Medical Home Promising Practices Forum:

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Medical Home Promising Practices Forum

• Successes and Lessons Learned Highlights from
  the Field!

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I saw the angel in the marble and carved until I
set him free.
Michelangelo
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Who We Are

• PrimeCare Pediatrics, Ohio
• Illinois Medical Home Project (IMHP)
• Pennsylvania Medical Home Initiative --Educating
  Practices In Community Integrated Care (EPIC IC)
• Florida Telehealth Connections
• Central Massachussetts Medical Home Network
• Center for Medical Home Improvement (CMHI), NH
• National Medical Home Autism Initiative,
  Wisconsin
• Suffolk Medical Home Network, New York

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Why Were Here

• We have been working to address core themes of
  this meeting
• Family-Professional Partnerships
• Community Based Systems
• Transitions
• Value
• Look at what weve accomplished.

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Family Professional Partnership

• We Value
• A trusting, collaborative, working partnership
  with families, respecting their diversity and
  recognizing that they are the constant in a
  childs life

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Illinois Medical Home Project

• QI teams include two parent partners from each
  of 16 practices.
• The IMHP has a cadre of 32 active parent
  partners.
• The parent partners have helped each of the
  practices to better serve families through
• Quality improvement feedback and needs
  assessments.
• Developing information sheets on specific chronic
  conditions.
• Developing family support groups.
• Developing communication improvements.
• Development care templates and other products

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Center for Medical Home Improvement

• Medical Home Improvement Parent as Partners
• Model Established 1997
• Parents as Authors
• Do You Have a Medical Home? Exceptional Parent,
  2006
• Parents as Advisors
• Members of the NH Council on the Future of the
  Primary Care Medical Home and the NH Primary Care
  Task Force
• Parents as Educators Co authors of CMHIs
• Extra-Ordinary Care Improving Your Medical
  Home (PowerPoint and teaching guide)

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Florida Telehealth Connections

• Grandmothers as family health partners and
  cultural brokers to reach families in their
  neighborhoods
• To provide liaison support to talk with families
  about health care, health insurance for their
  children
• To identify families with uninsured CSHCN and
  provide encouragement to come to the CHC to
  establish a medical home

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Suffolk Medical Home Network

• Integration of parent and consumer members into
  Developmental Disabilities Center Advisory
  Committee
• Establishment of Parent Partners to train medical
  school students and pediatric residents about
  developmental disabilities
• Plan for appointment of family advisors to
  medical center

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PrimeCare Pediatrics, Ohio

• Dedicated parents on our core Medical Home Team
• Parent Advisory Group that meets quarterly to
  advise, share and learn

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Pennsylvania EPIC IC

• EPIC IC has grown the participating parent
  partners to over 60 statewide
• Parents
• Paid stipend to attend practice team meetings
• Reimbursed for travel childcare to attend EPIC
  ICs bi-annual conferences
• Parents recruited via practice focus groups and
  resource nights

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National MH Autism Initiative

• Acknowledge Family as Key Partner
• Designed ASD Medical Home Framework with family
  as the center of attention and collaboration.
• Continually Involve Family Members
• Convened Family Forum to solicit comments on
  Autism Service Guidelines for the Medical Home.

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Central Massachusetts Medical Home

• Quality Improvement Teams
• Parent Groups
• providers and/or staff attend
• Providers and parents team up and present
  at community events  
• Providers and parents creating community resource
  center and/or resource binder in practices   
• Forms development
• Family-based care coordination measurement study

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Reaffirm the Value

• Families are the synergistic movers and shakers
  that impact the system
• Quality improvement partners
• Resource development and sharing
• Support to the practice community
• Communication leaders

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Community Based Systems

• We Value
• A family-centered, coordinated network designed
  to promote the healthy development and well being
  of children and their families

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Pennsylvania EPIC IC

• 62 practices have been trained in medical home
  principles. Practices include
• - rural, urban, suburban
• - hospital systems
• - 6 PA DOH regions and 30 counties
• 10,000 CYSHCN have been identified on practice
  registries
• 29 practices have received funding for care
  coordination

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Central Massachusetts Medical Home

• Parent Professional Advocacy League (Pal)
  collaboration
• in-service at practice, response to Rosie D RFI,
  education sessions for patients providers
• Central Mass Partnership (CMP) Collaboration
• community based organizations linked to practices
  for outreach and trainings
• Title V Collaboration
• working together to enhance care coordination in
  primary care practices
• Massachusetts Family Voices Collaboration
• in-serve for families and providers, MH trainings
  for families
• Center for Medical Home Improvement (CMHI)
  Collaboration
• joint meeting and learning sessions for families
  and providers

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National MH Autism Initiative

• ASD Medical Home Framework was designed to
  promote partnerships between medical home primary
  care practice and other community based services.
• Service System Guidelines include a number of
  recommendations to support community based
  collaborations.
• Designed format (with others) for development of
  a State Plan to promote coordination of planning
  and delivery of services, involving all partners.

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Suffolk Medical Home Network

• Online and hardcopy Long Island resource
  directory of resources for CSHCN
• Creation of a Long Island Toolkit for providing
  care coordination (including enrollment services,
  DME authorization, entitlements) to CSHCN
  available on website or in PDF by e-mail
• Trainings for professionals and families in use
  of the Care Coordination Toolkit

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PrimeCare Pediatrics, Ohio

• Office based care coordinator
• Lunch Lessons

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Illinois Medical Home Project

• The IMHP has developed strong relationships and
  partnerships with the
• following community-based organizations/systems
  for a variety of activities
• Child and Family Connections (CFCs) Early
  Intervention (EI)
• Special Education in Public Schools
• Division of Specialized Care for Children (DSCC)
  staff participate as facilitators for many of the
  QI teams other regional DSCC staff regularly
  attend QI team meetings.
• The Family to Family Health Information and
  Education Center serves as a primary source of
  information for parents of children with special
  needs.
• The ARC of IL is collaborating with ICAAP on the
  Life Span program.
• All Kids (IL Medicaid program) works
  cooperatively with the IMHP and ICAAP to ensure
  every child in IL has a Medical Home.
• The ICAAP, IMHP, DSCC and other state agencies
  sponsored a medical home coloring contest for
  children in grades one through five, from which a
  2008 calendar was developed and widely
  disseminated. A 2009 calendar is in the works.

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Center for Medical Home Improvement

• Community Collaboration Communication Teams
• Cross community teams meet with medical home
• Create community wide values statement/education
• CareShare-CMHI.org
• online communication resource designed for
  families who have children or youth with special
  health care needs, and the health, educational
  and other professional partners with whom they
  regularly interact.
• Careshare allows for family directed exchange of
  day to day information

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CARESHARE
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Florida TeleHealth Connections
Spoke Site Specialist
Spoke Site CMS Enrollment And Care
Coordination

• Developed system for connecting care using
  telemedicine

Hub Site Community Health Center
Spoke Site Med Center
Spoke Site Community Health Center
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Reaffirm the value

• Many creative ideas for
• Trainings related to care coordination and
  connections with other systems/practices
• Development of infrastructure (e.g., staff) to
  provide coordination
• Use of technology to access distant systems of
  care
• Financing care coordination

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Transitions

• We Value
• The provision of high-quality, developmentally
  appropriate, health care services that continue
  uninterrupted as the individual moves along and
  within systems of services and from adolescence
  to adulthood

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Pennsylvania EPIC IC

• EPIC IC practices
• completed surveys in 2005 2008 measuring
  transition activities
• working on a posted transition policy
• developing transition care plans
• Family satisfaction with transition efforts
  measured via PA medical home family survey

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Center for Medical Home Improvement

• The Courtship of Family Medicine Adult Care
• Progressive Transition Checklists
• Transition Summaries
• Staggered transfer of care (the dance) with
  consultative co-management

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National MH Autism Initiative

• Acknowledge Successful Transition as
  Responsibility of Medical Home
• ASD Medical Home Framework identifies Transition
  to Adulthood as a key service function.
• Service System Guidelines include a number of
  recommendations to support transition to adult
  services.

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Illinois Medical Home Project

• All 19 of the IMHP practices received training
  around transition issues at Learning Sessions.
  Presentations were given by experts on transition
  (Darcy Contri, RN, BSN, MPH Patience White, MD,
  MA) and shared with QI teams and promoted to
  Chapter members.
• The Division of Specialized Care for Children
  (DSCC) hosts an annual statewide conference on
  transition during which Medical Home QI teams are
  invited to participate.
• The DSCC surveys families it serves every three
  years to determine how services and supports can
  be improved. Transition issues remain a high
  priority.
• ICAAP and DSCC are writing a new grant to
  implement a medical home/integrated services
  project specific to transition issues.

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PrimeCare Pediatrics, Ohio

• Anticipatory guidance on ALL well visit sheets
• Primary Care Physician and Care Coordinator
  interface directly with the new provider

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Suffolk Medical Home Network

• An annual Transition Institute, a day-long
  workshop for parents of youth ages 14 to 15 in
  transition to adulthood
• Quarterly Transition Support Group meetings
  covering a variety of topics and providing an
  opportunity for open discussion
• A masters level course at Stony Brook University
  covering Transition to Adulthood for education
  and health professionals working with CSHCN

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Reaffirm the Value

• Importance of training and understanding needs of
  transitioning young adults
• Importance of tools to aid transitioning youth
• Importance of care plans and starting early to
  develop links with adult care providers

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Value

• We Value
• A high-performance health care system with
  appropriate financing to support and sustain
  medical homes that promote system-wide quality
  care with optimal health outcomes, family
  satisfaction, and cost efficiency

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PrimeCare Pediatrics, Ohio

• Marked decrease in ER visits, hospitalizations
  and office scheduling errors
• Reimbursement for careplan oversight completion
  through our state title V program

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Pennsylvania EPIC IC

• Care coordination time tracking study
• Over 2 years
• Tracked outcomes, focus, time on care
  coordination
• Practice reports
• Partnership with PA Department of Public Welfare
  for cost effectiveness of medical home.

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Center for Medical Home Improvement

• Future of the Medical Home in New Hampshire
• Grant supports care coordination to continue
• Vet medical home and pilot Care Plan Oversight
  prospective payment of 225/year for CYSHCN
• - Anthem NH
• - Harvard Pilgrim Health Care
• NH Council on the Future of the Primary Care
  Medical Home
• NH Primary Care Task Force
• Public Private Multi Payer Medical Home Pilot
  1/09

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Florida TeleHealth Connections

• Telemedicine as a value
• Solves access barriers
• Geographical barriers
• Network barriers
• Time barriers
• Is a potentially significant cost saver
• E.g., reimburse for an office visit vs the cost
  of transportation, lodging, missed visits, etc.
• Project contributed to state (Title V) efforts to
  develop Medicaid reimbursement for telemedicine

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Suffolk Medical Home Network

• Case studies of value to institutions of
  specialized care coordinators that maximize
  insurance coverage for services
• Case studies establishing earlier inpatient
  discharge and maintenance on home care instead of
  placement in skilled nursing facility
• Data compilation demonstrating efficiencies in
  insurance enrollment and access to Medicaid
  waiver coverage programs
• Data supporting cost estimates for care
  coordination reimbursement

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Illinois Medical Home Project

• The evaluation component for Phase I of the IMHP
  (2004 to 2006) yielded the
• following findings (see expanded PP at display
  table for more information)
• Medical home practices demonstrated more
  efficiently managed healthcare through better
  care coordination and improved continuity of
  care.
• Reduction in overall health costs, less use of ER
• Positive outcomes for families
• Increased satisfaction, reduced stress, less
  missed school and work days
• Better treatment adherence and focus on
  preventive care
• Better and enhanced use of community resources
• Increased use of written care plans
• The Division of Specialized Care for Children
  (state title V program) reimburses for care
  coordination services and phone consultation.
• Beginning to see some private payers reimburse
  individual practices for care coordination
  services, eg. Blue Cross/Blue Shield, United
  Healthcare.

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National MH Autism Initiative

• As project promoted greater attention to ASD, it
  did so by recommending action steps that would
  promote more effective and efficient services for
  all children. (e.g., promotion of developmental
  screening and follow-up for all children.)
• Project is an example of how to promote the
  application of medical home concepts for a single
  condition, in such a way that it brings attention
  to the value of the medical home for all
  children.

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Reaffirm the Value

• Multiple demonstrations that investment in
  Medical Home
• Improves quality of care for children and
  families
• Creates efficiencies that can impact providers
  positively if they have the resources to develop
  the infrastructure
• Reduces healthcare costs by reducing
  inappropriate use of healthcare
• BUT, reimbursement and other financing strategies
  are necessary to develop and sustain the
  investment

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How to Find out More????

• Visit the display tables at the reception tonight