Provide and Document Planned, Proactive

Comprehensive CareJill S. Rinehart, MD FAAP

Associate Clinical Professor Pediatrics, University of Vermont Medical School

Owner/PediatricianHagan, Rinehart & Connolly Pediatricians,

PLLC Florida Pediatric Medical Home Demonstration Project

Learning Session I September 23-24, 2011

Disclosure

I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

Objectives

Describe family centered tools that may be helpful in documenting care in a coordinated, proactive, preventative way

Example of Well-Child Visit Examples of coordinated comprehensive

care for CSHN

Medical Home Definition

AccessibleCulturally EffectiveContinuousComprehensiveCoordinatedCompassionateFamily Centered

Medical Home Definition

The Medical Home is the model for 21st century primary care, with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated and family-centered manner…~National Center for Medical Home Implementation

What is Bright Futures?

• Gold standard for pediatric care provides detailed information on well-child care for health care practitioners.

• A national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community

Bright Futures and Medical Home

“Bright Futures is an evidenced based approach to preventive health

care, that is best delivered in the medical home.”

Editors: Joseph F. Hagan, MD,FAAP Judy Shaw, EdD,RN, FAAP Paula Duncan MD, FAAP

Medical Home: Health Supervision

At any given time we have 2 distinct populations in Pediatrics:

1) Relatively healthy: need preventive health care, education and community support

Medical Home: Health Supervision

And 2) The pretty sick: who need preventive health care, education, community support AND chronic care management

Medical Home and Health SupervisionCoordinated, Continuous

• Lacation Consultation• Nurse phone call follow up• First touchpoint with office after infant born• Past 24 hours (stools,

swallowing, engorgement)• Feeding, jaundice• Explore supports• “Baby blues”

Medical Home and Health SupervisionComprehensive

11 year old boy, Bright Futures Visit

BMI: 87%, SMA IIStrengths based

assessment H-ome E-ducation A-ctivities D-rugs S-ex S-uicide S-afety

Medical Home and Health SupervisionFamily Centered, Comprehensive

Parent Concerns: Mom concerned about anxiety around swim meets and whether divorce adjustment ok

Youth Concerns: Warts-hands and fingers, biggest kid in 5th grade

Physician Concerns: Elevated BMI, needs Immunizations, puberty

Medical Home and Health Supervision

Strengths Based Assessment, developmental milestones of pre-adolescent

Generosity: likes younger kids, book buddy has special needs

Independence: self-reliance, supervises younger brother at Dad’s

Mastery: qualified New England’s 9 swim events

Belonging: loves school, has friends, loves Vermont

Medical Home and Health Supervision

Bright Future’s Evidenced Based Anticipatory Guidance:

Physical Growth/Development: puberty, BMIEmotional Well-being: decision making,

dealing with stress, mental health concerns, puberty

Risk reduction : parents know friends, limit screen time

Violence and Injury Prevention: helmet use, no guns, bullying

Health Supervision in the Medical Home

Conclude with “readiness to change steps”--switch from chocolate milk to skim at school, review healthy choices for food in all settings, identify opportunity for role as a babysitter/mother’s helper in the neighborhood

Support psychotherapy around divorce issuesImmunizations: HPV, Tdap, Menactra

Coordinated Care

Teagan is a 2 year old with Kabuki (Make-up) Syndrome

Had a Nissen and G-Tube placed in infancy for severe aspiration, oral aversion

Late last fall, she presented with seizures associated with hypoglycemia

Difficult IV access Sister, clown, cousin

Comprehensive

Pediatric Medical Home: Dr. Rinehart (HRC)

Pediatric Resident Team

Dr. Guillot Pediatric Nephrology

Dr. D’Amico Pediatric Gastroenterology

Dr. Kacer Endocrinology

Dr. Burke Pediatric Genetics

Dr. Modlinsky AnesthesiaDr. Mingin Pediatric

UrologyDr. Hubble Pediatric ENTDr. Sartorelli Pedi

SurgeryDr. Hastings Pediatric

OpthalmologyDr. Bingham Pediatric

NeurologyDr. Soll Neonatology

Coordinated Care

PICC placed by anesthesia

Dr. Mingin renal calculi surgery

Labs coordinated by genetics, endocrine, GI, me (some first a.m., fasting, hypoglycemic,etc.)

Evidence for Medical Home

Comprehensive care for high-risk infants resulted in more outpatient visits, but fewer life-threatening illnesses, PICU admissions and PICU days

Broyles RS, Tyson JEH, Heyne ET, et al. “Comprehensive follow-up care and life-threatening illnesses among high-risk infants: a randomized controlled trial,” JAMA. 2000;284 (16):2070 –2076

Evidence for Medical Home

For children with Asthma a decreased continuity of care is shown to increase hospitalizations

Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;107 (3):524 –529

Comprehensive

Review of evidence base for medical home model found that 28 of 33 articles reported benefits of medical home over a range of outcomes

Homer CJ, Klatka K, Romm D, et al. “A review of the evidence for the medical home for children with special health care needs.” Pediatrics. 2008;122 (4)

Care Coordination

A plan of care developed by the physician, CSHN, and family

A central record with pertinent medical information kept in the primary care office

When CSHN is referred for a consultation, the medical home assists the CSHN and family in communicating clinical issues

The medical home evaluates and interprets the consultant’s recommendations for the CSHN and the family

The care plan is coordinated with other community agencies

Documentation

Our “Medical Home Care Plan”

“Family Snap Shot,” “Team members,”“Strengths,” as well as “Problem List,” “Medications”

Tools for Change: Care Plans

Medical Home Care Plan

␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣

␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣␣␣␣␣␣␣

␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣

␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ ␣␣␣␣␣␣␣␣␣␣

Documentation

EHR templates match Bright Futures’ visitsEvidence based templates for standard of

care for chronic conditions (Asthma, ADHD, Depression)

Pre-Visit Questionaires (see Packet for Change for BF questionaire)

Documentation

Family eco-map as a tool for families with children with special needs Helps identify gaps in services Begin to see community based patterns

FAMILYFAMILY

MEDICALHOMEPRIMARY DOCTOR

CARE COORDINATOR

On-Going Care TeamSocial WorkerOT/PT/SLP TherapistsDaycare Staff & Aide

SupportFamily,

Friends, Groups, Advocacy

RespiteMedicaid ArisFIT

CSHNClinicsFundingEquipment

FundingInsurersMedicaidFITCSHN

SpecialistsNeurosurgeryNeurologyPhysiatristEndocrinology

Our Medical Home Post Diagnosis 1:35 pm 2/15/01

Eco-Map: Community Links

Know your community and its common health concerns

Parent to Parent Support Networks (Family Voices, Vermont Family Network)

Care Coordination

The medical home evaluates and interprets the consultant’s recommendations for the CYSHCN and the family

The care plan is coordinated with other community agencies

CSHN Registry at HRC

Method of “flagging” a child as needing care coordination Indicates “more time needed:” consult MD before

scheduling acute visit, or have scheduler find time spot for preventative visit

We initially had levels based on types and number of medical and or psychosocial needs, contacts per week/month, complexity of disease -medical and psychosocial

See Change Package-examples of registries and levels of care coordination

Comprehensive

Having a medical home is associated with increased ease of use of community services by families

Baruffi G, Miyashiro L, Prince CB, Heu P. Factors associated with ease of using community-based systems of care for CSHCN in Hawaii. Matern Child Health J. 2005;9 (suppl 2):S99

Comprehensive

2 brothers live with their dad and paternal Grandma in Burlington

Scotty is 6, has CPSam is 7 has AutismChief Complaint: TruancyScotty unable to get a

power chair because home is not accessible

Accessible “units” not possible due to Sam’s sleep dysfunction

Coordinated

Care Conferences: Kidsafe Collaborative, Burlington Housing Authority, Howard Center, Bridge Program, Burlington School district, Shelburne School District, psychologist, CSHN social worker, school nurses, PT, OT, SLP

Compassionate

BHA found a house in Shelburne, needed indoor modifications and a ramp

Generous donor--donated supplies, laborFamily moved in AprilNegotiated with town Historical

Preservation Society Ramp built in August, 2011Power chair due September

Take Home Ideas

Eco-maps for familiesEco-map for communityBright Futures VisitsMedical Home Care PlansPractice based CSHN RegistryCare Coordination: create a system

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Thank You to Our Parent Partners

Carolyn Brennan Kimberly CooksonSandy JuliusScott MetevierPeggy Mann Rinehart Theresa SoaresKate & Michael Stein

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Resources

Antonelli RC, Stille CJ,Care , Antonelli DM, “Coordination

for CYSHCN: A descriptive Multisite Study of Activities, Personnel Costs, and Outcomes,” Pediatrics, July 2008

Baruffi G, Miyashiro L, Prince CB, Heu P. “Factors associated with ease of using community-based systems of care for CSHCN in Hawaii,” Maternal Child Health J, 2005

Broyles RS, Tyson JEH, Heyne ET, et al. “Comprehensive follow-up care and life-threatening illnesses among high-risk infants: a randomized controlled trial,” JAMA. 2000

Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001

Cooley C, McAllister J, “CMHI National Outcomes Study Cost/Utilization,” Pediatrics, July 2009

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Resources

Christakis D, Mell L, Koepsell TD, Zimmerman FJ, Connell RA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001

Hagan, J.F, Duncan, P., Shaw, J., Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, p.4

Homer CJ, Klatka K, Romm D, et al. “A review of the evidence for the medical home for children with special health care needs.” Pediatrics. 2008

MCHB/NCHS. National Survey of Children with Special Health Care Needs, 2002

National Center for Medical Home Implementation “Building Your Medical Home Toolkit,” website:http://www.pediatricmedhome.org/

Strickland, et.al.,“New Findings from the 2005-2006 NS-CSHN,” Pediatrics, June 26, 2009

Questions?