medical home collaboration. “we don’t know what we don’t know”

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  • Slide 1
  • Medical Home Collaboration
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  • Children with Special Health Needs-Overview Care coordination Medical Home Initiative Pediatric Hi-Tech Personal Care Childrens Palliative Care Child Development Clinic Cleft Palate Clinic Rehab and Neurology clinics Respite Financial Technical Assistance Community Nutrition Newborn Screening Newborn Hearing Screening Birth to age 21
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  • Medical Home CIS Early Intervention Collaborative Team Child Development Clinic & CSHN Services Chittenden Social Worker
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  • Our Medical Home Program Three pediatricians, Dr. Joseph Hagan, Dr. Jill Rinehart, Dr. Greg Connolly Two Pediatric Nurse Practitioners, Maryann Lisak &Ashley Boyd One main RN Care Coordinator Kristy Trask Business manager, office manager, two office assistants, six additional part-time nurses two medical assistants ~4500 Active Patient List
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  • Medical Home History 1967: First published reference to Medical home was in the AAP s Council on Pediatric Practice s Standards of Child Health Care Defined Medical Home as the respository of medical records for a child, emphasized the importance especially for CSHCN
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  • Medical Home History 1970 s: AAP first addresses the policy implications of the term medical home 1977: Fragmentation of Health Care Services for Children, Clarified the concept of single medical home for every child
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  • Medical Home History 1980 s: The first Medical Home is attributed to Hawaii Pediatrician, Dr. Cal Sia 1992: AAP published first policy statement defining the medical home
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  • Medical Home History 1998: Called for imaginative methods, backed by insurance and government funding [that] must be developed and used to improve financing for care coordination and other needs ~Polly Arango and Merle McPhereson New Definition of Children with Specia Health Needs, Pediatrics,1998
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  • Medical Home History 2002: Medical Home Policy Statement was published that defines the concept of Medical Home we use today
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  • Medical Home History 2002-2004 in VT: Medical Home Improvement Project 2006: ACP created The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care promoting an evidence based medical home
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  • 13 Medical Home History 2007: Bright Futures embraces the concept of Medical Home for all children and states that the Medical Home is the most effective model for the provision of health supervision. Linked to Affordable Care Act
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  • What Is Bright Futures? Gold standard for pediatric care provides detailed information on well-child care for health care practitioners. A national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community A part of the Affordable Care Act
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  • Medical Home History Joint effort led to the National Center for Quality Assurances (NCQA) creation of Physician Practice Connections-Patient- Centered Medical Home (PPC PCMH) Created 2008 PPC PCMH Standards March 2011, then 2014 PCMH guidelines
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  • Medical Home Definition Accessible Culturally Effective Continuous Comprehensive Coordinated Compassionate Family Centered
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  • Medical Home Definition 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 ~ National Center for Medical Home Implementation
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  • Why is A Family- Centered Medical Home Important to family? Opportunity for the family to build a trusting and collaborative relationship with the pediatrician and office staff. Care coordination provides smooth facilitation among all members of the childs care team including family, specialists, pharmacy staff, community and school services. Comprehensive source of complete patient medical history Victoria Garrison, Innovations in Medical Home, VFN annual conference, April 2013
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  • Franklin Cty Peds Mousetrap St. Albans Newport Peds Rainbow Peds MPAM Gifford Green Mountain Pediatrics Mousetrap Milton Timber Lane SB Timber Lane Mousetrap Peds Enosburg Mousetrap Peds Swanton Associates in Pediatrics Barre Pediatrics UPeds Burl UPeds Williston Shelburne Peds Richmond Peds Essex Peds Brookside Peds Cornerstone Peds Dr. H. Taylor Yates Jr. Dr. David Toll Dr. Joe Nasca Dr. Martin R. Luloff Just So Peds Womens & Childrens Services Pediatric Associates Upper Valley Peds Springfield Pediatric Network Ryderbrook Peds PedMed Dr. Rebecca Collman NVRH St. J Peds H&R Peds Milt on Burling ton S. Burl Benning ton St. Johnsbury Middleb ury Has been scored Has anticipated NCQA recognition date Has not started process PCMH Recognition Status, VT Pediatric Practices as of 12/12 St. Albans Mt. Ascutney Physicians Practice South Royalton Health Center
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  • Pediatric Collaborations Chittenden County
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  • 5 Key Elements of Highly Effective Care Coordination The Concept 1.Needs assessment for care coordination and continuing care coordination engagement 2.Care planning and communication 3.Facilitating care transitions 4.Connecting with community resources and schools 5.Transitioning to adult care The Person Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009
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  • A Framework for Highly Performing Pediatric Care Coordination Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009.
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  • Principles for Successful Use of Shared Plan of Care 1.Children, youth and families are actively engaged in their care. 2.Communication with and among their medical home team is clear, frequent and timely. 3.Providers/team members base their patient and family assessments on a full understanding of child, youth and family needs, strengths, history, and preferences. 4.Youth, families, health care providers, and their community partners have strong relationships characterized by mutual trust and respect. 5.Family-centered care teams can access the information they need to make shared, informed decisions. McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: 2014 (in press), Lucille Packard Foundation for Children's Healthcare
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  • Principles for Successful Use of Shared Plan of Care 6.Family-centered care teams use a selected plan of care characterized by shared goals and negotiated actions; all partners understand the care planning process, their individual responsibilities, and related accountabilities. 7.The team monitors progress against goals, provides feedback and adjusts the plan of care on an on-going basis to ensure that it is effectively implemented. 8.Team members anticipate, prepare and plan for all transitions (e.g. early intervention to school; hospital to home; pediatric to adult care). 9.The plan of care is systematized as a common, shared document; it is used consistently by every provider within an organization, and by acknowledged providers across organizations. 10.Care is subsequently well coordinated across all involved organizations/systems. McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: 2014 (in press), Lucille Packard Foundation for Children's Healthcare
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  • Partnership Care Planning Model McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: An Implementation Guide. 2014, Lucille Packard Foundation for Children's Healthcare: Lucille Packard Foundation for Children's Healthcare.
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  • Care Coordination Rounds Regular meetings (typically 1 hour) with practice care coordinator, physicians, CHT social worker, ( sometimes other community partners as needed) Discussion of patients (who needs more intervention and who is doing what part of the work) Systems issues
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  • ECOMAP Informal Supports Extended Family Friends Groups Religious Organizations Cultural Supports Clubs Recreation Camps Community and State Services CSCHN Economic Services Developmental Services Mental Health Early Intervention Home Health Services Childrens Palliative Care WIC Child Protection Private Therapists Personal Care School Teachers Case Manager Speech PT/OT Other Services Medical Specialists Specialty Providers Clinics Financial Supports Insurance Respite Childcare Subsidy Economic services Social Security Food Subsidy Employment Childcare Teachers Genogram of Household Members Parents Siblings Child Extended Family Others
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  • VG CG 5 yo 7 yo 4 yo Hagan, Rinehart and Connolly Pediatricians Shelburne Community School Special Educator Speech Language Pathologist School Physical Therapist Occupational Therapist Swimming at YMCA Rue Kendrick- classroom teacher PCA Debbie- Para-profes


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