- 1. Medical Home:Just What the Doctor Ordered to Fix American
Healthcare? GIH TeleconferenceRichard C. Antonelli, MD, MS
Associate Professor of Pediatrics Univ of Connecticut School of
Medicine Senior Fellow Child Health and Development Institute
September 29, 2008
2. Learning Objectives
- Articulate the key components of pediatric Medical Home
- Understand primary care-based pediatric care coordinationand
how it is different than adult CC
- Articulate a process to measure care coordination in the
pediatric primary care setting
- Describe the different challenges and opportunities to provide
care coordination to children and youth with special health care
needs
3. Care coordination is the answer! 4. Whats the question?
Carolyn Clancy, MD,Director, AHRQ 5. Definition of Medical Home
6. Definition of Medical Home
- And for which the primary care provider shares responsibility
with the family.
7. Patient-Centered Medical Home Joint Principles Statement
- Major Focus of Advocacy for All Primary Care Specialties
- Relationship between PCP and patient (adult MH) versus family
(pediatric MH)
8. Care Model for Child Health in a Medical Home Informed,
Activated Patient/Family Prepared, Proactive Practice Team
Supportive,IntegratedCommunity Prepared, Proactive Practice Team
Functional and Clinical Outcomes Resources and Policies Community
Health System Health Care Organization (Medical Home) Delivery
System Design Decision SupportClinical Information Systems Care
PartnershipSupport Family -centered Coordinated and Equitable
Timely & efficient Evidence-based & safe 9. What is Care
Coordination?
- A process that facilitates the linkage of children and their
families with appropriate services and resources in a coordinated
effort to achieve good health.
10. What Is Case Management?
- Began in era of managed care as mechanism of ensuring access to
appropriate benefits package of services: utilization review
approach.
- Any effective, sustainable community-based Medical Home system
must support linkages between practice-based CC and community-based
CM!
11. What Constitutes CC in a Pediatric Medical Home? 12. 13.
National Study of Care Coordination Measurement in Medical Homes
Antonelli, Stille, and Antonelli, 2008 14. 15.
- Health Outreach for Medical Equality (HOME)
- Pilot Project to Assess Feasibility and Outcomes of
Co-LocatedCC model in anurbanpediatric setting
- CC provided by Community-based partner (Hispanic Health
Council) with clinic and community-based CC
- Funded by Hartford Foundation for Public Giving, Childrens Fund
of CT/ Child Health and Development Institute, Conn Childrens
Medical Center, and CT Medicaid agency
16. Implications for Policy and Practice
- With the advent of Patient-Centered Medical Home, all primary
care provider organizations are focusing on CC as critical
function
- Payers and purchasers are looking at P4P to incentivize CC
- CC for adult chronic condition CC is very different from
pediatric CC
17. Implications for Policy and Practice
- Pediatric disease-specific CC (aka, chronic condition
management/ CCM) should be quite implementable
- However, comprehensive pediatric CC is not the same as CCM
- Mechanisms of operationalizing and measuring CC functionality
at MH practice level must be developed
- CC as a discipline must be developed in order to achieve high
performing health care system
18. Transition for Youth You think pediatrics or adult CC is
difficult, what about Transitioning youth with chronic conditions
from one side of the chasm to the other? 19. Outcome Realities
YSHCN
- 90% of YSHCN reach their 21 stbirthday
- Nearly 40% cannot identify a primary care physician
- 20% consider their pediatric specialist to be their regular
physician
- Significant numbers have extensive primary health concerns that
are not being met
- Fewer work opportunities, lower high school grad rates and high
drop out from college
CHOICES Survey, 1997; NOD/Harris Poll, 2000; KY TEACH, 2002 20.
What Can Be Measured re:CC?
-
- Parent/ youth partners in QI at practice level
-
- Developmental and behavioral screening
-
- Screening for secondary disabilities (much less prevalent than
adult practice)
-
- Presence of registry and its utilization
-
- Development and deployment of Care Plans (these have CPT codes
already)
-
- Mechanism for linkage from practice-based CC to community-based
CM
-
- Training opportunities for CCers
-
- ED and in-patient utilization for patients with chronic
conditions
21. How Can We Improve Quality and Increase Capacity?
- Co-Management as means of increasing access and quality:
- Targeted Child Psychiatric Services
- Connor, Antonelli, et al (Clinical Pediatrics,June, 2006)
22. What Will Incentivize Change In Primary Care?
- Patient-Centered Primary Care Collaborative (PCPCC)
- Medicare Medical Home Pilots (2009)
- State Level Medicaid Medical Home Projects
23. PCMH-PPC: NCQA, AAFP, ACP, AAP and AOA Medical Home
Qualifying Criteria Linked to Reimbursement 24. NCQA 6 Pts 2 4
- Standard 4: Patient Self-Management Support
- Assesses language preference and other communication
barriers
- Actively supports patient self-management**
20 Pts 3 4 3 5 5
- Standard 3:Care Management
- Adopts and implements evidence-based guidelines for three
conditions **
- Generates reminders about preventive services for
clinicians
- Uses non-physician staff to manage patient care
- Conducts care management, including care plans, assessing
progress, addressing barriers
- Coordinates care//follow-up for patients who receive care in
inpatient and outpatient facilities
21 Pts 2 3 3 6 4 3
- Standard 2: Patient Tracking and Registry Functions
- Uses data system for basic patient information (mostly
non-clinical data)
- Has clinical data system with clinical data in searchable data
fields
- Uses the clinical data system
- Uses paper or electronic-based charting tools to organize
clinical information**
- Uses data to identify important diagnoses and conditions in
practice**
- Generates lists of patients and reminds patients and clinicians
of services needed (population management)
9 Pts 4 5
- Standard 1: Access and Communication
- Has written standards for patient access and patient
communication**
- Uses data to show it meets its standards for patient access and
communication**
4 Pts 1 2 1
- Standard 9: Advanced Electronic Communications
- Availability of Interactive Website
- Electronic Patient Identification
- Electronic Care Management Support
15 Pts 3 3 3 3 2 1
- Standard 8: Performance Reporting and Improvement
- Measures clinical and/or service performance by physician or
across the practice**
- Survey of patients care experience
- Reports performance across the practice or by physician **
- Sets goals and takes action to improve performance
- Produces reports using standardized measures
- Transmits reports with standardized measures electronically to
external entities
4 PT 4
- Standard 7: Referral Tracking
- Tracks referrals using paper-based or electronic system**
13 Pts 7 6
- Standard 6: Test Tracking
- Tracks tests and identifies abnormal results
systematically**
- Uses electronic systems to order and retrieve tests and flag
duplicate tests
8 Pts 3 3 2
- Standard 5: Electronic Prescribing
- Uses electronic system to write prescriptions
- Has electronic prescription writer with safety checks
- Has electronic prescription writer with cost checks
25. Useful Websites
- http:// www.medicalhomeinfo.org : American Academy of
Pediatrics hosted site that provides many useful tools and
resources for families andproviders
- http:// www.medicalhomeimprovement.org :tools for assessing and
improving quality of care delivery, including the Medical Home
Index, and Medical Home Family Index
26. References
- Antonelli, RC ,Stille, C, and Antonelli, DM, Care coordination
for children and
- youth with special health care needs: a descriptive, multisite
study of activities,
- personnel costs, and outcomes.Pediatrics. 2008
Jul;122(1):e209-16
- Turchi, R, Gatto, M, and Antonelli, R, Children and Youth with
Special Health
- Care Needs:There is No Place Like (a Medical) Home, Curr Opin
Pediatr
- Connor, D, McLaughlin, T, Jeffers-Terry, M, OBrien, W, Stille,
C, Young, L, and
- Antonelli, R,TargetedChild Psychiatric Primary Clinician-Child
Psychiatry
- Collaborative Care, Clin Pediatr. 2006; 45:423-434.
- Antonelli, R., Stille, C., Freeman, L.,Enhancing Collaboration:
Roles of Primary
- and Subspecialty Care Physicians in Providing a MH for CYSHCN,
MCHB,
- Stille, C and Antonelli, R, Coordination of care for children
with special health
- care needs,Curr Opin Pediatr 2004;16:700-705.
- Antonelli, R and Antonelli, D, Providing a medical home: the
cost of care
- coordination services in a community-based, general pediatric
practice,
- Pediatrics 2004; 113:1522-1528
27. References (continued)
- McPherson, M., Arango, P., Fox, H., et al. (1998). A new
definition of children with special health care
- needs.Pediatrics ,102 ,137140
- Committee on Children with Disabilities, American Academy of
Pediatrics. (1999). Care coordination:
- Integrating health and related systems of care for children
with special needs.Pediatrics ,104 (4, Part 1),
- Committee on Quality of Health Care in America, Institute of
Medicine. (2001). Crossing the quality chasm:
- A new health system for the 21 stcentury
- Friedman, Mark, Trying hard is not enough; excellent reference
on Results-Based Accountability.