“Building Your Own Pediatric Medical Home for CSHCN”

1. “Building Your Own PediatricMedical Home for CSHCN” Jennifer Lail, M.D. Jacksonville, FL October 16, 2010

2. With Help From: • Blue Cross Blue Shield of NC Foundation • Division of Medical Assistance of NC, Quality Management Dept. • NC Title V Program • Joseph, Christina and Teresa

3. Disclosures • “I have no relevant financial relationships with the manufacturer(s) of any commercial products and/or provider of commercial services discussed in this CME activity.” • “I do not intend to discuss an unapproved or investigative use of a commercial product/device in my presentation.”

4. Objectives • Identify Medical Home adaptations to pediatric practice that support patient-centered care for all, esp. CYSHCN • Discuss how patient-centered and planned care promotes communication between patients and multiple providers and facilitates all medical transitions • Understand new initiatives that link Medical Home practices to reimbursement • “I want to try that!” ideas

5. What is a Medical Home? • “The Medical Home is the model for 21st century primary care, with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated and family-centered manner.” -American Academy of Pediatrics www.pediatricmedhome.org/

6. “Crossing the Quality Chasm: A New Health System for the 21st Century” -New Performance Expectations for care that is: • PATIENT-CENTERED • SAFE • EFFECTIVE • TIMELY • EFFICIENT • EQUITABLE -Institute of Medicine, Committee on Quality of Health Care in America, 2001

7. Quality Chasm Rules for Practice Redesign • 1. Care is based on continuous healing relationships • 2. Care is customized according to patient needs and values. • 3. The patient is the source of control. • 4. Knowledge is shared and information flows freely. • 5. Decision making is evidence-based. • 6. Safety is a system property. • 7. Transparency is necessary. • 8. Needs are anticipated. • 9. Waste is continuously decreased. • 10. Cooperation among clinicians is a priority.

8. “System Changes? I have patients to see!” • One in 5 families has a CSHCN • Survival/Longevity among CSHCN is increasing • Design is for 1 problem in 10 minutes • Retail-based Clinics erode our acute care base • Reimbursement will be linked to system change

9. Suburban Private Practice, 2 offices, self-owned Duke University and University of NC Medical Centers within 15 miles 12 MD providers, 9 F.T.E. 74% Managed Care 13% Self Pay (incl. HSA) 13% Medicaid + SCHIP >30 year history of collaboration with both medical centers Office hours 365 d/year Evening/weekend office hours Nighttime Nurse triage and daytime Advice Nurses Transition to EMR in fall 2007 Around 50,000 visits/year at 2 sites; 12,233 physicals See til 21, 43% in registry are 12 and older Age 12-21 = 24% of 2009 physicals; 4% > age 18 27% CSHCN in registry are Medicaid-insured Welcome to Our Medical Home!

10. Imagine: • Staff recognizing a parent when appt. is made • Adequate time scheduled for that child • Specialist’s records in your hands prior to the visit, including lab and X-ray results • Parent concerns identified before the visit; multiple tasks completed • Lab slips ready, and EMLA cream on child prior to visit • Help by your staff for families with referrals, resources, equipment • Followup to assure completion of tasks

11. Essential Components of a Medical Home System • Relationships/Respect • Ready Access • Registry and Records • Resources • Reimbursement • Recruitment

12. Relationships • Youth and family • Supportive staff • Care coordinators • Specialty Providers and their staff • Schools • Insurers • Community Providers

13. Ready Access • Accept Medicaid, many insurers • Evening, Weekend and Holiday office hours • 24-hour advice nurses • Care til age 21 • Translation Phone • Privacy protection for Teens • ADA accessible physical plant • Handicapped parking spaces • Identified Adult Providers

14. Registry & Care Coordination Program • “The Left Ventricle of the Medical Home” • Identifies who needs more help • Separate from Advice Nurses • Direct Phone Extension • Brochures and Business Cards • Care Coordinators Link to Other Care Coordinators!

15. Care Coordinators: • -Maintain registry of 1434 pts.; data entry, annual purge, data enquiries • -Referrals: 1690 in 2008, 1800 in 2009 -contact parent -assure referral data is at specialist -obtain and scan notes from specialist appt. -referrals directly from parent after familiar with CC system • -Pre-Visit Contacts: 298 in 2008, 473 in 2009 • -Transition Care: -Hospital and ED fup, locating records, calling family, scan to EMR -Newborn entry to practice; discharge summary, NBS results -New pts: obtain old med records, PVC’s with families -Capture of episodic care and return to care system -Bridge of information for parents between school/Medical Home • -Pre-authorizations -radiology procedures -insurance authorizations for specialists • -Medical Necessities: -durable med. eqpt -mattress/pillow covers -Bipap machinery -authorizations for CAP-C, CAP MR/DD • -Medicaid Interface: -capture of episodic care -collaboration with Medicaid Case Managers -Followup on missed primary and specialty appts.

16. Registry: Knowing Who Needs Care • Maintained by Care Coordinators • Notebooks  Excel  Access EMR • Alerts schedulers to need for more time • Assures key data to specialist for consult • Track referrals and specialist reports • Prompt Pre-visit contacts

17. Risk Stratification = Complexity Scores • More time? • Communication devices? • Technological support? • Translator? • Pre-Visit Contact?

18. Registry-Helps Document Care • Permits data collection for negotiation with insurers • Permits recall by dx for research, parent-to-parent • Aids in NCQA certification process for PCMH • Assists with chart retro-fit for EMR • Risk-stratification for Care-Planning • Population-based care (flu, Synagis, etc.)

19. Registry permits Planned CarePVC = Productive Visit Lab and XR slips are created, EMLA cream made available

20. PVC’s streamline care • Parent survey of PVC’s- 93% rate as “very helpful” • “it shows you care about my child” • “makes my visit more useful and efficient” • “less reviewing, more looking forward”

21. MH Services aid Collaboration/Comanagement with Specialists • Care coordinators as facilitators • Assure that referral data sent and visit accomplished • Access to Specialist records (letter, fax-back, electronic) • Phone/email dialogue re: care • Specialty followup at PCP office (weight checks, labs) • Synthesis of thought from multiple specialists

22. Our Parents/Families as Resources • Education! • Parent-to-Parent Collaboration • Advocacy Groups • Personal Knowledge of Local Providers and Services • Word-of-mouth referrals • Physical Plant walk-through • Boardmaker

23. CommunityResources Directory “answers in our pockets” • Ask MD’s to submit their favorites from all disciplines • MD’s who respond get a copy!! • Parent Partner and Care Coordinator add Local Resources • Every Fall, update from margin notes and new mailings • Pocket size fits Lab coat • 5th edition now in use

24. State Programs for CSHCN Alternative Medicine Audiology Augm. Comm./Asst.Technology Autism Baby Nurses Carseats for CSHCN Child Abuse Child Psychiatry/Psychology Community MD’s Compounding Pharmacies Dentistry Devel. Eval and Therapy Domestic Violence Early Intervention Eating Disorders G-tube and Trach care Genetic Testing Grief Counseling/Hospice Group Homes Gynecology Handicapped Parking Health Depts. Home Health Care/Eqpt. Lactation Services Nutrition Orthotics OT/Feeding Parent-to-Parent Podiatry PT PT Sports/Injury Rare Disorders Recreation for CSHCN Rehabilitation Specialists Respite/Residential Care School Systems Social Services Smoking Cessation Speech SSI Substance Abuse Travel for CSHCN Voc. Rehab. Misc. CSHCN Directory Index

25. Resources for Young Adult Care • Med-Peds Trained ? • Family has prior relationship? • Identify by Transition Fax-Back • Transition Provider List • Update List yearly • Give list before Transition

26. A Medical Home for CYSHCN eases transitions • Trusted relationships • Established access to care • Providers identified (medical and support) • Current Problem List defined • Established mechanisms of communication • Resources and obstacles identified • Upcoming needs anticipated

27. Reimbursement-How to Pay for Improvement • Market your Medical Home services • Optimize MD time with Care Coordination • Proper coding for care of CSHCN • Careful attention to charge capture • Contract renegotiations with insurers (data!) • Medicaid Community Care-case management fee pm/pm • NCQA- Physicians’ Practice Connection/Patient Centered Medical Home • Pay-for-Performance Programs

28. Families want a Medical Home!

29. Adequate time for the visit promotes appropriate coding • Remember CYSHCN visits often are 99214 • Learn to use modifiers • Learn to code for time • Capture all charges • Do coding reviews • Code for after-hours

30. Appropriate Coding for Enhanced Care

31. Better Quality = Better Reimbursement Renegotiate Contracts with Data

32. Adequate time for care Better planned visits Better links with specialists Help with referrals and resources Family satisfaction Fiscal Viability Caution-Don’t wait for consensus Big Goals— Small Steps

33. Docs re-educated on coding for CSHCN Title V 3 year grant Forum with CHPA, Parents and School Admin. for CSHCN in schools “Listening Session” with CHPA parents to identify needs Streamlined “checkout” process Joined NC Medicaid Managed Care Network Computer Access for UNC, Duke “Backlines” to Specialty Care Identified 1500+ in registry and Office Mgmt. System Care Coordinator from 3 hrs./wk to 2 full-time positions 5th ed. CSHCN pocket phonebook; transition referral options 93 % of Families find PVC’s helpful Reduced ED and after-hours utilization for 4 years Boardmaker for commun. impaired BCBS “Bridges to Excellence” P4P program; NCQA certification; BQPP participation Countless Small Steps Later 4/03—10/10NICHQ Medical Home Learning Collaborative

34. So how do we get there? • Identification of problem areas • Establish explicit goal to address • Break process into tiny steps • Create tools to support weak spots • Try ONE SMALL change • Measurement of improvement (or failure!) • Try another test of change and see if you’re ready to grow that change

35. BTE,QI, PPC-PCMH, BTEBQPP, NCQA, PDSA?? • Enhanced reimbursement for quality improvements • PLAN-consider a needed improvement • DO-try some SMALL changes to make it better (“test of change”) • STUDY-measure if your changes helped • ACT-refine the process to make it work even better

36. IMPORTANT… NCQA CERTIFICATION is NOT the same as A Patient-Centered Medical Home

37. Pay for Performance program Promotes processes and information systems to improve patient care Three levels of incentive payments Certification by NCQA for 3 years. EVALUATES: Access and Communication Patient Tracking and Registry Functions Care Management Pt. Self-Management E-prescribing Test Tracking Referral Tracking Performance Reporting and Improvement Advanced Elec. Communication NCQA Certification Process

38. BQPP - demands NCQA certification • Enhanced reimb. on E&M codes to max of 176% of Medicare • Measures: • Clinical Quality Outcomes (NCQA cert.) • Administrative Efficiency • Patient Experience with Care • 2 levels of reimb. increase • 15% over standard • 30% over standard

39. “When you stop getting better, you stop being good”---Wyatt Taylor • “Changing a Pediatric practice is like changing the tire on your bike while you’re riding it” --- Carl Cooley

40. “My family, with all its challenges, is a success story, but part of that success is because we have had a Medical Home”… Libby

41. Relationships/Respect • Ready access • Registry and care coordination • Resources • Reimbursement • RECRUITMENT?? WHAT DO YOU WANT TO TRY?