high-value integrated care outcomes depend on care ......3 » introduction 4 » facilitator...

Pediatric Care Coordination CurriculumMODULE 1

Richard Antonelli, MD, MS, FAAPRenee Turchi, MD, MPH, FAAPKathleen Huth, MD, FRCPC, MMSc-Medical Education

Module 1

Module 2

Module 3

Module 4

Module 5

Antonelli R, Huth K, Rosenberg H, Bach A. Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in achieving Optimal Child Health Outcomes, 2nd Edition. Boston Children’s Hospital, 2019.

Antonelli R, Turchi R, Huth K. Module 1, High Value-Integrated Care Outcomes Depend on Care Coordination. In Antonelli R, et al, Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in achieving Optimal Child Health Outcomes, 2nd Edition. Boston Children’s Hospital, 2019.

The development of the Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes, 2nd Edition is supported through a sub-contract with the National Center for Medical Home Implementation (NCMHI), a cooperative agreement with the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS). The information or content are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by MCHB, HRSA, HHS or the U.S. Government.

High-Value Integrated Care Outcomes Depend on Care Coordination

2 » Module Overview

3 » Introduction

4 » Facilitator Guide–Slide Deck

24 » Case-Based Learning

© 2019 Boston Children’s Hospital. All rights reserved.

Module 1Pediatric Care Coordination Curriculum 2nd Edition 1© 2019 Boston Children’s Hospital.

All rights reserved.

High-Value Integrated Care Outcomes Depend on Care Coordination

Module 1—ObjectivesAt the end of this session, participants should be able to:

• Discusskeycomponentsofcarecoordinationwithinanintegratedmodelofcaredelivery.

• Assesscurrentpracticesthatsupportcarecoordinationandintegratedcaredeliveryinavarietyofsettingsincludingstate,regional,deliverysystem,communityagencies,orclinics.

• Prioritizeareasofimprovementincareintegrationandcarecoordinationintheircurrentpractice.

• Identifyestablishedtoolsandprocessesthatcanbeusedtoimplementkeycomponentsofcarecoordination.

• Developanactionplanoutliningspecificgoalstofacilitatecarecoordinationintheirpractice.

Note to the facilitator:

Pleasebeawarethatwhenimplementingthismodule,itiscrucialtoincludelocal-,state-,andregion-specificcontent.

A foundinthemoduleindicatestheneedforlocalcontenttobeadded, butfacilitatorsshouldfeelfreetoincludelocalcontentwherevertheyseefit. Localcontentincludes,butisnotlimitedto,thefollowing:

• Culturalaspectsofthecommunity(includingassets,vulnerabilities, and language)

• Sociodemographicfactors• Geography• Local,state,and/orregionalresources

Thereare2tablesincludedbelow.Thefirstisahigh-levelagendaofthemodule.Thesecond is the facilitator guide that includes a breakdown of slide content and talking points.Thefacilitatorshouldusetheguideasaresourcetotailorthetraining.

Thecurriculumisintendedtobetailoredtofitthetrainingneeds,andthecontent canbemodifiedfordifferentaudiences.Therefore,contentfromthismodulecanbeselectedandincorporatedintothetailoredtraining.However,asuggestedagenda forimplementingthismoduleasastand-aloneisincluded.

Module 1Pediatric Care Coordination Curriculum 2nd Edition 2

Pre-sessionreading

Introduction

Didactic: care coordination fromtheoryto practice

Teamactivity:asset and needs assessment

Casestudy:KeystonePediatrics

Shared plan of care

Action-oriented exercise: SMART goals

Closing/summary

N/A

5min

15min

20min

35min

25min

15min

5min

Can be found at: https://jamanetwork.com/journals/jamapediatrics/article-abstract/2716802

Createtheslidedeckusingcontentfromthedidacticportion.Makesurethereisopportunity forparticipantstospeak.

Addlocalcontenttotheslidesasneeded.

Distributethehandouttoteamsorindividualparticipantsasappropriate.Giveparticipants 5minutestodotheassetsandneedsassessment asateam(ifapplicable).

Ask the learners to reflect on their current activities,thenaskforsome“headlines”tobe sharedinthelargergroup.

Giveparticipantsanopportunitytopracticetheconceptsandtoolstheyhavelearnedduringthetraining.Casestudiescanbetailoredsothattheyarerelevanttotheaudience/population.

Createtheslidedeckusingcontentfromthedidacticportion.Makesurethereisopportunity forparticipantstospeak.

Addlocalcontenttotheslidesasneeded.

ReferparticipantstoAppendixBofthismodule formorein-depthinformationondevelopingthesharedplanofcare. Participantsshouldcompletetheworksheet,detailing next steps to take after the session, basedonworktheyhavedoneinthesession.

Agenda Item Time Materials Required Instruction/Notes

Table 1


The Pediatric Care Coordination Curriculum is offered for educational purposes only and is not meant as a substitute for independent medical judgment or the advice of a qualified physician or health care professional. Users who choose to use information or recommendations made available by the Pediatric Care Coordination Curriculum do so at their own risk and should not rely on that information as professional medical advice or use it to replace any relationship with their physicians or other qualified health care professionals.

Ten Essential Characteristics of Care Coordination

N/A

Slides

Handouts,asneeded(The assets and needs assessment can be found in the facilitator guide Getting Started: Identifying and Prioritizing Opportunities for Implementing High-Performing Care Coordination)

Copiesofcasestudy, as needed

Slides

Copies of handout, as needed

N/A

Module Overview

https://jamanetwork.com/journals/jamapediatrics/article-abstract/2716802

https://jamanetwork.com/journals/jamapediatrics/article-abstract/2716802



Introduction

Note from the authors

Thecontentincludedinthismoduleprovidesaframeworkforfacilitatorstoexplorehowcarecoordinationactivitiesservethedeliveryofintegratedhealthcarefor patientsmostvulnerabletocarefragmentation.Thegoalistoprovidepracticalguidanceforlearnerstobeabletoidentifyopportunitiesforimplementingcarecoordinationactivitiesintheirownpractices.Learnersmaybephysiciansornonphysiciancliniciansofalldisciplines,schoolorcommunitypartners,payers,agencies,orpatientsandfamilies—ensurethatallappropriateteammembersareincludedinthistrainingopportunity.

Generalprinciplesandrecommendationsforcarecoordinationgroundedintheliteraturearesharedinthismodule,whileenablingdiscussionofcontext-specificchallengesandareasforimprovement.Itisimportanttoembedlocalinformation,includingresourcesorcontacts,intothecontentofthismodule—thiswillmakethelearningexperiencemorevaluableandrelevant.Forexample,facilitatorsmayconsiderreachingouttocommunityearlyinterventionprograms,schooldistricts,behavioralhealthclinicians,TitleVorganizations,AmericanAcademyofPediatricschapters,andfamilyadvocacygroups,amongothers.Thereisawidebreadthofservicesusedbyfamiliesandchildrenwithspecialhealthcareneeds,someofwhicharelistedinAppendixAofthismodule.

Animportantaspectofthismoduleforunderstandingtherelevantexperiencesofparticipatingteamsistheassetsandneedsassessment.Whatdocareteamsdotofacilitatecaretransitionsintheirpractices?Howdotheyconnectpatientsandfamiliestocommunityresources?Thesequestionswillhelpguidefacilitatorsindeterminingthekeyfocuspointsandresourcestosharethroughoutthesession.

Followingaresomequestionstodebriefthelearnersaboutthepre-sessionreading:

• Whatessentialcharacteristicofcarecoordinationresonatedmostwithyourexperience?

• Wereanyoftheseassumptionsasurpriseorsomethingyoudidnotrealizewasanaspectofcarecoordination?

• Thinkofyourownteam.Whichofthesedoyoudoparticularlywell,andwhichhaveopportunityforimprovement?

Thesequestionswillbedelvedintofurtherthroughoutthismodule.


Bemindfulthatthisactivitywillhaveoptimalimpactifitispresentedasaninterprofessionallearningevent,withpatientsandfamiliesasco-facultyandco-learners.Thismulti-stakeholderlearningeventisintendedtosetthefoundationforajointlycreated,sharedvisionforempoweringpatientsandfamiliestoimpactthequalityofthecareprocessesthatimpacttheiroutcomes.Tactically,acommonlanguageofexpectations,terms,andperformancemeasureswillbehighlighted,ultimatelyresultingincareteammembersunderstandingtheirrespectiverolesandresponsibilities.

SLIDE 1 » Title Slide

SLIDE 3 » Objectives


Afterparticipatinginthismodule,learnerswillbeabletoachievetheobjectivesincludedonthisslide.

SLIDE 2 » Educational Purpose Only–No Medical Advice

ThePediatricCareCoordinationCurriculumisofferedforeducationalpurposesonlyandisnotmeantasasubstituteforindependentmedicaljudgmentortheadviceofaqualifiedphysicianorhealthcareprofessional.UserswhochoosetouseinformationorrecommendationsmadeavailablebythePediatricCareCoordinationCurriculumdosoattheirownriskandshouldnotrelyonthatinformationasprofessionalmedicaladviceoruseittoreplaceanyrelationshipwiththeirphysiciansorotherqualifiedhealthcareprofessionals.

Facilitator Guide–Slide Deck

This slide is an overview of the activities that support the learning objectives.

SLIDE 4 » Overview

SLIDE 5 » Objective

SLIDE 6 » Care Coordination

SLIDE 7 » What is Care Coordination

Facilitator Guide–Slide Deckcontinued


Informthelearnersthatthesessionwillstartwithadiscussionaboutthekeycomponentsofcarecoordinationwithinanintegratedmodelofcaredelivery.Thediscussionwilldistinguishbetweencarecoordinationandcareintegrationandexplorehowtheyarerelated.

Explaintothelearnersthattoday’sportionofthetrainingsessionwillteachthemhowtotakecarecoordinationfroman“in-the-clouds”concepttoon-the-groundactionintheirpracticesandcommunities.

Care coordination is the set of activities in the space between visits, careteammembers,andhospitalstays.Examplesmayincludebookingappointments,followingupontestresults,andliaisingwithcommunityservices.

Metricsofcarecoordinationincludeassessmentsofcaretransitions (eg,informationhandoffs)andcareplanimplementation.


Words matter!Itisessentialtoacknowledgethattheremaybe somevariationinterminology,butthefacilitatormustgetthegrouptocometoconsensusonhowtodefine,operationalize,andmeasureperformanceofcarecoordination,careintegration,casemanagement,etc.

Care planningisanactivityofcare coordination, and care coordination leads to care integration. Care coordination is a domainofthebroaderframeworkofcareintegrationandisnecessary—butinsufficient—toachieveintegration.Whencare isintegrated,familiesperceivecollaborationbetweencareteammembers.SeeAppendixBofthismoduleonhowtobuildasharedplanofcare.

Case managementiscommonlyconfusedwithcarecoordination andcareintegration.Casemanagementisaprocessthataddresses thehealthneedsofpatients.Ittendstobefocusedonalimitedset ofpredetermineddiseasesorconditionsandguidedbypotentialhealthcarecostsavings.Traditionally,casemanagementservices areprovidedinabenefitspackage,oftensupportedbyahealthplan ormanagedcareorganization.

SLIDE 8 » Care Coordination Enables Integrated Care

SLIDE 9 » Integrated Care Framework

SLIDE 10 » Who Is Involved in Care Coordination?



Thisistheframeworkforcareintegration,whichistherightsideofthecarefragmentationdcareintegrationdiagraminthepreviousslide.Thisframeworkisfoundationaltounderstandinghowvariousactivitiesofcarecoordination(eg,referraltocommunityresources orplanningforthefuture)supporttheoutcomesofcareintegration.

Further,itshouldbeemphasizedthatthisbroadlyinclusiveframeworkisdesignedtoincludekeypriorities(health,medical,nursing,social,behavioral, and educational aspects of health) for care coordination implementationbyaddressingwhatisimportanttofamilies,physicians,nonphysicianclinicians,andcommunityleaders.

Carecoordinationisamultidisciplinaryteamsport,andpatientsandfamiliesareessentialteammembers.

Askthelearnerswhethertheyhavetherightpeopleintheroomwhendiscussingcarecoordinationandtoconsiderallofthedifferenttypesofcareteammembersandsettings.AgenciesmightincludetheDepartmentofMentalHealth,theDepartmentofDevelopmentalServices,andtheDepartmentofChildrenandFamilies.


Thisimageofonefamily’scaremapdepictsallthedifferent“loci” ofcare.Caremappingisanimportantactivityforframingcarecoordination.Itisaprocessthatguidesandsupportstheability offamiliesandcareteamprofessionalstoworktogethertoprioritizeneedsandachievethebestpossiblehealthoutcomes. Source: http://bostonchildrenshospital.org/integrated-care-program/care-mapping

ThecaremappingprocessisdiscussedinmoredetailinModule2 asaneffectiveandvaluabletoolforfamily-leddiscussionsofcarecoordinationneedsandgoals.

ThecaremapshownherewasdevelopedbyCristinLind,whoinventedthecaremap.

SLIDE 11 » One Family’s Care Map

SLIDE 12 » Impact of Care Fragmentation



Considertheimpactoffragmentedcare.Someexamplesareincluded onthisslide.

Presenteeismiswhenemployeesarephysicallypresentatworkbut notfullyfunctioning(eg,duetodistractionsorconcernsfortheirownhealth).

Caregiversofchildrenandyouthwithspecialhealthcareneeds(CYSHCN),particularlycaregiversofchildrenwithcomplexmedical andbehavioralhealthneeds,aremorelikelytoreducetheirtimeorresponsibilitiesatworkortoquit,whichcontributestotheirstress. Toimproveemployeejobattendanceandproductivity,suggestthat thelearnersinterfacewithemployersintheirregiontodetermine howcarecoordinationforCYSHCNimpactswork.

Promptthelearnerstoconsidertheimpactofcarefragmentationonpatientswithbehavioralhealthneeds:86%offamiliesaresingularlyresponsibleforcoordinatingcareformentalandbehavioralhealthservices(Pondetal.,2012).

Familyexperiencewithcoordinatingcarefortheirchildrenand youthwithbehavioralhealthneedsdemonstratesthatthispopulation 4isespeciallyvulnerabletocarethatisfragmented,leadingtosignificantstressorsuponfamilies.


http://bostonchildrenshospital.org/integrated-care-program/care-mapping

Carecoordinationisadomainofthebroaderframeworkofcareintegration.Metricsofcarecoordinationincludeassessmentsofcaretransitions(eg,informationhandoffs)andcareplanimplementation.

TheotherdomainsofcareintegrationarecriticallyimportantindefiningacomprehensivesetofperformancemetricsthataregearedtowardachievingtheQuadrupleAim.

SLIDE 13 » Measure What Matters

SLIDE 14 » Achieving the Quadruple Aim



CareintegrationiscorrelatedwithQuadrupleAimoutcomes.

• Improved quality indicators: Care and services are integrated sothatdecisionsaremadecollectivelyandownershipoftasks andresponsibilitiesisdeterminedtogether.Thisclosesgapsinotherwisepotentiallyfragmentedsystems.

• Improved family experience:Familiesfeelmorecohesivewiththeirchildren’scareteams.

• Improved provider experience: Aprovider’sabilitytoprovidecomprehensivecareimproves.

• Reduction of unnecessary costs: The intention is to shift care fromhigh-costutilizationservicestolowercostambulatory,orhome-orcommunity-basedservices.

These are the goals and purposes that care coordination activities canserve.

Share the following evidence for care coordination with the learners usingtheframeworkshownontheslide:

• AccordingtoanAmericanAcademyofPediatrics(AAP)policystatement,theprovisionofcarecoordinationwaspositivelyassociatedwithpatient-andfamily-reported“receiptoffamily-centeredcare,”resultingin“partnershipswithprofessionals,satisfaction with services, ease of getting referrals, lower out ofpocketexpensesandfamilyfinancialburden,fewerhoursperweekspentcoordinatingcare,lessimpactonparentalemployment,andfewerschoolabsencesandEDvisits.”

• AnIllinoisstudyshowedthatchildren,youth,andtheirfamilies hadahigherneedforcarecoordinationwhencommunicationbetweenhealthcareteammemberswasinadequate.

• Carecoordinationwithinprimarycarepediatricpracticesisassociatedwithdecreasedunnecessaryofficeandemergencydepartment(ED)visits,enhancedfamilysatisfaction,andreducedunplannedhospitalizationsandEDvisits.

• Carecoordinationconductedasastandardofpediatricpracticeresultedinincreasedfamilysatisfactionwiththequalityofcare andalsodecreasedbarrierstocare.

(Reference: AAP CC Policy Statement, 2014)


Contributorstocomplexityincludepsychosocial,socioeconomic,demographic,medical,behavioral,andenvironmentalfactors.Communityleaders,advocates,anddeliverysystemleadersmustconsiderthebroadneedsandassetsofthecommunitywhendefiningcarecoordinationcompetenciesandoutcomes.Understandingthismultifactorialmodelofhealthoutcomesisessentialindesigninginterprofessionalcareteams,withthepatientandfamilyatthecenter.

SLIDE 15 » Matching Services to Complexity

SLIDE 16 » Prevalence of Pediatric Complexity

SLIDE 17 » Evolving the Care Model to Achieve High Value

SLIDE 18 » Impact of Care Fragmentation



Theprevalenceofcomplexity,chronicconditions,and“typically”functioningchildrenandyouthsuggeststheneedtodefinethecharacteristicsofeachsegmentofthepediatricpopulationwhenone isdevelopingcarecoordinationandcaremanagementcompetencies.

Effectivecarecoordination,especiallyforchildrenandyouthwithspecialhealthcareneeds,requiresaninterprofessionalteam.Thecomplexityofthegivenchild’soryouth’sneedsoftendeterminesthelocusofcarecoordinationandintegration,alongwithhowmultiplestakeholderscollaboratetoachieveoptimaloutcomes.

Familyexperiencewithcoordinatingcarefortheirchildrenandyouthwithbehavioralhealthneedsdemonstratesthatthispopulationisespeciallyvulnerabletocarethatisfragmented,leadingtosignificantstressorsuponfamilies.


Carecoordinationcanseemlikeagreatconceptbuthardtofigure outhowtooperationalizeandsystematize.

Basedonevidence,theAAPpolicystatementoncarecoordinationincludesrecommendationsforpursuingcarecoordination.

Thisslideincludesexamplesofactionableitemsthatcanhelpachievesomeoftheserecommendations.

SLIDE 19 » AAP Policy Statement

SLIDE 20 » AAP Policy Statement, Select Recommendations

SLIDE 21

SLIDE 22



TheAAPpolicystatementfacilitatesastructuredapproachtodefiningactivitiesofcarecoordinationandtoaligningkeystakeholdersinimplementationandperformancemeasurements.

FacilitatorsmaywishtohighlightaparticularAAPrecommendationthatispertinenttothelearnersorteam.Usingtheprovidedmodel,suggestactionableitemsforanyrecommendationschosenfordiscussion.

Foreachrecommendationthatisdiscussed,asklearnerstoshareanyactionstheybelievesupportthatrecommendationintheircurrentpractice.Facilitatorscanthenshowsomesuggestedactionsliketheexamplesprovidedinthisslide.

Delineationofrolesandresponsibilitiesincludesthepatientandfamilyaswellasallmembersofthecareteam.Thisprocesspresagesthefunctionalityofthecareplanningtoolknownastheactiongrid,beginningwithslide44inthismodule.


Identifymembersofachild’scareteam.

Theentireteamisusuallynotlocatedinthesamephysicalspace andisoftengeographicallydispersed.

SLIDE 23

SLIDE 24 » Key Elements of Care Coordination




Whatarethingsthatthelearnersdoeverydaythatmightalign withtheserecommendations?Practically,whatdotheymean?

Thisslideincludesaframeworkofwhatcarecoordinationactivitiesmightlooklike.

Askthelearnerstodoapracticeassetsandneedsassessmenttoseewhattheirteamisdoingtosupportcarecoordinationineachofthedomainsincludedintheframeworkandwhichdomainsmayhaveopportunitiesforimprovement.

Facilitatorsshouldsummarizetheobjectiveshere.


Distributethehandouttoteamsorindividualparticipantsasappropriate.Giveparticipants5minutestocompletetheasset andneedsassessmentasateam(ifapplicable).

Asklearnerstoreflectontheircurrentactivities.

• Whataretheyalreadydoingtoprovidecarecoordination for patients?

• Whatgapsdidtheyidentify?

• Whatareawouldtheyliketoprioritizeasanopportunity forimprovement?

~Encouragethemtoconsiderinstitutionalpriorities,stakeholderinterests,andlocalresources.

Askforsome“headlines”tobesharedinthelargergroup.

SLIDE 26 » Asset and Needs Assessment

SLIDE 27 » Care Coordination Framework




Gainingconsensusontheframework,withitsorganizedapproachtodefiningelements,activities,androles,willleadtoarobustapproachtomeasurement.

Facilitatorsshouldsummarizetheobjectivehere.


Ask learners:

• Doesthiscasestudyresonate?

• Isitrealistic?

• Whatarethegaps??

Informthelearnersthattoday’sdiscussionwilladdresscommon issuesassociatedwithadolescentvisits.

SLIDES 29 & 30 » Case Study: Keystone Pediatrics

SLIDE 31 » Identifying Areas for Improvement

SLIDE 32 » Areas of Improvement



Askparticipantstoidentifypotentialareasforimprovement. Hereare2opportunitiesthatcanbeexploredfurther:

• Thegapinthestructuredprocessforcompletingwellvisits.

• Thegapinthesystemofreferralsandhandoffsbetweenteammembers.

Thisslideincludescommonissuesassociatedwithfamilywell-visitattendance.

TheAAPpolicystatementoffersseveralexamplesofhowtoimprovetheseissues.


Thismodulefocuseson2oftheAAPrecommendationsfor carecoordination.Wewilltalkthroughoperationalizingtheserecommendationsandimplementingtoolsandmeasuresto supportthem.

Forexample,howcanmeetingtheneedsofpatientsandfamilies beensured?Thefirststepistounderstandpatientandfamilyexperienceswithhealthcare.

SLIDE 33 » The Focus with Today’s Case

SLIDE 34 » Measuring Patient and Family Experience

SLIDE 35 » Family Experience with Coordination of Care



Thisslideincludes2toolsthatcanbeusedtomeasurepatientandfamilyexperience.Bothtoolsincludequestionsthatareframedas“inthepast12months.”Versionsofthetoolsareavailablefortransitionsandhandoffs,andbothareavailableinEnglishandSpanish.

• TheFamilyExperienceswithCoordinationofCare(FECC)surveyfocuses on structure and processmeasures,includingtoolsandresourcesthatareavailabletosupportcarecoordination.

• ThePediatricIntegratedCareSurvey(PICS)focusesonoutcome measures,includingfamilyexpectationsofcareintegration.

TheFECCsurveyfacilitatesassessmentof20caregiver-reportedqualitymeasuresforchildrenwithmedicalcomplexity.


Thisslideincludes1samplequestionfromeachofthe3domainscoveredintheFECCsurvey.

Differentquestionscanbeselectedfromthesurveyandshared withthelearners,dependingontheirinterestsandpriorities.

The full tool is available at: https://www.seattlechildrens.org/research/centers-programs/child-health-behavior-and-development/labs/mangione-smith-lab/measurement-tools/

SLIDE 36 » Family Experiences with Coordination of Care

SLIDE 37 » PICS

SLIDE 38 » PICS

SLIDE 39 » PICS



PICSisavalidatedoutcomemeasureofpatientandfamilyexperiencewithcareintegration.ThesurveyisalreadybeingimplementedinmultiplesettingsacrosstheU.S.andisbeingconsideredforusebysomestateMedicaidprograms.

PICSassessesparentandcaregiverexperiencewithintegrationacrosstheentirecareteamoraspecificentity(eg,aparticularsubspecialtyclinic).Itassessesparent/family/caregiverexperiencewithmedicalservicedelivery,behavioralhealth,education,andlinkagetocommunityorganizations.

PICScontains19experience-relatedquestionsin5domains:access,communication,familyimpact,caregoalcreation,andteamfunctioning.

ThisslidecontainssomeexamplesfromPICS.

Differentquestionscanbeselectedfromthesurveyandshared withlearners,dependingontheirinterestsandpriorities.

The full tool is available at: http://www.childrenshospital.org/integrated-care-program/patient-and-family-experience-outcome


https://www.seattlechildrens.org/research/centers-programs/child-health-behavior-and-development/labs/mangione-smith-lab/measurement-tools/

https://www.seattlechildrens.org/research/centers-programs/child-health-behavior-and-development/labs/mangione-smith-lab/measurement-tools/

http://www.childrenshospital.org/integrated-care-program/patient-and-family-experience-outcome

http://www.childrenshospital.org/integrated-care-program/patient-and-family-experience-outcome

Inadditiontothetoolsformeasuringpatientandfamilyexperience that have been shared during the session, patient experiencetoolsarealsoavailablefromPressGaneyandNRCHealth.

However,thisnextportionofthemodulewilllookattoolsthat canbeusedtosupporthigh-qualityhandoffsbeforeandafteraclinicalencounter.

SLIDE 40 » Tools to Support High-Quality Handoffs

SLIDE 41 » High-Quality Handoffs



What is a handoff? Itisthetransferofpertinentknowledgebetweenmembersofapatient’scareteam,enablingacareteammembertosafelyassumeresponsibilityforsomeaspectofcare.

Handoffsoccurinnumerouscontexts:

• Toandfrompediatriciansandotherphysicianstopediatricsubspecialists,pediatricsurgicalspecialists,ornonphysicianclinicians

• Toandfromcommunitiesandhospitals

• Toandfromanon-callphysiciansandnonphysicianclinicians

• Toandfrompediatricmedicalsubspecialistsorpediatricsurgicalspecialists on other services

Thegoalofahandoffistoenablethecareteamtomaximizethe utilityofeverypatientinteractionbyensuringknowledgelearned byonepartofapatient’scareteamiscommunicatedtoother membersattherighttimeandplace.

Structuredhandoffcommunicationusingastandardizedtemplate inconcertwithteamtraininghasbeenassociatedwithreducedmedicalerrors(Starmeretal.2014).


Asklearnerswhatsomeofthekeypiecesofinformationarenecessarytooptimizingclinicalencounterswithpatientsandfamilies.

InformthemthatauditsacrosstheUnitedStatesdemonstratethatonly5%to20%ofreferralstopediatricmedicalsubspecialistsandpediatricsurgicalspecialists(?)includepediatricians’orotherphysicians’reasonsforrequestingconsultations,andinformationaboutevaluationsconductedtodate,andexpectationsofconsultations.

Itmaybehelpfultoclarifyherethedistinctionbetweenareferralrequesttoapayertoobtainapprovalandaphysician-informedornonphysicianclinician-informed reason for subspecialty consultation.Thiscurriculumfocusesonthelatter.

SLIDE 42 » Collaborative Consults

SLIDE 43 » High-Quality Handoffs: Collaborative Consults

SLIDE 44 » High-Quality Handoffs: Closing the Loop



Thisslidefeaturesamodeltemplatethatcanbeusedtoensurethattheelementsincludedinthetemplateareavailablepriortoeveryencounter.

This template is available to learners at: http://www.childrenshospital.org/integrated-care-program/high-quality-handoffs.

TheHigh-QualityHandoffstoolcanbeusedtostructureessentialinformationforeachmemberofthecareteam.Thiswouldinclude caretransitionsfromprimarycaretosubspecialist,subspecialisttoothersubspecialist,orprimarycaretoothermembersofthecare team,suchasnursing,socialwork,andcommunity-basedproviders.

Askthelearnerswhatsomeofthekeypiecesofinformationarethatneedtobediscussedwiththepatientandfamilyand/orothermembersofthecareteamfollowingaclinicalencounter.Also,whatneedstobedonetoensureclearcommunicationofpatientandfamilygoalsandtheplanofcarewithatimelineandresponsibilityforimportanttasks?Whatpracticessupportreliableinformationsharingamongmembersofthehealthcareteamsothatnothingfallsthroughthecracks?

Thesearecommonchallenges,particularlyacrosstransitionsincareandwhenteammembersaredispersedacrossmultiplesites.

Informthelearnersthatthenextpartofthesessionwilldescribeatoolthatsupportsasharedmentalmodelandclosed-loopcommunicationacrossthecareteam.


Anactionitemgridisdevelopedwiththepatientandfamily.Itoutlinesanoverallcaregoal,tasktobecompleted,whoisresponsible,timelineforcompletion,andacontingencyplan.Thehigh-qualityhandoffisacriticalfirststeptoinformthepatientencounter,and theactiongridhelpsensureclosed-loopcommunicationbacktothereferringcareteam.

This template is available to learners at: http://www.childrenshospital.org/integrated-care-program/multidisciplinary-care-planning

SLIDE 45 » Closed-Loop Communications: Action Grid

SLIDE 46 » Principles of the Action Grid

SLIDE 47 » Pause for Reflection



Sharethekeyprinciplesoftheactiongridfromthisslidewiththelearners.

Ofnote,finalizingtheactiongridmaytakemoretimethanwhat isavailableduringasingleappointment.Theactiongridshouldbeaccessibleandsharedacrossthewholecareteam,asdefinedby familypreferences.

Ifitsupportsthelearners’goalsandtimepermits,usetheactivity fromcasestudy#1toguidelearnersthroughaclinicalscenario usingtheactiongrid.

Allowlearnerstodiscussinsmallgroupspriortosharingafewexampleswiththelargergroup.


http://www.childrenshospital.org/integrated-care-program/multidisciplinary-care-planning

http://www.childrenshospital.org/integrated-care-program/multidisciplinary-care-planning

Returningtothecasestudyexample,askthelearnerstothinkabouthowthesetoolscanbeusedtomeasureandaddressthegapsincarethatwereidentified.

SLIDE 48 » Intervention

SLIDE 49 » Collaborative Consults

SLIDE 50 » Action Grid



Astructuredapproachtodefiningrolesandresponsibilitiesisessential,whetheritisforpatientswithchronicandcomplexneeds orthosewithstraightforwardandnoncomplexneeds.Thetoolfeaturedonthisslidecanbeadaptedfornonmedicalinteractions aswell(eg,behavioralhealthorsocialservice).

Theactiongridiscocreatedwiththepatientandthefamilyor caregiver.Itassuresclarityandtransparencyacrossallmembers ofthecareteam.Italsospecifiesadesiredgoal,necessaryactivities, atimeline,andtheaccountableentity.Theactiongridtemplatewascreatedasaresultoffamilyreportsabouthowtoreducefragmenta-tionofcareaspartoftheprojectthatcreatedthePICSinstrument.Experiencehassincerevealedthathealthcareteammembersalso findthistoolusefulforessentiallythesamereasonsasfamilies.


Asklearnerstoreflectontheirexperiencesasacareteammemberand/orfamilymember.

ThesequestionsarefromthePediatricIntegratedCareSurvey(PICS).FeelfreetouseothermeasuresfromthePICSiftheyaremorerelevanttoacasestudythathasbeenadapted.

SLIDES 51 & 52 » Implementing a Shared Plan of Care

SLIDE 53



Askthelearnerstoconsiderhowtheywouldoperationalize the following phases for this particular case:

• Phase 1: Family outreach/engagement Thefamilywasinvitedandprovidedwithathoroughdescription

ofwhatacarecoordinationinterventioncoulddotohelpthem, andtheyagreedtoparticipate.

• Phase 2: Family and team pre-visit work An assigned care coordinator reached out and learned that the

familyhadnomeansoftransportation,thefatherhadnowork leavetime,andtheirEnglishwasverylimited.Theywouldrequirethe following supports to ensure a successful period of care coordination:aMedicaidcab,acarseat,aspecificdialecttranslator,andavisittimedtothefather’sschedulebecause hedoesthecommunicationforthefamily.

• Phase 3: Population-based teamwork TheteammemberssharedinsightsintoBurmesecultureand

addressedtheinterventionsneededtohelpthefamilyattendaplannedcarevisit(transportation,interpretation,safety,etc.). Theteammembersreviewedthemedicalrecordandotherdocumentsandbegantopopulatethemedicalsummary.


The 10 steps found on this slide are foundational for ensuring a broad, strategicapproachtoimplementingasharedplanofcare.

SLIDE 54 » Ten Steps to Achieving a Shared Plan of Care


SLIDE 56 » SMART Goals



Thistrainingsessionhasaddressedidealelementsofcarecoordinationinhigh-functioningclinicalteams,potentialgapsinclinicalpractices,andpracticalstrategiesandtoolsforachievingAAPrecommendationsforcarecoordination.

Thecontentcoveredthusfarwasintendedtoequipthelearnerswithconcreteideasforimplementingneededcarecoordinationactivities…tomorrow!

Now,itistimeworkondevelopinganactionplan. [hand out action plan worksheet]

Askthelearnerstoreflectasateam(orindividually)ontheirneedsassessmentfromthebeginningofthetrainingandsomeofthestrategiesandtoolsthathavebeendiscussed.

Asklearnerstoidentify1short-termgoal(within7days)and1long-termgoal(within90days)theyhavetoimprovecarecoordinationintheirpractices.

SharethefollowingmnemonicforSMARTgoalsetting:goalsshouldbeSpecific,Measurable, Achievable, Relevant, and Time-bound.


Now,asklearnerstoconsiderthefollowingquestionsforeachgoal:

• Whatbarriersdoyouanticipate?

• Whatisyourspecificplantoachievethisgoal?

Consideringthesetypesofquestionshavebeenshowntoimprovetransfer of training to the work setting and to increase likelihood of follow-throughongoals.

Invite 3 to 4 participants to share their goals and action plans with the largegroupandtoobtainfeedback.

Then,discussfollow-up.

Consider:

• Havingteamsmailaletterwithinadefinedtimeframe tothemselveswithacopyofthisworksheet.

• Havingteamsemailasupervisor,director,orotheridentifiedleadertoensureaccountabilityandtoarrangeacheck-in.

• Arrangingafollow-upphonecallwiththemodulefacilitator.

SLIDE 57 » Your Action Plan

SLIDE 58 » Take-Home Points

SLIDE 59 » Take-Home Points



The facilitator should get a sense of how the diverse group of learnershasreactedtothedynamicofthesession,aswellaswhetherthe participants have been able to integrate the content into their cognitiveframing.

Encourage the group to reflect on the following:

• Howcanyoubegintoimplementcarecoordinationinyour workinthenextfewdays?

• Whataresomedriversthatwillencouragebroadadoption?

• Howcanoutcomemeasurementbeimplementedtoassuresustainability?


& 61 » Resources





Whatcanbedonetoensureclearcommunicationofthepatient’sandfamily’sneeds andplannedcarewithacleartimelineandresponsibilityforimportanttasks?

Whatpracticessupportreliableandbidirectionalinformationsharingamong membersofthehealthcareteamsothatnothingfallsthroughthecracksacrosstransitions in care?

Note to the facilitator: Thismoduleincludesaclinicalscenariothatcanbeusedtoillustratepracticalwaystooperationalizetheaboverecommendations.Thisscenariocanbeadaptedoranewscenariocanbedevelopedthatresonateswiththeparticipants.Forexample,insteadofhavingparticipantsplacethemselvesintheshoesofapediatricianorotherphysician,theycoulddiscussthecaseofasubspecialistoralliedhealthproviderwhoisseekingtodeveloprecommendationsandcommunicatethemtoprimarycare,communityagencies,orschool.Ensurethecasehasthefollowingelements: • Patientcharacteristics(Whattypesofpatientsdotheparticipantssee?Istherea

particulardiseaseprocessorfunctionalchallengecommonlyfacedamongtheparticipants?)

• Clinicalsetting(Inwhatsettingarepatientstypicallyseen?Isitaninterprofessionalclinic,privatepractice,specialtyconsultantservice,orcommunityagency?)

• Need(s)tobeaddressedoutsideoftheclinicalsetting(Thismayincludeasubspecialtyreferralthatisbeingplacedforaclinicalquestion,afollow-uprequiredwithapediatricianorotherphysician,oraconcernraisedinaschoolorcommunity settingorbyabehavioralhealthclinician.)

Independentlyreadandreflectonthefollowingcasethendiscussitinyoursmallgroup.After5minutes,wewilldebriefasalargergroup.

Case-Based Learning

AAP policy statement recommendation #3: Continuallyinvolveandengagethepatient/family(eg,familiesaspartners/advisors),buildonthestrengthsofthepatient/family,clearlydelineateresponsibilitiesofteammembers,andcreatecarefulhandoffswhentransitioningacrosssettings(eg,betweeninpatient and outpatient settings and between pediatric and adult care providers, systemsand/orsettings).

AAP policy statement Recommendation #5: Usecarecoordinationacrosstransitionsbetweenentitiesofthehealthcaresystem(eg,betweenandamongpatientcareteams,acrosssettings,betweencaregivers,andbetweenhealthcareorganizations)andwithtransitionsovertime(eg,acrossthelifespan,betweenepisodesofcare,andacrosstrajectoryofillnesses).

AAP policy statement recommendation #6: Ensurethatco-managementandcommunicationoccuramongspecialistsandprimarycareproviders.Thiscaremodelrequiresreciprocalandbidirectionalcommunication(eg,securee-mails,phonecalls,notes,andfaxes),whichcanbeaugmented,butnotreplaced,withhealthinformationtechnology.

CASE STUDY #1

Sharing Information and Coordinating Care Across Transitions



EricEricisa12-year-oldboywithsicklecelldiseasewhohadarecentischemicstroke,whichhasledtothedevelopmentofaseizuredisorder.YoucoordinateEric’scare intheprimarycareclinicandarereviewinghiscasebetweenvisits.Heisalreadyfollowedinthegeneralneurologyandsicklecellhematologyclinics.Athislastneurologyappointment,transferringrecommendationwasmadetotransferEric’s caretoapediatricstroketeamatthelocaltertiarycarecenter.YoualsoseethatEric’smothercalledthecliniclastweek,expressingconcernthatEric’slearningdifficultieshaveworsenedatschool,andyourecognizethathisindividualizededucationplan fromschoolneedstobeupdated.

• Whoaretheteammembersthatneedtocometogethertobest coordinateEric’scare?

• Whattransitionisoccurring?

• Whatneedsandcaregoalscanyouidentify?

• WhatactionswillyoutaketocoordinateEric’scaretoensureasmooth transitionforEricandhisfamilyacrossmultiplesettings?

• Whatchallengesmightyoufaceinthisprocess?

Probe:WhoarethenewmembersonEric’steam? Howwillyoucommunicatetheserolestothefamily?

Note to the facilitator: Assmallgroupsdiscusstheirresponses,consideroffering thefollowingprobingquestionstostimulatediscussion:

• HowwillyoucommunicatewithEric’sfamilyregardingthenewmembership androlesinhishealthcareteam?

• Howwillyoushareinformationbetweenmembersofthehealthcareteam?

• WhattoolsorresourcesmightyouneedtobestassistEricandhisfamily?

After5-10minutes,debriefinalargergroup.Write2headingsontheboard:“Challenges”and“Actions.”Askeachsmallgrouptosharetheir“headlines”— 1or2keypointsthattheydiscussedorkeyquestionsthattheyhad.


Case-Based Learningcontinued


Actions may include:

• NotifyEric’sfamilyoftherecommendationtoreferhimtoastrokeclinic.

• Sendthereferraltothestrokeclinicadministrationwitharecommendedtimeframe.

• ContactthefamilytoensuretheschoolisawareofEric’smedicalconditionand risks,andcommunicatewiththeclinicnursetoensurethatanymedicationsneededatschoolhaveanupdatedmedicationorder.

• ReconveneameetingwithEric’sschoolteamandadvocateforareevaluation tobecompletedorfinanciallysupportedthroughtheschool.Considerexploringwhetherhavingtheassessmentcoveredbymedicalinsuranceisafeasibleand/orfasteroption.

• ExplaintoEric’sfamilyexactlywhotheirnewhealthcareteamis(pediatrician,neuropsychologist,administrativeassistant,nurse,etc.)andwhotocontactforpotentialissues(i.e.,Whowillmanagefeversorurgentcareneeds?Whowillprescribeandmonitoreachmedication?Identifytheneedforafeveractionplan in the care plan, outlining steps to initiate, who to call, and when to take Eric to theemergencydepartmentforafeverorpaincrisis.)

• DevelopandupdateacareplanforEric.Includethenames,roles,andcontactinformationforeachcareteammember.(Decidewhoisresponsibleforupdating andmanagingthecareplanamongthemultiplepartnersinvolvedinEric’scare.)

• Ensurethecareplanisaccessibletoallmembersofthehealthcareteam(i.e.,in theelectronichealthrecordandpatientorfamilyportalandgiveahardcopyto thefamily).

• Advisethefamilythatiftheyhavenotheardfromthestrokeprogramadministrationin2weeks,forexample,theyshouldcontacttheclinicdirectly.

~Tellthefamilythatthistypeofactionisanexampleofcontingencyplanning—outliningstepstobetakenifexpectedresultsdonotoccurandpreparingforalternativeoutcomestoensureimmediateandappropriatefollowupofpotentialissues.

~Also,highlighttheimportanceofclosingthelooponthisreferral—makeaplantoreconnectwiththefamilyorclinictoensuretheappointmentwasmadeandattended.




Challenges may include:

• EnsuringEricisseenbythestroketeaminatimelyfashionandestablishing amechanismtofollowuponthis

• MaintainingcommunicationwithEricandhisfamilysotheyareawareofthetransitiontothestrokeclinic,understandtherolesofthenewcareteammembers,andunderstandwhoisresponsibleformanagingeachpotentialhealthissue

• Developingacomprehensivecareplanandcomanagingwithcareteammembersindifferenthealthcaresettings

• Identifyingapointpersontocoordinatecareteammemberrolesandfollowup onactionitems

• Ensuringaccessibilityofthecareplan—formsofcommunicationthatarereliableand secure

• CommunicatingwithEric’sschoolandarrangingforaneuropsychologistevaluationtoinformanewindividualizededucationplan

• Ensuringthecareplanisupdatedconsistentlyandaccurately,reflectingall ofthecarebyEric’scareteam

Didactic

Slide: Coordinating Care Across Transitions

Transitionsincarearefrequent!Eachtransitionshouldbeaccompaniedbyathoughtfulhandofftoensureimportantinformationisn’tlostorforgotten.

• Handoff:Thetransferofpertinentinformationbetweenmembersofapatient’scareteam,enablingthepersontosafelyassumeresponsibilityforsomeaspectofcare.

• Handoffsoccurinmultiplecontexts: ~Toandfromthecommunityandhospital ~Toandfromanon-callphysicianornonphysicianclinician ~Toandfromaconsultant ~Toandfromamedicalsubspecialistorsurgicalspecialistonanotherservice ~Toandfromhomecareservices ~Frompediatrictoadultcareteammembersorsettings

Facilitator notes: This training session has addressed suggested actions that thelearnerscantaketotheirpracticetofacilitatesmoothtransitionsincareforpatientslikeEric.Herearesometoolsthatcanhelpthelearnersimplementtheseactions…tomorrow!




Slide: Tools for Ensuring Smooth Transitions in Care

• Collaborative consults: outlining the purpose of a visit, relevant clinical information, requested referral relationship, and timeline

• Caremapping:creatingavisualrepresentationofapatient’scareteammembersincollaborationwiththefamily,discussingrolesandwho-tolinesofcommunication

• Action grid: development of an action item grid with the family outlining the overall care goal, task to be completed and person responsible for completing the task, timeline for completion, and contingency plan

• Careplan:acomprehensive,integrated,shared,anddynamicdocumentthatincorporatesasummaryofmedicalissues,careteammembership,prioritized goalsofcare,andnecessaryactionstoachievethegoals

Facilitator notes:Demonstratehow2ofthesetoolscouldbeusedinEric’scase.

Slide: Collaborative Consults

Reason for Visit

First-timeevaluationformultidisciplinarycarefollowingischemicstrokeinachildwithsicklecelldisease.

Requested Referral Relationship

4 One-timeconsultation

4 Comanagement/sharedcare

4 Subspecialty-basedmanagement

p Tobedetermined

Relevant Clinical/Psychosocial Information

12-year-oldboywithhistoryofsicklecelldisease.Developedaseizuredisorderfollowingischemicstroke, hasbeenfollowedingeneralneurologyprogramuptothispoint.Learningdifficultiesnotedatschool.

Question to Be Answered

WhatsurveillanceisrequiredgivenEric’shistoryofischemicstroke?

Pediatric Stroke Program Referral






Slide: Action Grid

Transfer of care to the pediatric stroke program

Neuropsychologicalevaluationtoinform anewIEP

Ensure school has updatedmedicalinformation

Incorporateplans/recommendationsfromallspecialistsandPCPs,IEPcompo-nents, specialists into care plan

Engage patient and familytoobtaininputandidentifyneedsandtheir goals

Distribute care plan to membersofthehealthcareteam.

Referral sent on Jan 2ndrequestinganappointmentwithin 4weeks.

WillestablishschoolcontactJan9thandconveneschoolteammeetingtoplanreevaluation.

WillcallschooltheweekofJan9th.

Willcollectthisinputpriortoappointmentbelow.

Appointmentarrangedfor week of Jan 16th to discusscareplan.

NurseandPCPwillsend care plan to the patient portal and email/mailacopytoparents, school, specialists for review andtocommunityrecreation center after aboveappointment.

Iffamilyhasnotreceivedacallfromthestroke clinic in 2 weeks, theyshouldcalltheclinicdirectlyat (111)111-1111.

Clinicadministrativeassistant will contact familyin2weekstofollowuponreferral.

Social worker will contactfamilytheweekof Jan 16th to coordi-natemeetingandsharecareplanwithschool.

Nursewillcallfamilytoconfirmwhencontacthasbeenmade.

Ensure appointment management and preventative care for stroke and its sequelae

Support Eric’s learning at school

Update/maintain care plan for Eric with input from all team members and family

ActionGoalWho is responsible Timeline Contingency

WhatpracticeswillYOURTEAMusetoshareinformationandcoordinatepatientcareacross transitions?

Wehavediscussed2toolsthatyoucanusestarting tomorrow: • Thecollaborativeconsult • Theactionitemgrid

PCP

Social worker

Clinic nurse

Clinic nurse/PCP

Clinic nurse/PCP

Clinic nurse/PCP




AAP policy statement recommendation #1: Useandcreatemechanismsforpatients/familiestolearntheskillstheymayneedto be partners in their own care andindecision-makingforoptimalcarecoordination.

AAP policy statement Recommendation #2: Ensurethatthepatient’sandfamily’sneedsforservicesandinformationsharing (eg,careplanning)acrosspeople,systems,andfunctionsaremetvia(a)formalassessments,(b)infrastructure(eg,teams),and(c)tracking(eg,registries); thisiscrucialinoperationalizingcarecoordination.

AAP policy statement recommendation #4: Useanddevelopefficientandaccreditedhealthinformationsystemsandinformationtechnologyadvancestofostersuccessfultransferofinformation;tosupportcollaborativecommunicationsbetweenpatients,families,andthecareteam; andtofacilitateshareddecision-making(eg,developingandusingcareplans).

AAP policy statement recommendation #5: Usecarecoordinationacrosstransitionsbetweenentitiesofthehealthcaresystem (eg,betweenandamongpatientcareteams,acrosssettings, between caregivers, and betweenhealthcareorganizations)andwithtransitionsovertime(eg,acrossthelifespan,betweenepisodesofcare,acrosstrajectoryofillnesses).

AAP policy statement recommendation #6: Ensure that comanagementandcommunicationoccuramongspecialistsandprimarycareproviders.Thiscaremodelrequiresreciprocalandbidirectionalcommunication (eg,securee-mail,phonecall,note,fax),whichcanbeaugmented,butnotreplaced,withhealthinformationtechnology.

AAP policy statement recommendation #7: Ensure ongoing educationofelementsofcarecoordinationandthemedicalhome forpracticingphysicians,nursepractitioners,physicianassistants,nurses,medicalstudents,residenttrainees(acrossdisciplines),mental/behavioralhealthcarepractitioners,socialworkers,andotherhealthcareprofessionalsviaspecific training/curricula,continuingmedicaleducationprograms,andpublications.

AAP policy statement recommendation #10: Understandandusenewcarecoordinationcodes(99487–99489;99495-99496) and advocateforpaymentofthesecarecoordinationservicesbypayers.

CASE STUDY #2

Care Planning and Coordinating Care Across Transitions

• Whatcanbedonetofacilitateshareddecision-makingforfamiliesandfostercare integration?

• Howshouldcareteammembersengagepatientsandfamiliesincareplanningandshareddecision-making?

• Whatstrategiesandtools(eg,healthinformationtechnology)cancareteammembersuseincomanagementandtoensureaneffectivetransitionofcare?

• Whatbillingcodescanbeusedtohelpsupportthetimespentincoordinatingcare in practice?

Independentlyreadandreflectonthefollowingcasethendiscussthecase inyoursmallgroup.After5minutes,wewilldebriefasalargergroup.


LuciaLuciaisa14-year-oldfemalewithspinabifida,whoyouhavecaredforsincebirth.Youandyourteamaretheprimarycarecliniciansandworkcloselywithherspecialtyteam,includingorthopedics,urology,neurology,andphysicalmedicineandrehabilitation. Hermother,asinglecaregiver,hasbeenforcedtomoveseveraltimesduetohousinginstabilityandfinancialchallenges.YouhavestartedtoaddressLucia’sadolescence,including learning self-care, in recent visits to allow her independence at school and in thecommunity.Yesterday,hermotherleftamessageforyouindicatingconcernabout arecenthospitalizationandnewurologyteam.ShestatedLuciawasrecentlyadmittedandtherewere“changesbeingmade.”Uncertainofthenewplanandnewmedications,shealsostatedtheyhadnotreceivedthenewcathetersfromthemedicalequipmentcompanythatwereorderedatthelasturologyvisit.

• DiscusstheteammemberswhoareneededtobestcoordinatecareforLucia.

• IdentifysomeofthepsychosocialissuesthatneedtobeaddressedwithLucia’smotherasoneofthecareteammembers.

Probe:Thinkaboutfamily-centeredcareandbuildingtrust.

• WhataspectsofcaretransitionneedtobeaddressedforLucia? ~Transitiontoadult-orientedsystems(self-care) ~Transitionofcareacrosssettings,fromhospitaltohome

• Whatisthebiggestchallengeincoordinatinghercare?

Facilitator notes:Assmallgroupsdiscusstheirresponses,considerofferingthefollowingprobingquestionstostimulatediscussion:

• Socialdeterminantsofhealthhaveaprofoundimpactonhealthoutcomes.Somesocialdeterminantsofhealthincludepoverty,literacy,foodandhousingsecurity,environmentalrisks,healthinsurancestatus,immigrationstatus,interpersonalandneighborhoodsafety,energysecurity,andtransportationneeds.

• WhatrolearethesocialdeterminantsofhealthplayingincaringforLuciaand herfamily?

• Howcanyouensuremedicalneeds,communitypartners,andidentifiedresourcesarepartofthecareteamandcareplanning?Thinkabouttherolesofthehospitalistteam,dischargeplanningteam,andmedicalequipmentproviders.

• Whattoolscanfostercomanagementandensurecommunicationacrosssettings?Thinkaboutcareplanning,patientportals,shareddecision-making,andtransitionofcareplanning.

After5-10minutes,debriefinalargergroup.Write2headingsontheboard:“Challenges”and“Actions.”Askeachsmallgrouptosharetheir“headlines”—1to2keypointstheydiscussedorkeyquestionstheyhad.




Actions may include:

• MeetwithLucia’smothertobetterunderstandherhousingandfinancialchallengesandidentifyresourcesthatmayhelpher.

~Connecthertocommunitypartner(s)andresourcesthatcanassistheror asocialworkerwhocandiscusspotentialoptionswithher.Besuretofollow uptoconfirmthatthisconnectionoccurredtoclosetheloop.

~Consideremployingascreeningtoolforsocialdeterminantsofhealthtofacilitateaproactiveapproachwithpatientsandfamilies.Recognizethatfamiliesmaybemorelikelytodisclosefinancialstrugglesandchallengesrelatedtosocialdeterminantsofhealthonpaperversusface-to-facescreening.

• Contacttheurologygrouptobetterunderstandanychangesmadeandplansforfollow-up,necessaryequipment,andmedicationchanges.BesuretocheckthatLucia’smotherisawareoftheseplansanddemonstratesanunderstandingof therecommendations.

• WorkwithLucia’smothertosetgoalsforLucia’scareandensureherunderstandingofLucia’smedications,care,andequipmentandencourageherunderstandingofshareddecision-making,bothinyourofficeandwithothercareteammembers.

• DevelopandmaintainacareplanforLuciathatincludesallofherspecialistinformation,medicalequipmentproviders,therapists,IEPinformation,communitynursingservices,medications,communityproviders,school/educationalinformation,names,phonenumbers,homenursinginformation,insurance, andsupplies(eg,size,amount,andtypeofformula).

~BesurethatLuciaandhermotherreviewandinformthecontentofthe careplanpriortofinalizingthecontent.

~Ensurethattheroleofeachcareteammemberisoutlinedinthecareplan soLuciaandhermotherknowwhotocontactforissuesastheyarise.

~WorkonreconcilingthehomenursingordersforLuciawithyourcare plan,ensuringaccuracy,parentgoalsbeingmet,andsmoothcommunicationaboutLucia’sneeds.

~Trackyourtimecoordinatingcare,andbillcarecoordinationcodes (99487–99489)asoutlinedinthecontractswithLucia’sinsurancecarrier.

• ProvideLuciaandhermotherwithseveralhardcopiesofLucia’scareplan.Fax oremailLucia’scareplantothespecialistsinvolvedinhercare,theappropriatecontactsatherschool,hertherapists,andhermedicalequipmentproviders.

• AddLucia’scareplantoherpatientportaltomakeiteasilyaccessibleforhermother.

~EnsurethatLucia’smotherunderstandshowtologintothepatientportalandaccessitviahersmartphone,andwhenLuciaishospitalized,howtoaccessthepatientportalincommunitysettingsandcommunicatethecareplanacrosssettings.

• WorkwithLuciaandhermotherontransitioncareplanningforadult-orientedcare.Considerusingaself-managementtooltobegintoteachLuciaaboutself-careandspinabifidaandtoassessherreadinesstotakeamoreactivepartinherhealthcare.

• ContactthehospitalistteammanagingLuciaduringahospitaladmission,and haveyourcarecoordinatorconnectwiththedischargeplanningteamtobetterunderstandtheeventsthatoccurredduringheradmission,recommendations, andherdischargeplan.






• Talkwiththehospitalteamtodeterminetheoptimalprocessforachievingbidirectionalcommunication(includingphonecallsandsharingofinformation)whenyourpatientsareadmittedtothehospital.

~Discussroles,teammembers,andinformationsharing,includingcare plansandreasonsforadmissions).

~Considerimplementingpost-dischargefollow-upcallsforallofyourpatientsfollowinghospitalizationstoassessfamilies’understandingofdischargeinstructions,necessarymedications,priorauthorizations,andneedforfollow-upvisits.

~Establishastandardofcareforschedulingpatientsforpost-hospitalizationswithin7to14days.

~Familiarizeyourselfwiththerequiredcommunication,documentation,timingofpost-dischargevisits,andbillingcodesforpost-hospitaldischargevisits(99495and99496).

• ExplaintoLuciaandhermotherwhothemembersofLucia’shealthcareteam are(physicians,nonphysicianclinicians,mentalhealthpractitioners,communitypartners)andwhotocontactforpotentialissues(ie,Whowillmanagefeversorurgentcareneeds?Whowillprescribeandmonitoreachmedication?Whowillorderandmanageequipment?).BesurethisisclearonLucia’scareplan.

• Setupameetingwiththetop3insurancecarrierstodiscusspaymentforcodesassociatedwithcarecoordinationandhospitalfollow-up.Ifthesecodesare notincludedinyourcurrentcontract,explaintheamountofcommunication thatisrequiredbyyouandyourteamforcarecoordinationandhospitalfollow-up.Discusspossiblebenefitsforpatients,yourpractice,andthepayer,andpaymentstructures.

~Transitionofcarecodes(99495and99496) ~Carecoordinationcodes(99487–99489)

• Workonregulareducationsessionsand,possibly,astaffretreatonpatient-andfamily-centeredcare,teambuilding,huddles,transitionofcareplanningandcaretoadult-orientedsystems,andtheroleofcarecoordination.Besuretoincludephysicians,nursepractitioners,physicianassistants,nurses,medicalstudents,residenttrainees(acrossdisciplines),mental/behavioralhealthcarepractitioners,socialworkers,communityhealthworkers,parentpartners,andcommunitypartners.

• Engageparentpartnersinyourpracticetogivefeedbackandparticipateincarecoordinationeducationforyourstaffsupportingthecriticalroleoffamily-centeredcare.

• AdviseLucia’smotherthatifshehasnotreceivedhernewcatheterswithin 24hoursorhasanyquestionsaboutmedicationadministration,sheshould contacttheclinicdirectly.

~Highlightthistypeofactionasanexampleofcontingencyplanning—outlining steps to be taken if expected results do not occur and preparing foralternativeoutcomestoensureimmediateandappropriatefollow-up ofpotentialissues.

~InstructLucia’smothertomakeafollowupappointmentwiththeurologyofficeandtocontactyourofficewithanyissues.Ensuresomeonefrom yourofficeisfollowingupwithher.


Challenges may include:

• ThesocialdeterminantsofhealthchallengesfacingLucia’smother,includinghousingandfinancialinstabilitywiththelackofhandicappedaccessiblehousing,andlackofresources,time,andsocialworkersinpractice.

• Understandingandlaunchingthetransitiontoadult-orientedsystemswith Luciaandhermother,andaddressingself-care.

• Gettingteambuy-inacrossthepracticeforcarecoordinationtrainingandunderstandingrolesanddefinitions.

• Workingwithinsurancecompaniesoncodingandpaymentforcarecoordinationandtransitionofcare.

• EnsuringadequatecommunicationwiththehospitalistteamandthespecialistscaringforLucia.

• EnsuringthatLucia’smotherunderstandsshareddecision-makingand canadvocateforherself.

• Developingacomprehensivecareplanandcomanagingwithcareteam membersindifferenthealthcaresettings.

• RemindingLucia’smomabouttheavailabilityofthecareplaninthe electronicpatientportal.




Didactic

Slide: Social Determinants of Health

• Conditionsintheplaceswherepeoplelive,learn,work,andplaythatcan informtheirhealthrisksandoutcomes

• Theroleofpatient-andfamily-centeredcareandtrust

• Examples: ~Housing ~ Access to food ~ Transportation ~Exposuretocrime,violence,domesticviolence,interpersonalviolence ~ Social support ~Accesstoeducational,economic,andjobopportunities

• Identifyandworkwithcommunitypartners. ~WIC,housingresources,HUD

• Usetoolsdesignedforsocialdeterminantsofhealth ~Foodinsecurity ~Adversechildhoodevents(urban)

Slide: Care Coordination Tools

• Careplanninglistofcomponentsforacareplan • Instructionsforpatientaccesstothepatientportal • Patienthuddles • Shareddecision-makingforfamilies

Slide: Transition to Adult-Oriented Systems Tools

• Sixcoreelementsoftransition ~Transitionpolicy(Facilitator note: Have teams work through

what their ideal transition policy might include) ~ Transition index for practices

• Self-managementtools/transitionreadinessassessmenttools ~OnTraq ~Assesscaregiversandyouthwhenappropriate ~Addressguardianshipandpowerofattorneywhenindicated

• Gottransition.org




Slide: Billing for Care Coordination Services and Transition of Care

CARE COORDINATION 99487–99490Chronic care management services,atleast20minutesofclinicalstafftimedirected byaphysicianorotherqualifiedhealthcareprofessional,percalendarmonth, withthefollowingrequiredelements:

• Multiple(2ormore)chronicconditionsexpectedtolastatleast12months, or until the death of the patient

• Chronicconditionsplacethepatientatsignificantriskofdeath, acuteexacerbation/decompensation,orfunctionaldecline

• Comprehensivecareplanestablished,implemented,revised,ormonitored

99487: Usedifanonphysicianstaffmemberspendsmorethan 1hourovera30-dayperiodoncarecoordination

99488: Includes1hourofcarecoordinationwithanonphysician and a face-to-face visit

99489: Usedfor30-minuteincrementsovertheinitialhour ofcarecoordination.

TRANSITION BETWEEN CLINICAL SETTINGS 99495 Transitionalcaremanagementserviceswiththefollowingrequiredelements:

• Communication(directtelephonecontact,telephone,electronic)withthe patientand/orcaregiverwithin2businessdaysofdischarge

• Medicaldecision-makingofatleastmoderatecomplexityduringtheserviceperiod

• Face-to-facevisitwithin14calendardaysofdischarge

99496 Transitionalcaremanagementserviceswiththefollowingrequiredelements:

• Communication(directcontact,telephone,electronic)withthepatientand/orcaregiverwithin2businessdaysofdischarge

• Medicaldecisionmakingofhighcomplexityduringtheserviceperiod

• Face-to-facewithin7calendardaysofdischarge

Slide: Tools for Ensuring Smooth Transitions in Care

• Pre-encounter handoff: outlining the purpose of a visit, relevant clinical information, and requested referral relationship and timeline

• Caremapping:creatingavisualrepresentationofthepatient’scareteam membersincollaborationwiththefamilyanddiscussingtheirrolesand who-tolinesofcommunication

• Post-encounter handoff: development of an action item grid with the family outlining the overall care goal, task to be completed, who is responsible, timeline for completion, and contingency plan

• Careplan:acomprehensive,integrated,shared,anddynamicdocument thatincorporatesasummaryofmedicalissues,careteammembership, andprioritizedgoalsofcareandactionstoachievethem

Facilitator note:Demonstratetheuseof2ofthesetoolsinLucia’scase.




Slide: Action Grid—Develop Care Plan Components for Lucia

Facilitator note: Haveparticipantslistcoreelementsofthecareplan.

Someideasarelistedbelow:LUCIACAREPLAN

Essential Fields/Components • Name • Dateofbirth • Insurance(primaryandsecondary) • Phonenumberandemergencycontactinformation • Parentorcaregivers’names • Diagnoses • Medications • Allergieswithdoses • Specialists’namesandphonenumbers • Hospitalizationsandsurgeries • Childoryouthstrengths • Familygoalsfortheirchild

Support Services • Equipment(ifapplicable,catheters,tracheostomies,gastrostomytubes,

wheelchair,orthotics,etc.) • Therapies(speech,PT,OT) • School/childcare/IEP • Homecareand/ornursingservices • Pharmacy • Mentalhealthagenciesandproviders • Dentalcare • Communityagencies • Transitioncareplanelements,ifapplicable

Secondary Elements • Pastmedicalhistoryandreviewofsystems • Communicationdevices • Homemodifications • Activitiesofdailyliving(challenges,toileting,hygiene) • Respite • SSI • Schoolinformation(grade,teacher,IEP,IFSP) • Feeding,diet,nutrition • Housingandtransportationneeds • Hearingandvisionservices

Alternative Medicine, Palliative Care




Works Cited


AmericanAcademyofPediatricsCouncilonChildrenwithDisabilitiesandMedicalHomeImplementationProjectAdvisoryCommittee.Patient-andfamily-centeredcarecoordination:aframeworkforintegratingcareforchildrenandyouthacrossmultiplesystems.Pediatrics.2014;133(5):e1451–e1460

PondB,LambertM,VianoM,LambertL;Parent/ProfessionalAdvocacyLeague.(2012). Linkingmedicalhomeandchildren’smentalhealth:listeningtoMassachusettsfamilies. http://ppal.net/wp-content/uploads/2011/01/Medical-Home-Report.pdf.PublishedJune2012 Accessed May 16, 2019

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