Title: Partnership in the Care of Children with Chronic Illness
1Partnership in the Care of Children with Chronic
Illness
- Access, Manpower Shortage, Cost Containment,
Geography, and Collaboration Among Competitors
2- North Carolina Population 8.3 million with 2.01
million Children (under 18yo) and 0.57 million
(under 5 yo) -2004 US Census Data) - State population centered in 5 major areas
- 5 Medical Centers with Teaching Programs for
Pediatrics (4 other Regional Medical Centers
invested in or investing in expansion of tertiary
services for children)
3Current NC Medicaid Facts
- 1.6 million unduplicated eligibles covered (15.2
0f population) - 810,000 children covered
- 45 of all babies born covered
- 30 of recipients consume 74.5 resources
- Inpatient care (hosp,NH,MRC) consumes 40
- Physicians account for only 9-10 of costs!!!
- Over 1.5 billion spend on mental health services
- Total budget over 8.5 billion
4 Improving Medicaid Quality and Controlling
Costs by Building Community Systems of Care
L. Allen Dobson ,Jr. MD FAAFP Assistant
Secretary NC Department of Health Human
Services
5CCNC Organizational Features
- Medical Home / Network of Primary Care Physicians
- Primary Care access 24 hours a day. Nurse Advice
Line - Local partnership Physicians, Hospital, Health
Department, and DSS (Variations) - Quality Initiatives
- Steering Committee
- Medical Director
- Case Managers
- State support
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7Tertiary Childrens Program
Developing Childrens Prog
Teaching Medical Center
8Issues for Children with Chronic and Complex
Illness
- Number and location of pediatric subspecialists
(NC has 25 of the national average per
population of Ped Subspecialists) - Access to the subspecialists (long waits for
appointments-up to 45 weeks) - Communication with PCPs
- Where is the Medical Home
- Family confusion
- Coordination of access to services
9IMPACCImproving Pediatric Access through
Collaborative Care
- Collaboration among 5 Teaching Medical Centers
and a Regional Medical Center with Tertiary
Childrens Services - Financial Partners include NC Medicaid
(AccessCare, CCNC, DMA), Duke Endowment,
Foundation for Health Care Improvement,
Departments of Pediatrics at the Teaching Medical
Centers
10Long Term Outcome Targets
- Improve access to necessary pediatric
subspecialty care in a timely and efficient way - Develop statewide evidence based management
schemes for complex and chronic illnesses in
children - Establish co-management guidelines to streamline
consultation - Reduce cost of care for children with special
health care needs - Facilitate communication and care coordination
- Improve involvement of patients and their families
11Project Model
- Developing Connections between the Subspecialty
Care Location with the Medical Home of the
Patient -
- Examine Primary Care Physician-Family-Subspeciali
st Dynamics - Why are patients referred?
- Are families satisfied with referral process and
outcome? - What is the perspective of the Subspecialist
receiving and performing the consultation? - Case Management at Subspecialty Care location in
contact with the Care Manager at the Medical Home - Health Outcome tracking using clinical outcome
marker (e.g. HgA1c with Diabetes) - Financial Impact (costs, number of ER visits,
admissions, and subspecialty clinic visits) using
NC Medicaid Database - Telephone Consultation
- trial of subspecialist reimbursement
- looking for changes in tertiary center Transfer,
ER visits, and Admissions - Co-Management Guidelines for Primary Care
Physicians and Subspecialists
12Examine Primary Care Physician-Family-Subspecialis
t Dynamics
- Survey of subspecialist (was the referral
appropriate?), survey of PCP (why was the
referral made?) survey of family (why was the
referral made and did the visit to the
subspecialist achieve what you expected? - Surprising agreement by the 3 groups 85
although data analyses are still underway
13Case Management at Subspecialty Care location in
contact with the Care Manager at the Medical Home
- All 5 participating centers received funding for
1 or more medical center based case managers. - Role coordinate care of Medicaid patients with
CCNC network case manager for the PCP and
medical home. - Assessment of impact on care continues
14Trial of Medical Center Based Case Manager for
Children with Type 1 Diabetes
- Case manager (PNP) identified at one center and
trained with the tools of the PCP case manager,
introduced to network case managers, and select
group of patients identified for intervention - Patients were selected who participated in the
Childrens Type 1 Diabetes Clinic who had
demonstrated poor compliance to management plan,
increased HgbA1C (8.5), and enrolled in
Medicaid through CCNC. Intervention in one
geographic area, control group in a separate area.
15Demographic data
16Changes in HbA1c levels
HbA1c ()
17What is different?
- Closer interaction with patient and their
environment - Increased awareness in their social environment
- Focused diabetic training
- Feeling that somebody cares about them
- Frequent contact with diabetes team
18Telephone Consultation
- Subspecialists at the medical centers completed
short information cards for each telephone
consultation including, demographic information,
diagnosis, time spent, and avoidance of services
(visit to ED, hospitalization, transfer to
medical center, referral to subspecialty clinic,
or improved quality of care) - Medicaid patients were identified and
confirmation of avoidance of services performed
using Medicaid payment data - PCP assessment of outcome of telephone
conversation performed.
19Time Required to Complete
IMPACC
20Estimated Costs AvoidedSub-Specialist Data
- Value of 163 services described as avoided
493,958 - Costs 12,240 if paying 40/Consult to
specialist - 40 saved/dollar spent
- Averages charges for Medicaid children at UNC
in 2006 calculated for - ED Visits (both Emergent Non-Emergent)
- Specialist visits (CPT 99242 99245)
- Hospitalizations included Room Board, Physician
charges, and Lab/Drug/DME (Admissions beginning
in 1st week of life excluded)
IMPACC
21Validation Method 1 Claims
- Verify that services that specialists report as
avoided do not have claims filed - Preliminary analyses do not show claims for
avoided services
IMPACC
22Validation Method 2 PCP
IMPACC
23Establishing a Medical Home
- Objective To examine PCPs and
endocrinologists views about management of
children with insulin-dependent diabetes for - Routine, preventive and acute care
- Diabetes-specific care
- Family education and care coordination for
children with insulin-dependent diabetes
IMPACC
24Background
- Care Coordination in the Medical Home 1
- Collaboration Models of Shared Care 2
- Generalist as Manager Child with moderately
severe asthma - Specialist as Manager Child with particularly
rare or complex conditions - Co-management Child with Type I diabetes and
ADHD
1 AAP Policy Statement, 2005 2 Antonelli, Stille.
2005. Enhancing Collaboration Between Primary and
Subspecialty Care Providers for CYSHCN
IMPACC
25Survey
- Respondents
- 132 PCPs in one Medicaid Managed Care Network
that is spread throughout NC - 35 pediatric and adult endocrinologists who treat
children with diabetes in NC - Physicians were asked to choose whether PCP or
endocrinologist is primarily responsible for
providing various services to children with IDDM
in respect to the 3 types of care
IMPACC
26Table 1. Aspects of Care where a PCP Lead is
Favored by a Majority of All 168 Respondents
Table 2. Aspects of Care where a Specialist
Lead is Favored by a Majority of All 168
Respondents
27Table 3. Aspects of Care where Co-Management is
Favored by a Majority of All 168 Respondents
Results
Table 4. Aspects of Care where Respondents were
Split between Co-management and a Specialist Lead
28Table 5. Aspects of Care where PCP and
Endocrinologist responses differed significantly
regarding which provider type is primarily
responsible for care.
Results
Responses varied between 132 PCPs and 36 ENDO
with p
29Co-Management Guidelines for Primary Care
Physicians and Subspecialists
- Joint development of co-management guidelines
with PCPs and Subspecialists - Initial topic Obesity (at the request of NC
Medicaid, meeting completed on Nov 19, 2007) - Process Evidence-based review of literature
around the subject and published guidelines for
referral, pediatric endocrinologists, obesity
center directors, and PCPs from CCNC invited to
attend, discussion of the review, development of
consensus on management by PCP and
Subspecialists, web site initiated with NC
Medicaid to publish the guidelines - Expectation is CME for PCPs and Subspecialists
about the guidelines - Track outcomes by Medicaid payment and survey
- Repeat cycles with appropriate expert panels to
cover a series of diseases and disorders where
co-management is needed.
30The Medical Home
- A Medical Home should be delivered or directed by
well-trained physicians who provide primary
care.1 - As long as the operational elements of a Medical
Home are provided, the role of the PCP can be
fulfilled by either a generalist or a
subspecialist physician.2
1 AAP Policy Statement, 2002 2 Antonelli, Stille.
2005. Enhancing Collaboration Between Primary and
Subspecialty Care Providers for CYSHCN
IMPACC