Partnership in the Care of Children with Chronic Illness

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Partnership in the Care of Children with Chronic
Illness

• Access, Manpower Shortage, Cost Containment,
  Geography, and Collaboration Among Competitors

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• 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)

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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

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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
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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

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Tertiary Childrens Program
Developing Childrens Prog
Teaching Medical Center
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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

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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

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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

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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

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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

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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

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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.

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Demographic data
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Changes in HbA1c levels
HbA1c ()
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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

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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.

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Time Required to Complete
IMPACC
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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
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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
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Validation Method 2 PCP
IMPACC
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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
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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
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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
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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
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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
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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.

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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