Successful Transition from the Hospital to a Medical Home

1. Successful Transition from the Hospital to a Medical Home Lauri Levin, MSW

2. Creating a Medical Home while . . .

3. Learning Objectives • Understand families experiences in the NICU • Understand vital elements of discharge planning • Promote family-professional partnerships as a natural part of establishing a medical home. • Understand the importance of a medical home • Learn about available discharge planningtools and forms

4. How do you measure success? Outcomes: • Improved Family Satisfaction • Improved Mortality Rates • Decreased Readmission Rates • Decreased Emergency Room Visits • Decreased Life Threatening Events • Decreased Utilization of High Cost Health Care

5. Poor discharge planning results in worse outcomes including the higher likelihood of readmission. Under conditions of limited discharge options, professionals often feel they they have no choice but to send children home to families and communities that they consider questionable in their ability to provide the necessary care in a safe environment. (Dewitt and Janson)

6. Comprehensive follow up care by experienced caregivers results in: • Reduced life-threatening illness without increasing cost among high-risk inner-city infants. • Reduced total days of pediatric intensive care by more than 40% among high-risk inner city infants. Broyles, R. S, Tyson, J. E., Heyne, E., Heyne, R.J., Hickman, J. F., Swint, M., Adams, S, West, L.A., Porneroy, N., Hicks, P., Ahn, C. Comprehensive Follow-Up Care and Life Threatening Illness Among High-Risk Infants. JAMA. 2000; 284:2070-2076

7. Directing financial resources to ambulatory, comprehensive care results in: • Reduced admission for children with chronic conditions • Reduced the average length of stay • Hospital inpatient charges fell significantly, resulting in a savings to insurers of $10.50 for every $1 invested Liptak, G., Burns, C., Davidosn, P.,McAnarney, E. Effects of Providing Comprehensive Ambulatory Services to Children With Chronic Conditions. Archives of Pediatrics and Adolescent Medicine. 1998;152:1003-8

8. When stress increases in the lives of mothers of CSHCN, there is a higher risk of ED or hospital use for their children.(List, et al; PAS Meetings, 2002)

9. The NICU Experience Family’s Experience a Rollercoaster of Emotions: • Sorrow • Guilt • Anger • Regret • Confusion

10. Families are big, small, extended, nuclear, multigenerational, with one parent, two parents, and grandparents. We live under one roof or many. A family can be as temporary as a few weeks, as permanent as forever. We become part of a family by birth, adoption, marriage, or from a desire for mutual support…. A family is culture unto itself, with different values and unique ways of realizing its dreams; together, our families become the source of our rich cultural heritage and spiritual diversity…. Our families create neighborhoods, communities, states, and nations. Polly Arango, Family Voices, Algodones, NM

11. Family-Professional Collaboration • Promotes relationship in which family & professionals work together to ensure the best services for the child & family • Recognizes & respects the knowledge, skills and experience that families and professionals bring to the relationship • Acknowledges that the development of trust is an integral part of a collaborative relationship

12. Family-Professional Collaboration • Facilitates open communication so families & professionals feel free to express themselves • Creates an atmosphere in which the cultural traditions, values, and diversity of families are acknowledged and honored • Recognizes that negotiation is essential • Includes acknowledgment of mutual respect for eachothers’ culture, values, and traditions Bishop KK, Woll J, Arango P. Family/Professional Collaboration for Children with Special Health Care Needsand Their Families. Burlington, VT: Family/Professional Collaboration Project, Department of Social Work, University of Vermont; 1993:15

13. What Is a Medical Home? • An approach to providing health care services in a high-quality, comprehensive, and cost-effective manner • Provision of care through a primary care physician through partnership with other allied health care professionals and the family • Acts in CYSHCN’s best interest to achieve maximum family potential

14. Medical Home Common Elements Care that is: • Accessible • Family-centered • Continuous • Comprehensive • Coordinated • Compassionate • Culturally effective and for which the Primary Care Child Health Professional shares responsibility

15. Who Is Part of a Medical Home? • Child Health Professional • Family • Child/youth • Allied health care professionals • Family’s community • Pediatric office staff • If necessary, pediatric sub-specialists

16. The Role of the Medical Home • Gathering information, triage: medical; non-medical; “in-between” • Interpret medical information; integrate it all into care plan • Teach CYSHCN and families • Learn from CYSHCN and families • Mediate any potential conflicts

17. The Role of the Medical Home • Available 24/7 • Continuous throughout child’s life • Central medical record • Serve entire family • In child’s community

18. Evaluation of the Medical Home Model • Increased parent and patient satisfaction with pediatric primary care • Less days missed work for parents • Reductions in emergency room visits and hospitalizations • More outcomes to come…….

19. Discharge Planning Walk Through

20. Getting the Medical Home Team Ready for Discharge • Defining Roles • Developing the Family-Professional Partnership • Psychosocial Assessment • Assessing/Anticipating Needs • Referrals to Needed Services

21. Identify effective strategies for collaboration and communication in basic care management • The family’s role • The primary care child health professional’s role • The subspecialist’s role • The community’s role

22. What can you do on Tuesday? • Be proactive…not reactive • Start planning for discharge the day a child is admitted to the NICU • Partner with families in decision making • Empower Families to become the experts in their child’s care • Become knowledgeable of community and state resources

23. www.medicalhomeinfo.org

24. Learning Objectives • Understand families experiences in the NICU • Understand vital elements of discharge planning • Promote family-professional partnerships as a natural part of establishing a medical home. • Understand the importance of a medical home • Learn about available discharge planningtools and forms