1 / 20

Coordination of the Medical Home

Coordination of the Medical Home. Liza DeWitt, M.D. Katherine Ender, M.D. Heather Osborn, M.D. The Medical Home:.

seven
Download Presentation

Coordination of the Medical Home

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Coordination of the Medical Home Liza DeWitt, M.D. Katherine Ender, M.D. Heather Osborn, M.D.

  2. The Medical Home: • Definition: a system of health care for the child with special needs which is accessible, continuous, comprehensive, family centered, coordinated, compassionate and culturally centered • Increased need for home care secondary to advanced medical technology • Coordination is paramount

  3. Obstacles to the Medical Home -Lack of a single entry point linking systems of health care, social services, education, etc • Multiple services/systems with different goals/agendas • Varying eligibility criteria that determine eligibility of services

  4. The medical home’s team members • Patient • Family • Primary care provider • Medical sub-specialist • Therapists • Social Workers/Case managers

  5. Continued… • Nurses • Teachers • Transportation providers • Community • Pharmacist • Information resources

  6. So who’s in charge?“I need a leader!”-J.G.

  7. One option: the primary care physician • Families have indicated a greater need for involvement of their primary physician in the care coordination process • The absence of involvement can lead to incomplete coordination and episodic, expensive, fragmented care • The primary care physician should then have a framework from which they can help coordinate care of a child with special needs

  8. Coordinating the medical home 1. Gain access to and integrate services and resources 2. Link service systems to the family 3. Avoid duplication and unnecessary costs 4. Advocate for improved individual outcomes in a caring and compassionate manner

  9. Access and Integration • Creating a list of the community’s resources • Establish accessible lines of communication with those resources/services • Pairing “new” families with “experienced families” • Pairing “new” physicians with “seasoned veterans”

  10. Access and Integration cont… • Creating a case management summary • Dynamic and frequently updated • Thorough and concise • Facilitating a multi-disciplinary meeting • identifying obstacles and goals • assigning roles for each team member

  11. Linking services to families • Surveillance for disability • Identification of needs • Early referral to optimize development • Follow-up • Recognition of potential barriers

  12. “Logistics of Linking” • Facilitate pursuit of appropriate insurance services • Educating yourself on your community’s resources • Transportation

  13. Avoiding duplication and unnecessary costs • Case managements summary • Frequent contacts with sub-specialist • Sharing unbiased and complete information with the family • Home visits by equipment providers • In-hospital case managers • Recognizing individual limitations • Commitment to staying up-to-date

  14. Advocating for the child • Ongoing re-evaluation of goals • Family-the center of strength and support • Medical • Social • Educational • Cultural • Lifetime enjoyment

  15. Advocating for the child • Providing necessary information to insurance providers for timely approval of services • Exposing/educating the community • Political advocate for the child with special needs • Establishing an emergency plan • Family contingency plan • Being a resource for family during discharge planning

  16. Advocating for the child • Making ready your practice for care of the child with special needs • ensuring updated information to the on-call staff • Identifying contact information for families • Having a home equipment company that is available 24hrs a day, seven days a week • Being sure the child is receiving primary care/preventive care, as well as tertiary services

  17. Advocating for the child - Helping the family to cope with the personal barriers to a happy, healthy lifestyle • Strain on individual careers/marriage • Need for time spent with other children • The loss of personal/free time Simply being a compassionate and culturally-sensitive part of a family’s “extended support network” can make a significant difference in the life of a child with special needs…

  18. “I’ll be the Leader!”

  19. References: • Care Coordination; Integrating Health and Related Systems of Care for Children with Special Needs. AAP Policy Statement. Vol 104, #4. October 1999, pg 978-981 • The Medical Home. AAP Policy Statement. Vol 110, #1. July 2002, pg 184-186 • Guidelines for Home Care of Infants, Children and Adolescents with Chronic Disease. AAP Policy Statement. Vol 96, #1. July 1995, pg 161-164

  20. References: • www.medicalhomeinfo.org • www.eparent.com • www.mch-hotlines.org • Thank you to the families who have taught us

More Related