Pediatric Topics MiPCT Care Manager Training

1. Pediatric Topics MiPCT Care Manager Training Jane Turner M.D. Dana Watt MSN January 2013

2. Pediatric curriculum looking back • Break out sessions spring 2012 • ADHD as index condition • Focus on coordinating care are school and family • Webinar on social determinants of health • Face to face meeting fall 2012 • Community resources (asthma as index condition) • Principles of family centered care – parent perspectives

3. Pediatric Curriculum Plans • Webinars 2013 – third Friday of the month • January: Pediatric Metrics and CSHCS • February: Obesity • March: ADHD • April: ? Face to face meeting to learn from each other? We will ask care managers again about priority topics……..

4. MiPCT Metrics Overview

5. MiPCT Pediatric Clinical Measures Registry or EHR • Asthma: (ages 5-64) Self-Management Plan or Asthma Action Plan • Obesity (ages 2-17yrs) BMI Percentile • Tobacco (ages 13 and older) Percent smokers • Well Child Visits • 15 months (6 total) HEDIS • 3-6 years (1 per measurement year) HEDIS • 2-21 years (1per measurement year) HEDIS

6. MiPCT Pediatric Clinical Measures MCIR or EHR • Lead Screening: (Age 2) HEDIS Medicaid only • Immunizations • Childhood Immunizations (age 2) HEDIS • Adolescent Immunizations (age 13) HEDIS

7. 2013 Performance Incentive MetricsOutcome/Improvement Measures

8. ED Visits NYU Algorithm

9. AHRQ Pediatric Quality IndicatorsPotentially Preventable Inpatient Admissions (under 18 years of age)

10. 2013 Performance Incentive MetricsOutcome/Improvement Measures

11. 2013 Performance Incentive MetricsProcess Measures

12. 2013 Performance Incentive MetricsInfrastructure Process Measures* PGIP SRD Data

13. 2013 Performance Incentive MetricsInfrastructure Process Measures

14. Michigan Data Collaborative Feedback Reports • Starting in late spring 2013, MDC will report • MiPCT Quality metrics • Cost of care for key chronic illnesses: ADHD, Asthma and Obesity for pediatric practices • Gaps in care • Data is to be updated every 2 months • Practices must get the reports from their PO https://www.michigandatacollaborative.org/MDC/assets/MiPCT_Dashboards_Reports_UG.pdf

15. Children’s Special Health Care Services 2013 Jane Turner, MD, FAAP Chief Medical Consultant CSHCS

16. Why is this important to MiPCT care managers? • Prior to October 1, 2012, children and youth enrolled in CSHCS and Medicaid were all in fee for service (straight) Medicaid. • The transition to Medicaid Health Plans began Oct 1 and many children/youth who were not previously on the MiPCT list are now eligible for your services. • These are children/youth with severe and complex health conditions.

17. Topics for the Webinar • What is CSHCS? • Who is eligible and how is eligibility determined? • What are the benefits of CSHCS? • How can care managers improve the care for children and youth on CSHCS? • Who else is coordinating their care?

18. Children’s Special Health Care Services CSHCS is an important component of Michigan’s Title V program (Maternal Child Health) that addresses the medical needs of children and youth with special health care needs. The mission of the program is spelled out in Michigan’s public health code.

19. Criteria for Medical Eligibility • Diagnosis • Severity of Condition • Chronicity of Condition • Need for Treatment by a Physician Specialist(pediatric subspecialist)

20. Diagnosis • The individual must have a CSHCS qualifying diagnosis where his activity is or may become so restricted by disease or deformity as to reduce his normal capacity for education and self-support. • Psychiatric, emotional and behavioral disorders, attention deficit disorder, developmental delay, mental retardation, autism, or other mental health diagnoses are not covered by the CSHCS Program

21. Sample CSHCS diagnoses • Cystic fibrosis • Hearing loss • Insulin-dependent diabetes • Muscular dystrophy • Certain heart conditions • Epilepsy • Kidney disease • Sickle cell anemia • Certain vision problems • Cancer • Cerebral palsy • Cleft lip/palate • Liver disease • Club foot • Hypospadius • Spina bifida • Paralysis • Hemophilia

22. Severity • The severity criteria are met when it is determined by the MDCH medical consultant that specialty medical care is needed to prevent, delay, or significantly reduce the risk of activity becoming so restricted by disease or deformity as to reduce the individual’s normal capacity for education and self-support.

23. Chronicity • A condition is considered to be chronic when it is determined to require specialty medical care for not less than 12 months.

24. Need for Treatment by a Physician Specialist The condition must require the services of a medical and/or surgical subspecialist at least annually, as opposed to being managed exclusively by a primary care physician.

25. How is eligibility determined? • Subspecialist sends a report to CSHCS – often through the local health department. • The Medicaid Health Plan submits a MERF with medical reports from subspecialist. • A pediatrician at CSHCS reviews the reports and decides if the child/youth meets eligibility criteria. • Reports from primary care are not accepted.

26. Primary Care • Since CSHCS does not cover primary care, the “system of care” around each child has excluded primary care. Primary care will now be an integral part of the child/youth’s system of care. • Families who have primary care docs were encouraged to choose a plan that contracts with that practice. • Families who did not have primary care doc were encouraged to sign up with a practice that is prepared to care for CYSHCN.

27. Subspecialty Care • A major function of CSHCS is to ensure access to pediatric subspecialty care. • There is the risk that access to appropriate pediatric subspecialists will be jeopardized. • CSHCS is working with Medicaid and plans to ensure that children and youth continue to receive the services and supplies they need.

28. Subspecialty Care • Families have been encouraged to sign up for a health plan that participates with the child’s specialty providers. • If the subspecialists are not in the plan’s network, the plan is to authorize continued care with that subspecialist until the family and the plan both agree that it is safe to transition care to an in-network subspecialist.

29. Mental Health • Access to mental health services is problematic in Fee for Service Medicaid. • Community Mental Health • Severity/chronicity criteria • Long waits for services • Medicaid Health Plans provide up to 20 outpatient mental health visits per year. • CSHCS children/youth will now have access to outpatient mental health services.

30. What does CSHCS offer? • Access to the most appropriate subspecialist in Michigan (out of state if no one in MI) • Special therapies not usually covered by insurance • Orthodontics if related to the CSHCS qualifying condition (i.e. cleft palate) • Respite care • Children’s Multidisciplinary Services clinics

31. Children’s Multidisciplinary Services CMS Clinics • Team of specialists specific to the condition • Social work and psychology • “one stop shopping” • Team members talk to each other • Team generates a care plan including recommendations of all team members • Greater than the sum of the parts

32. CMS Clinic Themes • Apnea • Neurology • Neuromuscular • Amputee/Limb deficiency • Feeding Program • Rheumatology • Genetics • AIDS • Immunology • Gastroenterology/Nutritional Deficiencies • Nephrology • Metabolic Disease • Weight Management • Cardiology • Cleft Lip/Palate/Facial • Cystic Fibrosis • Diabetes • Endocrinology • Hematology/Oncology • Hemophilia • Myelodysplasia (Spina Bifida) • Pulmonary/Severe Asthma/Vent • Lead Toxicity • Sickle Cell Disease • Multiple Handicap /Disability/Chronic Disease • Infectious Disease

33. Coordination of Care • Practice level coordination • MiPCT care manager and practice team • Plan level coordination • MHPs have case managers • Local Health Department • CSHCS nurse • CMS clinic care plan

34. Coordination of the coordinators… • MHP contact list on our website • Local Health Department – link on our web site • Children’s Multidisciplinary Services • Check with your local health department for clinics in your region

35. MiPCT Care Manager • Work with the family to assess all the child/youth’s needs • Communicate with the MHP case manager • Communicate with the local health department • Document who is doing what so efforts are not duplicated and the family doesn’t get confusing messages

36. Recognize the family • Remember the family is at the center of the child’s system of care • Family members are usually experts in their child’s care. • Be sure to involve family in all decisions. • The Family Center can link families with other families and offer resources.