Key Community Resources for Children with Special Needs • Family Health Hotline • Early Intervention (ages 0-3) • School Districts (3-21) • Family Support • Public Health (0-18)

6. The Medical Home – Team-based, Proactive Primary Health Care • Comprehensive Care • Patient-centered • Coordinated Care • Vertical-(e.g specialty care) • Horizontal (e.g.community svs) • Longitudinal • Accessible Services • Quality and Safety • 2007 Joint Principles of Pt-Centered Medical Home

7. How is a Medical Home Different? Today’s Care Pt-Centered Medical Home Care Our patients are those who are registered in our medical home. Care is determined by a proactive plan to meet health needs, with or w/o visits. We measure our quality and make rapid changes to improve it. A prepared team of professionals coordinates all patients’ care. We track tests and consultations, and follow up after ED and hospital visits. • My patients are those who make appointments to see me. • Care is determined by today’s problem and time available today. • I know I deliver high quality care because I’m well trained. • Patients/families are responsible for coordinating their own care. • It’s up to the patient/family to tell us what happened to them. Source: WA State Dept of Health, WA Healthcare Improvement Network (WHIN)

8. The infographic includes definitions for each of these features, sample strategies used by health professionals, employers, and payers, and their collective impact on the health system. - See more at: http://www.pcpcc.org/resource/infographic-why-medical-home-works#sthash.AmZGtbjk.dpuf

9. Specialists & the Medical Home • Key: Clear communication about roles • Referrals • Co-Management • Specialist may BE the medical home doctor • Medical Home neighbor recognition programs and Communication Resources • Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms. White Paper. Agency for Healthcare Research and Quality. (2011) • The Patient-Centered Medical Home and Specialty Physicians - American College of Physicians (Internal Medicine) Checklists for referrals between PCPs and specialists, service agreements examples, FAQs and more

10. Medical Home Benefits for CYSHCN • Significantly less delayed or forgone care* • Significantly fewer unmet needs for health care and family support services* • Better health status** • Family centeredness ** • Improved Family Functioning ** • * 2005-06 National Survey of CSHCN- parent report • **Homer et al, 2008

11. How Do You Measure and Build Medical Homes? Formal National Recognition Programs National Committee for Quality Assurance (NCQA) http://recognition.ncqa.org/ to see who in WA has certification (1222) Joint Commission, other accrediting bodies Quality Improvement/Skills Building AAP: Building Your Medical Home Toolkit National Center for Medical Home Initiatives Center for Medical Home Improvement WA State Dept of Health – WA Healthcare Improvement Network Institute for Healthcare Improvement (IHI) Open School

12. Medical Home Transformation • Work in progress - Looks different in different clinics • Clinics that made the greatest changes in their systems were those that paid attention to the change process, esp regarding their culture and patient-centeredness (Solberg, L, Challenges of Medical Home Transformation Reported by 118 Patient-Centered Medical Home Leaders, JABFM, July 2014) • Paradigm shift and Funding shift

13. Medical Home Impact on Cost and Quality • PCMH studies continue to demonstrate impressive improvements across a broad range of categories including: • cost, utilization, population health, prevention, access to care, and patient satisfaction, • a gap still exists in reporting impact on clinician satisfaction. • The PCMH continues to play a role in strengthening the larger health care system, specifically Accountable Care Organizations and the emerging medical neighborhood model. • Significant payment reforms are incorporating the PCMH and its key attributes. • - See more at: http://www.pcpcc.org/resource/medical-homes-impact-cost-quality#sthash.80pHATzs.dpuf • The Medical Home’s Impact on Cost and Quality – An Annual Update of the Evidence, 2012-2013 (jan 2014) • Patient-Centered Primary Care Collaborative

14. Financing a Medical Home • Traditional models: Select most appropriate CPT codes; decrease down coding*. • Medical Home Initiatives are expanding**- providers, patients and payment incentives increased from 2009-13: • 26 -> 114 Medical Home Initiatives • Almost 5 million to almost 21 million patients • Decrease from 77-> 20% those with planned end date • Dominant Medical Home payment model is FFS payments augmented by PMPM payments and pay for performance bonuses. Increasing use of shared savings models. *HRSA Health Information Technology- How can a medical home be financed? Links to AAP coding info. http://www.hrsa.gov/healthit/toolbox/Childrenstoolbox/BuildingMedicalHome/medicalhomefinanced.html **Edwards, S et al. “Patient-Centered Medical Home Initiatives Expanded In 2009-12: Provides, Patients and Payment Incentives Increase”. Health Affairs. Oct. 2014, 33:10., 1823-1831.

15. Care Coordination- Key to MH • “A process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health.” • American Academy of Pediatrics, Care Coordination in the Medical Home, Pediatrics, 2005

16. Key Community Resources for CSHCN – Medical Home Neighbors You Want to Know

18. WithinReach WA State Health Information Information and Referral for Children and Families • Family Health Hotline / Answers for Special Kids (ASK) Line 1-800-322-2588 • www.ParentHelp123.org • HelpMeGrow Developmental Screening

20. Early Intervention (0-36 months)

21. Babies Can’t Wait ~ Refer! • When to refer? • When parents are concerned for any reason • Functional concerns—eating, sensory, child care, etc. • Possible delay of 25% in one or more area • If child/family would benefit from services

22. What is Early Intervention? • A comprehensive set of services and supports to help enhance a child’s development and to help parents understand how to help their children grow and develop. • Services are specifically tailored to meet a child's and family’s individual needs. • Services are available to all eligible children ages birth to three with developmental delays or disabilities and their families regardless of income.

23. WHO gets Early Intervention? Child is Birth to Three Years and: Has a 25% delay or 1.5 standard deviations in one or more area. Some diagnoses. Evaluation team uses “Informed Clinical Opinion”

24. WHAT are the services? • EVERYONE gets: • Family Resources Coordinator • Assessments—Both Initially and Ongoing • MOST FREQUENT Services: • Developmental Services (Individual Education) • Speech Therapy • Motor Therapy (Occupational or Physical Therapy) • Feeding Therapy and/or Nutrition Services

25. WHAT are the services? • OTHER Services are also available: • Audiology • Assistive technology devices & services • Family training, counseling, and home visits • Health services, Nursing services, Medical services for evaluating or diagnosing (most EI Providers do NOT diagnose children) • Psychological services • Social work services • Vision services

26. An Individual Family Service Plan (IFSP) is developed by the WHOLE Team! • Parents • Family Resource Coordinator • Service Provider(s)

27. WHERE does the early intervention happen? • At Home • In Child Care Settings • In Community Programs With Typically Developing Peers • 93% of WA families received early intervention in “Natural Environments” Early Intervention Services- “ to the maximum extent appropriate are provided in natural environments, including the home, and community settings in which children with out disabilities participate”-Individuals with Disabilities Education Improvement Act of 2004 Reauthorization (IDEA), Part C: Sec. 632

28. How to Access Early Intervention Evaluation • Statewide: Lead Family Resources Coordinator for the County • (WithinReach or ESIT directory at www.medicalhome.org/resources/local_contacts.cfm) • King County: Call CHAP Line Toll Free: (800) 756-5437 • OR Use Our NEW Map Tool http://www.kingcounty.gov/healthservices/DDD/services/babiesAndToddlers/EarlyInterventionProviderReferralMap.aspx

29. Too complicated for King County?

30. Early Intervention works! • 33 % of toddlers exiting EI did not qualify for special education at age 3! • 98% of families surveyed reported early intervention helped them effectively communicate their child’s needs.

31. Who pays for Early Intervention? • State, federal and school district funds • Provider fundraising • Parent Cost Participation (some services) • Medicaid • Private Insurance—family may have co-insurance, co-pays, or deductibles • If family does not have insurance or declines to provide access to insurance they may be placed on sliding scale for fees • If family below 200% of FPL family will pay no fees

32. Why Early Intervention? • Children close the gap on delays. • Whole family gets support and skills to help child. • Parents learn how to advocate for their children in education settings. • Smoother transitions IF child does qualify for school district services at 3.

33. More children are in need of services than are currently being served. In 2012, King County served 2.1% of the general population of children aged birth to 3. However, research indicates that as many as 13% of birth to 3 year olds have delays that would make them eligible. There is a need to serve children earlier. In 2012, King County served only 0.62% of the general population of infants aged birth to 1. Who are we missing?

34. Videos about Early Intervention for Families Available in English, Somali, Vietnamese & Spanish • https://www.youtube.com/watch?feature=player_detailpage&v=7WtnMy0I_xc • Parent Support • Preparing for your IFSP • Sibling Support

35. For Children 3-21: Schools • (45 days before 3rd Birthday or Older ) • Refer to Child Find in writing for testing to determine if child is eligible for services • Google School District Name +Child Find • Or Statewide directory of school officials: www.k12.wa.us/SpecialEd/pubdocs/SpecialEdDirectory.pdf • To ensure a timely response, parents need to track when they made the referral, and stay on top of it.

36. How MDs can help • School more likely to do a meaningful evaluation if understand what concerns are. • Write detailed letter explaining concerns – Dx, if there is one, and how it is interfering with school attendance, behavior, engagement, safety, academic achievement, social/emotional issues, transportation etc.

37. Special Education Eligibility • Student must meet following:  • The student has been identified as having a disability (ies). • The disability (ies) adversely affects the student’s educational performance. • The student requires specially designed instruction in order to access the general education curriculum. 

38. District May • Screen or Evaluate • Develop Individualized Education Plan (IEP) or 504 Plan • Provide Services • 3-5 Services • Kindergarten and older

39. Questions? Problems? • Office of the Education Ombuds (OEO) http://www.governor.wa.gov/oeo/ • Independent statewide agency within the Governor’s Office • Resolves disputes and conflict between parents and elementary and secondary public schools in all areas that affect student learning. • 1-866-297-2597. Phone interpreter svs. www.waparentslearn.org

40. Public Health CSHCN Coordinators (0-18 yrs) • http://www.kingcounty.gov/healthservices/health/child/cshcn.aspx

42. Family Support

43. Kate Orville Orville@uw.edu 206-685-1279 www.medicalhome.org Wendy Harris Wendy.Harris@kingcounty.gov 206-263-9052 Questions?