ADDRESSING PEDIATRIC SUBSPECIALTY ACCESS PROBLEMS THROUGH DELIVERY SYSTEM IMPROVEMENTS

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ADDRESSING PEDIATRIC SUBSPECIALTY ACCESS
PROBLEMS THROUGH DELIVERY SYSTEM IMPROVEMENTS

• Peggy McManus
• Co-Director
• Maternal and Child Policy Research Center
• Washington, DC
• Mchpolicy.org
• February 7, 2006

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PRESENTATION OVERVIEW

• Pediatric subspecialty workforce problem Federal
  Expert Work Group on Pediatric Subspecialty
  Capacity
• Importance of addressing demand
• Promising practices in referral, consultation,
  and collaborative management

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DEFINING THE PROBLEM

• Pediatric subspecialists among the growing list
  of health professions facing current projected
  shortages
• Insufficient numbers maldistribution have long
  been a concern
• Whats new is changing demand for PS care

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ADDRESSING DEMANDS

• Increasing prevalence severity of certain
  chronic childhood conditions
• Increasing survival of children with complex
  conditions resulting from medical/surgical
  advances
• Changing patterns of care, with PCPs referring
  more to PS
• Increasing preference by families to see PS
• Changing managed care and hospital markets
  shifts in health insurance status of children

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EVIDENCE THAT DEMAND EXCEEDS SUPPLY

• Small numbers relative to population and need
• Excessive appointment waiting and travel times
• Family and PCP difficulties obtaining referrals
• Unmet specialty care needs by families
• Significant recruitment and retention problems
• High levels of stress and burnout among PS
• Declining participation in Medicaid/SCHIP
  managed care

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FEDERAL EXPERT WORK GROUP ON PS CAPACITY

• Federal Maternal and Child Health Bureau formed
  work group in 2004
• Purpose to identify scope of problems, promising
  practices, and develop recommendations
• Membership 24 from AAP, ABP, NACHRI, Title V,
  AAMC, Family Voices, AACAP, etc.
• MCH Policy Research Center provides staff support

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PEDIATRIC SUBSPECIALISTS

• 30 pediatric subspecialties adolescent medicine,
  allergy/ immunology, anesthesiology, cardiology,
  clinical genetics, critical care medicine,
  dermatology, developmental-behavioral pediatrics,
  emergency medicine, endocrinology,
  gastroenterology, hematology/oncology, infectious
  diseases, medical toxicology, neonatal/perinatal
  medicine, nephrology, neurodevelopmental
  disabilities, neurology, ophthalmology,
  orthopedics, otolaryngology, pathology,
  psychiatry, pulmonology, radiology,
  rehabilitative medicine, rheumatology, sports
  medicine, surgical specialties, urology
• Except for neonatalogy, all other PS experiencing
  some level of workforce capacity problem
• Some worse than others child adolescent
  psychiatry, neurology, developmental-behavioral
  pediatrics, endocrinology, rheumatology,
  gastroenterology, orthopedics, surgical
  specialties

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DELIVERY SYSTEM DESIGN IMPROVEMENTS

• It is vital that all providers within the
  Medical Home model of care understand their
  interdependent roles and effectively serve the
  child and family. (Antonelli, Stille, Freeman)
• Improvements identified referral (transfer of
  care), consultation (one-time or time-limited),
  and collaborative management approaches (ongoing
  shared management)
• Care coordination/case management, telemedicine,
  expanded nurse roles, informatics not addressed

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PROMISING REFERRAL APPROACHES

• Referral Guidelines
• Pre-Appointment Management of Referrals
• Referral Management for Special Populations
• Pre-Visit Contacts

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REFERRAL GUIDELINES

• Madigan Army Medical Centers Referral
  Guidelines offers guidance on initial diagnosis
  and management, ongoing management objectives,
  indications for specialty referral, criteria
  for return to primary care
• Institute for Clinical Systems Improvements Care
  Guidelines (for providers for families)
  presents algorithm for addressing symptom review,
  triage, diagnosis, prevention, appropriate
  treatment follow-up, criteria for specialty
  referral

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PRE-APPOINTMENT MANAGEMENT OF REFERRALS

• University of Wisconsin Medical Foundations
  Rheumatology Pre-Appointment Management Office
  staff collect referral information, records, labs
  xrays. Specialist decides if 1) appointment
  request approved ( scheduled as urgent or
  routine with brief, usual or extended time), 2)
  further info. requested from referring MD, 3)
  care continued with referring doctor following
  conversation with patient PCP, 4) other more
  appropriate consultation arranged, or 5)
  appointment not provided if referral
  inappropriate or records not provided.
• Each of 3 rheumatologists devote 45 minutes/week
  for more than 100 referred patients. Only 59 of
  referred patients actually required a specialty
  appointment.

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REFERRAL MANAGEMENT FOR SPECIAL POPULATIONS

• Referral Management Initiative at NYs Childrens
  Health Project (also in DC, Dallas, So. Florida,
  L.A.) for homeless children. PCP ranks severity
  of childs referral problem (immediate, urgent,
  routine) case manager makes appointment.
  Reminders by mail, phone, and in person (with
  shelter staff). CM assures no insurance or
  transportation obstacles, assists at PS office,
  including translation services, facilitates
  transfer of information between PC and PS.
• Evaluation results increased appointment
  adherence, 7 to 61, reduced time between
  referral appointment, fewer barriers to care,
  and fewer PCP/PS communication problems

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PRE-VISIT CONTACTS

• Chapel Hill Pediatrics and Adolescents
  Pre-visit contacts conducted by phone by care
  coordinator with selected special-needs families
  identified based on severity score and MDs
  recommendation
• Families asked about ER, hospital, or specialist
  visits since last visit, including reasons,
  records, labs, x-rays, outcomes. Also, asked
  about 3 major areas or concerns that need to be
  addressed during preventive/chronic care visit.
• Results Improved family satisfaction, sufficient
  appointment time, improved coding for time
  complexity

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PROMISING CONSULTATION APPROACHES

• Child Psychiatry Consultation Liaison
• Title V Pediatric Subspecialty Consultation
• Family Practice Pediatric Consultation

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Child Psychiatry Consultation Liaison

• Targeted Child Psychiatry Services at UMass
  Medical Center (Worcester) Regional team of 2
  child psychiatrists, nurse, social worker, care
  coordinator working with 22 primary care
  practices. By paging child psychiatrist, PCP
  receives either 1) answers to questions, 2)
  referral to team coordinator to access routine
  behavioral care, 3) face-to-face or telephone
  transitional assistance by team social worker, or
  4) referral to team psychiatrist for acute
  medication or diagnostic consultation.
• Half of referred children managed by telephone
  consult, 16 scheduled within 3 weeks for 90 min.
  eval. At UMass psychiatry unit and returned to
  PCP with treatment plan. Only a third referred to
  CMHCs for ongoing care.

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Title V Pediatric Subspecialty Consultation

• Illinois Division of Specialized Care 20
  pediatric subspecialties are available for PCP
  phone consultation. Medical home providers
  simply call and ask about the management of a
  specific condition. Specialists reimbursed 300
  to respond to 7 phone consults and PCPs are
  reimbursed if child is enrolled in the states
  Title V program.

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Family Practice Pediatric Consultation

• Ventura County (CA) Medical Center Network of 8
  family practice clinics and residency program
  uses a pediatrician anchor and monthly onsite
  pediatric subspecialist consults from 3 So.
  Calif. medical schools to provide evaluation and
  ongoing support for family practitioners serving
  as medical homes for children with special needs.

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PROMISING COLLABORATIVE MANAGEMENT APPROACHES

• Service Agreements
• Co-Management and Multidisciplinary Approaches

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Service Agreements

• Used by NICHQs Epilepsy Collaborative, the VA,
  and others Service agreements developed in
  partnership with PCPs/specialists to formalize
  collaborative process. Consist of 1) core
  clinical competencies describing conditions
  services provided by PCP and PS 2) referral
  agreements, including referral guidelines,
  work-up recommendations, preferred
  communication processes 3) access agreements,
  defining waiting times for emergency, routine,
  and ongoing referrals, questions, consults,
  evaluations 4) graduation criteria for return to
  PCP, 5) QA agreements, identifying standards of
  care, education training processes, and
  measures.
• Process involves 2 meetings with an objective
  facilitator.
• Benefits PCPs have more timely access and
  feedback from specialist, and PS have reduced
  demand more appropriate referrals

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Co-Management and Multidisciplinary Approaches

• Special Needs Program (SNP) at Childrens
  Hospital of Wisconsin Tertiary care/primary care
  medical home partnership for medically fragile
  children needing multiple specialties, with
  frequent hospitalizations tertiary clinic
  visits, multiple community services. SNP team
  4 nurses, 2 part-time MDs, 1 coordinator, 1 AA.
  All children have pediatric case manager. Subset
  have SNP physician coordinating with PCP 24/7
  providing inpatient, outpatient, and emergency
  consults, home visits, arbitrating divergent PS
  opinions Tx options.
• Evaluation In 2004, 5 million saved with 46
  children, primarily from fewer tertiary hospital
  admissions and shorter LOS