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Partnership in the Care of Children with Chronic Illness

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State population centered in 5 major areas. 5 Medical Centers with Teaching Programs for Pediatrics (4 other Regional ... Collaboration Models of Shared Care 2 ... – PowerPoint PPT presentation

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Title: Partnership in the Care of Children with Chronic Illness


1
Partnership 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)

3
Current 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
5
CCNC 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

6
(No Transcript)
7
Tertiary Childrens Program
Developing Childrens Prog
Teaching Medical Center
8
Issues 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

9
IMPACCImproving 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

10
Long 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

11
Project 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

12
Examine 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

13
Case 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

14
Trial 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.

15
Demographic data
16
Changes in HbA1c levels
HbA1c ()
17
What 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

18
Telephone 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.

19
Time Required to Complete
IMPACC
20
Estimated 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
21
Validation 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
22
Validation Method 2 PCP
IMPACC
23
Establishing 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
24
Background
  • 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
25
Survey
  • 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
26
Table 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
27
Table 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
28
Table 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 29
Co-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.

30
The 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
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