Medical Home Collaboration

1. Medical Home Collaboration

2. “WE DON’T KNOW WHAT WE DON’T KNOW”

4. Children with Special Health Needs-Overview Care coordination Medical Home Initiative Pediatric Hi-Tech Personal Care Children’s Palliative Care Child Development Clinic Cleft Palate Clinic Rehab and Neurology clinics Respite Financial Technical Assistance Community Nutrition Newborn Screening Newborn Hearing Screening Birth to age 21

5. CIS Early Intervention Collaborative Team Medical Home Chittenden Social Worker Child Development Clinic & CSHN Services

6. Our Medical Home Program • Three pediatricians, Dr. Joseph Hagan, Dr. Jill Rinehart, Dr. Greg Connolly • Two Pediatric Nurse Practitioners, Maryann Lisak&Ashley Boyd • One main RN Care Coordinator Kristy Trask • Business manager, office manager, two office assistants, six additional part-time nurses two medical assistants • ~4500 Active Patient List

7. Medical Home History • 1967: First published reference to “Medical home” was in the AAP’s Council on Pediatric Practice’s Standards of Child Health Care • Defined Medical Home as the “respositoryof medical records” for a child, emphasized the importance especially for CSHCN

8. Medical Home History • 1970’s: AAP first addresses the policy implications of the term “medical home” • 1977: “Fragmentation of Health Care Services for Children,” Clarified the concept of single medical home for every child

9. Medical Home History • 1980’s: The first Medical Home is attributed to Hawaii Pediatrician, Dr. Cal Sia • 1992: AAP published first policy statement defining the medical home

10. Medical Home History 1998: Called for “imaginative methods, backed by insurance and government funding [that] must be developed and used to improve financing for care coordination and other needs…” ~Polly Arango and Merle McPhereson “New Definition of Children with Specia Health Needs,”Pediatrics,1998

11. Medical Home History 2002: Medical Home Policy Statement was published that defines the concept of Medical Home we use today

12. Medical Home History • 2002-2004 in VT: Medical Home Improvement Project • 2006: ACP created “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care” promoting an “evidence based” medical home

13. Medical Home History 13 • 2007: Bright Futures embraces the concept of Medical Home for all children and states that the Medical Home is the most effective model for the provision of health supervision. • Linked to Affordable Care Act

14. 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 • A part of the Affordable Care Act

15. Medical Home History • Joint effort led to the National Center for Quality Assurance’s (NCQA) creation of Physician Practice Connections-Patient-Centered Medical Home (PPC®PCMH™) • Created 2008 PPC®PCMH™ Standards • March 2011, then 2014 PCMH guidelines

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

17. 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

18. Why is A Family- Centered Medical Home Important to family? • Opportunity for the family to build a trusting and collaborative relationship with the pediatrician and office staff. • Care coordination provides smooth facilitation among all members of the child’s care team including family, specialists, pharmacy staff, community and school services. • Comprehensive source of complete patient medical history Victoria Garrison, “Innovations in Medical Home,” VFN annual conference, April 2013

19. PCMH Recognition Status, VT Pediatric Practices as of 12/12 Mousetrap Peds Swanton Newport Peds Franklin Cty Peds Mousetrap Peds Enosburg St. Albans Dr. H. Taylor Yates Jr. Mousetrap St. Albans Milton Mousetrap Milton Dr. Joe Nasca Burlington H&R Peds Dr. Rebecca Collman UPeds Burl St. Johnsbury Ryderbrook Peds Essex Peds NVRH St. J Peds Timber Lane S. Burl Dr. David Toll Timber Lane SB UPeds Williston PedMed Richmond Peds Shelburne Peds Associates in Pediatrics Barre Pediatrics Upper Valley Peds Rainbow Peds Middlebury Gifford South Royalton Health Center MPAM Has been scored Has anticipated NCQA recognition date Pediatric Associates Has not started process Mt. Ascutney Physicians Practice Springfield Pediatric Network Cornerstone Peds Brookside Peds Green Mountain Pediatrics Just So Peds Bennington Dr. Martin R. Luloff Women’s & Children’s Services

20. Pediatric Collaborations Chittenden County

21. 5 Key Elements of Highly Effective Care Coordination The Concept The Person • Needs assessment for care coordination and continuing care coordination engagement • Care planning and communication • Facilitating care transitions • Connecting with community resources and schools • Transitioning to adult care Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009

22. A Framework for Highly Performing Pediatric Care Coordination Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009.

23. Principles for Successful Use of SharedPlan of Care • Children, youth and families are actively engaged in their care. • Communication with and among their medical home team is clear, frequent and timely. • Providers/team members base their patient and family assessments on a full understanding of child, youth and family needs, strengths, history, and preferences. • Youth, families, health care providers, and their community partners have strong relationships characterized by mutual trust and respect. • Family-centered care teams can access the information they need to make shared, informed decisions. McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs:  2014 (in press), Lucille Packard Foundation for Children's Healthcare

24. Principles for Successful Use of SharedPlan of Care • Family-centered care teams use a selected plan of care characterized by shared goals and negotiated actions; all partners understand the care planning process, their individual responsibilities, and related accountabilities. • The team monitors progress against goals, provides feedback and adjusts the plan of care on an on-going basis to ensure that it is effectively implemented. • Team members anticipate, prepare and plan for all transitions (e.g. early intervention to school; hospital to home; pediatric to adult care). • The plan of care is systematized as a common, shared document; it is used consistently by every provider within an organization, and by acknowledged providers across organizations. • Care is subsequently well coordinated across all involved organizations/systems. McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs:  2014 (in press), Lucille Packard Foundation for Children's Healthcare

25. Partnership Care Planning Model McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: An Implementation Guide. 2014, Lucille Packard Foundation for Children's Healthcare: Lucille Packard Foundation for Children's Healthcare.

26. Care Coordination Rounds • Regular meetings (typically 1 hour) with practice care coordinator, physicians, CHT social worker, ( sometimes other community partners as needed) • Discussion of patients (who needs more intervention and who is doing what part of the work) • Systems issues

27. ECOMAP Medical Specialists Specialty Providers Clinics Community and State Services CSCHN Economic Services Developmental Services Mental Health Early Intervention Home Health Services Children’s Palliative Care WIC Child Protection Private Therapists Personal Care Financial Supports Insurance Respite Childcare Subsidy Economic services Social Security Food Subsidy Employment Genogram of Household Members Parents Siblings Child Extended Family Others School Teachers Case Manager Speech PT/OT Other Services Informal Supports Extended Family Friends Groups Religious Organizations Cultural Supports Clubs Recreation Camps Childcare Teachers

28. Dr. Hastings- Peds-Ophthalmology Dr. Benjamin- physiatrist Dr. Bauer- Peds Neurosurgeon at Dartmouth Community Alliance Church in Hinesburg Hagan, Rinehart and Connolly Pediatricians Medical Store Dr. Filiano- Neurologist at Dartmouth Children's Ministry Dr. D'Amico- Gastroenterologist CSHN Social Worker Dr. Tranmer- Neurosurgeon 3 Squares Vermont Outings- Sugar House, Echo, Lowes, town activities, swimming etc. Biomedic Appliances Shelburne Community School Keen Medical Champlain College- Healthcare Technology PCA Apria VG Section 8 Housing CSHN Registered Dietitian Debbie- Para-professional CG • 5 yo SSA 4 yo 7 yo Child Only Reach Up Grant Swimming at YMCA SSI PSE School Physical Therapist (service dogs in training) S.&J., MGM friends Wheels for Johnny-Fundraiser for handicap accessible vehicle Shelburne Nursery School Occupational Therapist Petsmart Shelburne Community School Therapy Dogs of Vermont Rue Kendrick- classroom teacher Howard Center Medical Family State/Education/Community Special Educator Speech Language Pathologist Deborah Keel- Flexible Family Funding Delana- BRIDGE Garrison, Victoria . Interview by Marley Donaldson. Personal interview. 26 Mar. 2013.

29. Family Story

30. Care Conferences A facilitated, family-centered meeting (typically 1 hour) among the family, primary care, community providers, schools, formal and informal family supports to facilitate detailed communication about strengths, challenges, current services, and gaps in services. A coordinated plan of care is developed with goals, resources, and work load distribution among providers with family input and consent. Care conferences address communication issues, needs of the family and helps to resolve identified and anticipated needs.

31. Care Story • Mary is a 4 year old with tuberous sclerosis whose self-injurious behaviors, tantrums, sleep dysfunction-- heading towards inpatient psychiatry hospitalization • Despite having a VT developmental services waiver, respite care and a team of multidisciplinary medical experts at Mass General • Intractable seizures seemed the least of her concerns in comparison to behaviors • Strengths: strong parent involvement and expertise, loving respite family, Mary engaging, verbal with cognitive strength (can anticipate seizures)

32. Care Planning

33. Outcomes of Shared Care Planning • Builds community collaboration and communication across services • Builds knowledge base of services and system of care • Determines most appropriate referrals, reducing duplication and fragmentation. • Builds the capacity of primary care to provide long term chronic care management • Addresses systems issues and barriers proactively (i.e. financing, insurance poverty, access to care)

34. Pediatric Care Coordination Learning Collaborative • 12 Vermont practices that serve children • Each with a quality improvement team of provider, care coordinator and parent partner • Create 25 shared care plans with families

35. Building Partnerships Across the CommunityNext Steps • Reach out to the medical home care coordinators and get to know who they are. • Invite CSHN social worker to initial visits, team meetings, One Plan reviews-help families build relationships early with other providers, support the work you are doing with families during your time with them. • Suggest doing care conferences to PCP for your families where a meeting would be helpful to coordinate and problem solve. • Offer to do presentations of your program to other service programs and vice versa (establish a contact) so you will have a go to person to talk through situations as they arise. • Find out how other providers are working in their regions and what strategies they find helpful. Ask to shadow providers in other regions. Come observe a CIS-EI meeting in Chittenden or care conference.

36. THANK YOU!