Retrofitting the Medical Home for Children with Special Health Care Needs

1. Retrofitting the Medical Home for Children with Special Health Care Needs Mara McGrath, MPH Manager, Alameda County Medical Home & Help Me Grow Projects October 25, 2017

2. Objectives • Introduce the characteristics of a medical home • Describe the Medical Home Index • Give examples of how to strengthen the medical home infrastructure • Share outcomes of quality improvement projects • Identify barriers to shoring up the foundation • Questions and potential answers

3. Medical Home • Accessible: I can get care for my child 24 hours a day, 7 days a week. • Family-Centered: I am a valued and respected member of my child’s medical team. • Comprehensive: My child’s providers are familiar with who my child is and his/her health condition(s). I get the same doctor with every visit.

4. Medical Home • Continuous: My child’s doctor never gives up on meeting my child’s needs; this includes a “warm handoff” to adult provider • Coordinated: I can easily receive referrals to specialty care and community services when my child needs it; reports are integrated into personal health record • Compassionate: My child and I are treated with genuine concern and compassion • Culturally Sensitive, Humble and Competent

5. Medical Home Index • Short version has ten indicators • Three levels: (1), • Level 1: good, responsive pediatric care • Level 2: proactive care • Level 3: comprehensive care/care coordinator *Administered for baseline and then every three years

6. Family Feedback • Suggestion box • Focus groups, individual interviews • On-line reviews (Yelp) • Annual patient satisfaction surveys • Parent advisory board or process for parent input in policies/procedures

7. Cultural Competence As a medical provider, you: • Learn about other cultures; ask questions • Are aware of your own values and beliefs and how they help shape your actions and decisions • Respect family values and beliefs, including interest in alternative remedies; incorporate into care plan • Are nonjudgmental • Consider ways to sensitize the entire office staff about the diversity of families • Provide educational materials in multiple languages as needed, and offer translation and interpreter services • Decorate the office to reflect cultural diversity • Recognize what nonverbal behaviors are communicating to the family and vice versa

8. Identification of CSHCN • Track children who have involvement with Regional Center, California Children’s Services (including MTP), Special Education andMental Health • Flag electronic health record (EHR) on facesheet or problems’ list • Search on ICD-10 diagnostic codes and/or acuity levels

9. Care Continuity • Team made up of PCP, family and staff • Care plans include home, school and community with visit schedules outlined and communication strategies • Practice back-up/cross coverage is outlined • Medical condition protocols or algorithms for care coordination, eg. Autism Algorithm, are developed (include goals, services, interventions and referral contacts) • Care coordinator relies on these protocols for direction

10. Cooperative Management • Primary Care Provider (PCP) and family set referral and communication goals for Specialty Care: time lines and how communication will be handled with all parties involved • Parent(s) choose to be the “driver” and partner with PCP; specialists’ role is consultation only

11. Supporting Transition to Adulthood • Establish timelines and developmental approach to health & wellness, education & vocational planning, conservatorship, and community supports & recreation • PCPs identify adult providers and facilitate a “welcome” visit sometimes with help from health plans

12. Care Coordination/Role Definition • Provider and parents (or older child) partner to accomplish care coordination goals • Care coordination activities and services are offered by a designated care coordinator as part of the practice’s standards • Family needs/wishes drive their choice and level of practice involvement

13. Patient Needs Assessment/Care Plans • Review and update care plans twice a year (health status, hospitalizations, medication changes, equipment needs, mental health needs) • Care coordinators (mostly found in specialty practices) monitor and update care plan at every visit

14. CSHCN Community Needs Assessment • Providers raise questions (eg. eligibility based on number of prescriptions) • Seek pertinent information from families • Participate in community public health effort (eg. Special Needs Committee) • Bring observations/data to attention of local (eg. Special Needs Committee) or State (Family Voices) policy-maker

15. Quality Standards • Medical practice has quality improvement mechanism for CSHCN • Integrates into regular staff meetings • Parents of patients participate in QI activities (eg. Training on transition, developmental screening, and handouts for providers’ interactions with families

16. Quality Improvement Projects • Sonoma County FQHC • Specific to children with epilepsy • Federally funded • Federally qualified health center (FQHC) • Multi-disciplinary coalition(monthly) • Stabilized provider assignment • Spread included nursing training

17. Quality Improvement Projects • Large Pediatric Practice – BPMG • Specific to children who have CCS • Identification of all CCS children (200) and those who would be transitioning (25) • Monthly meetings with providers and representatives from front & back office • Flag charts and add visit time • Create transition packet and train

18. Quality Improvement Projects • Children’s Hospital • Specific to children with acute needs for intensive case management • Initially, monthly meetings with CCS team and Family Navigator (no patients) • Currently, quarterly meeting after two years • Address care coordination challenges • Effect policy changes (billing codes and specialists in primary care)

19. Quality Improvement Projects • Alameda County Behavioral Health Care Services • Spinoff from Special Needs Committee • Buy in from director at ACBHCS • Better communications between PCP and mental health providers • Billing code, conferences, website, communication tools

20. Barriers to Medical Home • Ability to be reimbursed (certification) • Leadership (champions) • Patient collaboration/encouragement • Practice environment/extended environment (eg, hospital linked to practice) • Staff capacity (other QI projects, unions) • An electronic health record (didn’t expect this!) • Adequate time for innovation and reflection (PDSA)

21. Key Strategies • Whatever documents/resources that are created for families or providers should be designed for interchangeability. • Dissemination to both families and providers simultaneously is critical for increased utilization and engagement. • Keeping documents simple makes for easier translatability and readability for low literacy. • Family leaders vet all documents.

22. Medical Provider’s Role • Information on Accessing Health Coverage • Knowledge of Entitlement System • Alert to Changes in Legislation and Impact on Families (Regional Center) • Awareness of Resources in Family Support and Navigation • Access to Current Health Records

23. Wrap-Up • Pediatric providers want a care coordinator in their office • PCPs want simple and practical recommendations for changing their practice • PCPs want technical assistance that can interface with their larger systems • PCPs want seamless integration of EHR • PCPs want family participation to feel comfortable for their families

24. Questions??? Email Mara McGrath: mmcgrath@stanfordchildrens.org