provide and document planned, proactive comprehensive care jill s. rinehart, md faap associate...
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Provide and Document Planned, Proactive
Comprehensive CareJill S. Rinehart, MD FAAP
Associate Clinical Professor Pediatrics, University of Vermont Medical School
Owner/PediatricianHagan, Rinehart & Connolly Pediatricians,
PLLC Florida Pediatric Medical Home Demonstration Project
Learning Session I September 23-24, 2011
Disclosure
I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.
Objectives
Describe family centered tools that may be helpful in documenting care in a coordinated, proactive, preventative way
Example of Well-Child Visit Examples of coordinated comprehensive
care for CSHN
Medical Home Definition
AccessibleCulturally EffectiveContinuousComprehensiveCoordinatedCompassionateFamily Centered
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
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
Bright Futures and Medical Home
“Bright Futures is an evidenced based approach to preventive health
care, that is best delivered in the medical home.”
Editors: Joseph F. Hagan, MD,FAAP Judy Shaw, EdD,RN, FAAP Paula Duncan MD, FAAP
Medical Home: Health Supervision
At any given time we have 2 distinct populations in Pediatrics:
1) Relatively healthy: need preventive health care, education and community support
Medical Home: Health Supervision
And 2) The pretty sick: who need preventive health care, education, community support AND chronic care management
Medical Home and Health SupervisionCoordinated, Continuous
• Lacation Consultation• Nurse phone call follow up• First touchpoint with office after infant born• Past 24 hours (stools,
swallowing, engorgement)• Feeding, jaundice• Explore supports• “Baby blues”
Medical Home and Health SupervisionComprehensive
11 year old boy, Bright Futures Visit
BMI: 87%, SMA IIStrengths based
assessment H-ome E-ducation A-ctivities D-rugs S-ex S-uicide S-afety
Medical Home and Health SupervisionFamily Centered, Comprehensive
Parent Concerns: Mom concerned about anxiety around swim meets and whether divorce adjustment ok
Youth Concerns: Warts-hands and fingers, biggest kid in 5th grade
Physician Concerns: Elevated BMI, needs Immunizations, puberty
Medical Home and Health Supervision
Strengths Based Assessment, developmental milestones of pre-adolescent
Generosity: likes younger kids, book buddy has special needs
Independence: self-reliance, supervises younger brother at Dad’s
Mastery: qualified New England’s 9 swim events
Belonging: loves school, has friends, loves Vermont
Medical Home and Health Supervision
Bright Future’s Evidenced Based Anticipatory Guidance:
Physical Growth/Development: puberty, BMIEmotional Well-being: decision making,
dealing with stress, mental health concerns, puberty
Risk reduction : parents know friends, limit screen time
Violence and Injury Prevention: helmet use, no guns, bullying
Health Supervision in the Medical Home
Conclude with “readiness to change steps”--switch from chocolate milk to skim at school, review healthy choices for food in all settings, identify opportunity for role as a babysitter/mother’s helper in the neighborhood
Support psychotherapy around divorce issuesImmunizations: HPV, Tdap, Menactra
Coordinated Care
Teagan is a 2 year old with Kabuki (Make-up) Syndrome
Had a Nissen and G-Tube placed in infancy for severe aspiration, oral aversion
Late last fall, she presented with seizures associated with hypoglycemia
Difficult IV access Sister, clown, cousin
Comprehensive
Pediatric Medical Home: Dr. Rinehart (HRC)
Pediatric Resident Team
Dr. Guillot Pediatric Nephrology
Dr. D’Amico Pediatric Gastroenterology
Dr. Kacer Endocrinology
Dr. Burke Pediatric Genetics
Dr. Modlinsky AnesthesiaDr. Mingin Pediatric
UrologyDr. Hubble Pediatric ENTDr. Sartorelli Pedi
SurgeryDr. Hastings Pediatric
OpthalmologyDr. Bingham Pediatric
NeurologyDr. Soll Neonatology
Coordinated Care
PICC placed by anesthesia
Dr. Mingin renal calculi surgery
Labs coordinated by genetics, endocrine, GI, me (some first a.m., fasting, hypoglycemic,etc.)
Evidence for Medical Home
Comprehensive care for high-risk infants resulted in more outpatient visits, but fewer life-threatening illnesses, PICU admissions and PICU days
Broyles RS, Tyson JEH, Heyne ET, et al. “Comprehensive follow-up care and life-threatening illnesses among high-risk infants: a randomized controlled trial,” JAMA. 2000;284 (16):2070 –2076
Evidence for Medical Home
For children with Asthma a decreased continuity of care is shown to increase hospitalizations
Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;107 (3):524 –529
Comprehensive
Review of evidence base for medical home model found that 28 of 33 articles reported benefits of medical home over a range of outcomes
Homer CJ, Klatka K, Romm D, et al. “A review of the evidence for the medical home for children with special health care needs.” Pediatrics. 2008;122 (4)
Care Coordination
A plan of care developed by the physician, CSHN, and family
A central record with pertinent medical information kept in the primary care office
When CSHN is referred for a consultation, the medical home assists the CSHN and family in communicating clinical issues
The medical home evaluates and interprets the consultant’s recommendations for the CSHN and the family
The care plan is coordinated with other community agencies
Documentation
Our “Medical Home Care Plan”
“Family Snap Shot,” “Team members,”“Strengths,” as well as “Problem List,” “Medications”
Tools for Change: Care Plans
Medical Home Care Plan
␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣
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␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣
␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣␣␣␣␣␣
Documentation
EHR templates match Bright Futures’ visitsEvidence based templates for standard of
care for chronic conditions (Asthma, ADHD, Depression)
Pre-Visit Questionaires (see Packet for Change for BF questionaire)
Documentation
Family eco-map as a tool for families with children with special needs Helps identify gaps in services Begin to see community based patterns
FAMILYFAMILY
MEDICALHOMEPRIMARY DOCTOR
CARE COORDINATOR
On-Going Care TeamSocial WorkerOT/PT/SLP TherapistsDaycare Staff & Aide
SupportFamily,
Friends, Groups, Advocacy
RespiteMedicaid ArisFIT
CSHNClinicsFundingEquipment
FundingInsurersMedicaidFITCSHN
SpecialistsNeurosurgeryNeurologyPhysiatristEndocrinology
Our Medical Home Post Diagnosis 1:35 pm 2/15/01
Eco-Map: Community Links
Know your community and its common health concerns
Parent to Parent Support Networks (Family Voices, Vermont Family Network)
Care Coordination
The medical home evaluates and interprets the consultant’s recommendations for the CYSHCN and the family
The care plan is coordinated with other community agencies
CSHN Registry at HRC
Method of “flagging” a child as needing care coordination Indicates “more time needed:” consult MD before
scheduling acute visit, or have scheduler find time spot for preventative visit
We initially had levels based on types and number of medical and or psychosocial needs, contacts per week/month, complexity of disease -medical and psychosocial
See Change Package-examples of registries and levels of care coordination
Comprehensive
Having a medical home is associated with increased ease of use of community services by families
Baruffi G, Miyashiro L, Prince CB, Heu P. Factors associated with ease of using community-based systems of care for CSHCN in Hawaii. Matern Child Health J. 2005;9 (suppl 2):S99
Comprehensive
2 brothers live with their dad and paternal Grandma in Burlington
Scotty is 6, has CPSam is 7 has AutismChief Complaint: TruancyScotty unable to get a
power chair because home is not accessible
Accessible “units” not possible due to Sam’s sleep dysfunction
Coordinated
Care Conferences: Kidsafe Collaborative, Burlington Housing Authority, Howard Center, Bridge Program, Burlington School district, Shelburne School District, psychologist, CSHN social worker, school nurses, PT, OT, SLP
Compassionate
BHA found a house in Shelburne, needed indoor modifications and a ramp
Generous donor--donated supplies, laborFamily moved in AprilNegotiated with town Historical
Preservation Society Ramp built in August, 2011Power chair due September
Take Home Ideas
Eco-maps for familiesEco-map for communityBright Futures VisitsMedical Home Care PlansPractice based CSHN RegistryCare Coordination: create a system
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Thank You to Our Parent Partners
Carolyn Brennan Kimberly CooksonSandy JuliusScott MetevierPeggy Mann Rinehart Theresa SoaresKate & Michael Stein
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Resources
Antonelli RC, Stille CJ,Care , Antonelli DM, “Coordination
for CYSHCN: A descriptive Multisite Study of Activities, Personnel Costs, and Outcomes,” Pediatrics, July 2008
Baruffi G, Miyashiro L, Prince CB, Heu P. “Factors associated with ease of using community-based systems of care for CSHCN in Hawaii,” Maternal Child Health J, 2005
Broyles RS, Tyson JEH, Heyne ET, et al. “Comprehensive follow-up care and life-threatening illnesses among high-risk infants: a randomized controlled trial,” JAMA. 2000
Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001
Cooley C, McAllister J, “CMHI National Outcomes Study Cost/Utilization,” Pediatrics, July 2009
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Resources
Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001
Hagan, J.F, Duncan, P., Shaw, J., Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, p.4
Homer CJ, Klatka K, Romm D, et al. “A review of the evidence for the medical home for children with special health care needs.” Pediatrics. 2008
MCHB/NCHS. National Survey of Children with Special Health Care Needs, 2002
National Center for Medical Home Implementation “Building Your Medical Home Toolkit,” website:http://www.pediatricmedhome.org/
Strickland, et.al.,“New Findings from the 2005-2006 NS-CSHN,” Pediatrics, June 26, 2009