Hilary Gillette-Walch, RN, MPH Program Director, Cowlitz Center of Foster Care Health

1. Building a Medical Home Brick by Brick: Strategies for Clinics Transforming Themselves into a Medical Home Hilary Gillette-Walch, RN, MPH Program Director, Cowlitz Center of Foster Care Health Phyllis M. Cavens, MD Chair of the Cowlitz-Wahkiakum Child Psychiatry Coalition Email: pcavens@pacifier.com Child and Adolescent Clinic, Longview, WA www.candac.com

2. Cowlitz County

3. Cowlitz County Overview • A resource-based economy with a population of 98,000 persons • Cowlitz County currently has highest rate of unemployment in the state (over 9%) • Low rate of college education attainment among adults (2000 Census) 13% of Cowlitz adults vs. 26% of Washington State adults • High rate of women delivering without a high school education (27%) and high rates of Medicaid utilization (64%) for prenatal care and delivery (2005 birth data)

4. Overview Continued Shortage of primary care clinicians One hospital to serve the region (SW Washington/NW Oregon) Escalating rates of suicide for the overall population High demand for primary care, mental health and dental services

5. Objectives • Describe the driving forces of the key tenets of the Medical Home • Implement strategies to develop a cost-effective Medical Home

7. The Child and Adolescent ClinicLongview, WA

8. Child and Adolescent Clinic • Pediatrician-owned practice and clinic • 10 pediatricians, 4 PNPs, 55 support staff • 20,114 patients (29% Medicaid) • 41,258 yearly visits (52% Medicaid) • 41% of annual income goes to the clinicians

9. Pediatrician & Policy Driven Family Centered Culturally Effective Compassionate Continuous Resource Driven Coordinated Comprehensive Accessible Medical Home

10. 7 Strategies to Develop a Cost-Effective Medical Home • Purpose: Locate resources and dollars (outside of the fee-for-visit system) to enable comprehensive, coordinated care and access.

11. Strategy 1: Create a 501(c)3 • Children’s Community Resources was founded to “serve the unmet medical needs of children in our county” Form a board of pediatricians and concerned parents • Purpose: to gather funds to provide medical care for needy children and to employ grant writers. • Obtain tax-exempt, non-profit status • Obtain funds from donors and grants • Facilitate Medical Home care for needy children by building partnerships

12. Strategy 2: Develop a Community Organization • Purpose: Develop a coalition of community organizations who care for children to plan, collaborate, and deliver services • Provide pediatrician leadership • Invite participation of community leaders who care for children • Write a strategic plan for the Medial Home • Commit to a family and child care charter • Develop policy and procedures. • Proceed as a collaborative care system

13. Strategy 3: Develop Cost-Effective, Coordinated Care • Purpose: Build partnerships with schools, agencies, organizations, and clinics that care for children. • Team Conferencing & Co-managed Care Plans • Mental Health • Early Intervention 0-3 • Early Learning 3-6 • Foster Care • Drug Affected Children

14. Strategy 4: Comprehensive Care • Purpose: Support partnerships, programs, services, and parent education that addresses the health care of our children. • Parent Education • Mental Health Partnerships • Telemedicine • Pediatric Subspecialists (annual rent - $22,365) • Insurance & Care Coordinators (grant revenue - $64,531)

15. Strategy 5: Affirm a Clinic Commitment to Open Access • Purpose: To recruit and retain quality pediatricians who share a commitment to the medical home system of care. • Medical Home program financing • Adequate Medicaid reimbursement ensures access • Training of clinic staff and other local agencies to enroll children directly into Medicaid • General pediatric practice with inpatient care, 24/7 care, one out of seven call • Oversight of pediatric nurse practitioners • Student loan forgiveness ($150,000) • Above average incomes and benefits

16. Strategy 6: Use a Business Approach to Cost Effective Care • Purpose: Develop a strategic plan and budget for each program and service. (C & AC Non-FFS revenue - $160,000) • Recall: disease and well child management • Pediatric practice oriented IT partner • Allocation of staff hours, facility use • Allocation of pediatrician time • Negotiation of contracts • Grant writing and funding • Coding and documentation

17. Right Coding and C & AC Revenue • Team Conference $16,619 • Developmental Screening $31,454 • Fluoride Varnish $15,407 • Vaccine Education $ 8,811 • Annual Well Child / Disease Review • Accurate Documentation of 99214

18. Strategy 7: Use Marketing to Ensure Cost Effective Care • Purpose: support a medical director, program director, and marketing consultant. • Budget 1.25% of gross income • Pediatrician medical director • Pediatrician marketing consultant • MPH program director • Brochures, newspaper ads, e-media flash ads, website • Disease management, patient binders, patient education, telemedicine

20. Quality Improvement Activities • Using the Center for Medical Home Improvement tools • Self-assessment tool – checking on our “medical home-ness” • Family survey • Weekly quality assessment meetings for clinical staff

21. Moving Forward to the Next Challenge…some opportunities • Support legislation that ensures systems of care through the medical home • Expanding early intervention services in our community • Looking for funding to expand the mental health-medical home collaboration throughout the county that would ensure all children have a medical home regardless of insurance status.

22. Questions? • Phyllis Cavens, MD, Medical Director • Email: pcavens@pacifier.com • Phone: 360-577-1771 • Hilary Gillette-Walch, RN, MPH, Program Director, Cowlitz Center of Foster Care Health and Healthy Tomorrows Grant • Email: hgillette-walch@pacifier.com • Phone: 360-577-1771, extension 282