Newport CountyNewport CountyCommunity Access to Child Community Access to Child

HealthHealth(CATCH)(CATCH)

Creating Medical Homes Creating Medical Homes for all Children in Newport for all Children in Newport

County, RICounty, RI

Newport, Middletown, Portsmouth, Newport, Middletown, Portsmouth, Tiverton, Little Compton, JamestownTiverton, Little Compton, Jamestown

22

Beginning Ideas Beginning Ideas Newport County CATCH grew out of the Newport County CATCH grew out of the

commitment to child well-being* of the commitment to child well-being* of the Newport Partnership for Families Newport Partnership for Families (NPFF)(NPFF), an existing community , an existing community collaboration representing over 35 human collaboration representing over 35 human service agencies, businesses and other service agencies, businesses and other organizations in Newport organizations in Newport

* Child well-being is one of four priority * Child well-being is one of four priority areas measured by the NPPFareas measured by the NPPF

33

Initial StepsInitial Steps

Step 1Step 1: Received a planning grant based : Received a planning grant based on the NPFF’s identification of access on the NPFF’s identification of access barriers to healthcare for young children.barriers to healthcare for young children.

Step 2Step 2: Conducted outreach to the : Conducted outreach to the community to assess the quality of community to assess the quality of Medical Homes and training needs Medical Homes and training needs required to care for Children with Special required to care for Children with Special Health Care Needs (CSHCN)Health Care Needs (CSHCN)

44

Newport County Newport County CATCH Purpose:CATCH Purpose: The primary purpose of the Newport The primary purpose of the Newport

County CATCH/Medical Home County CATCH/Medical Home Initiative is to facilitate the creation Initiative is to facilitate the creation of medical homes for all children in of medical homes for all children in Newport County. Medical homes will Newport County. Medical homes will posses the seven common elements posses the seven common elements as defined by the American as defined by the American Academy of Pediatrics (AAP)Academy of Pediatrics (AAP)

55

Newport County CATCH Newport County CATCH Goals:Goals:1.1. Develop and implement a careDevelop and implement a care

coordination systemcoordination system to support the to support the medical homemedical home

2.2. Identify and Identify and reduce barriersreduce barriers to medical to medical homes.homes.

3.3. Provide Provide medical homemedical home trainingtraining to to parents, medical and human service parents, medical and human service providersproviders

4.4. EvaluateEvaluate the impact of our interventions the impact of our interventions5.5. Implement systems to Implement systems to sustainsustain and ensure and ensure

quality medical homes for all children.quality medical homes for all children.

66

Newport County Newport County CATCH Funding CATCH Funding Current funding for Newport Current funding for Newport

County CATCH is provided by:County CATCH is provided by:– Newport HospitalNewport Hospital– RI DOH, Division of Family HealthRI DOH, Division of Family Health

77

Newport CATCH Newport CATCH Organizational Organizational

StructureStructure

CATCH Steering Committee

James SattelNewport CATCH Coordinator

Medical Home TrainingWork Group

Care CoordinationWork Group

Barriers to Medical HomesWork Group

88

Function DescriptionFunction Description

GroupGroup FunctionFunction

SteeringSteering

CommitteeCommitteeProvides oversight and Provides oversight and feedback to the work group feedback to the work group action plans.action plans.

Work Work GroupsGroups

Form work group objectives Form work group objectives and strategies and provide and strategies and provide medical home training.medical home training.

ProjectProject

CoordinatoCoordinatorr

Supports the advisory Supports the advisory committee and work groups; committee and work groups; produces reports; and is a produces reports; and is a single point of contact for single point of contact for providers and familiesproviders and families

99

Newport County CATCHNewport County CATCHMedical Home Advisory Medical Home Advisory CommitteeCommittee CEDDARs CEDDARs Covering Kids and FamiliesCovering Kids and Families Early InterventionEarly Intervention East Bay Community Action Program (EBCAP)East Bay Community Action Program (EBCAP) Family Practice PhysiciansFamily Practice Physicians Head StartHead Start Health PlansHealth Plans Newport & Middletown Public Schools Family Newport & Middletown Public Schools Family

Center/COZCenter/COZ Newport Partnership for FamiliesNewport Partnership for Families Newport County Health AdvocatesNewport County Health Advocates

1010

Newport County CATCHNewport County CATCHMedical Home Advisory Medical Home Advisory CommitteeCommittee

Newport County Community Mental Health Center’s Newport County Community Mental Health Center’s Child Intensive Services (CIS) and Child and Adolescent Child Intensive Services (CIS) and Child and Adolescent Services Program (CASP)Services Program (CASP)

Newport HospitalNewport Hospital ParentsParents Pediatric Practice Enhancement Project (PPEP) Parent Pediatric Practice Enhancement Project (PPEP) Parent

Consultant (PC)Consultant (PC) PediatriciansPediatricians Rhode Island Department of HealthRhode Island Department of Health Rhode Island Health Center AssociationRhode Island Health Center Association Special Education DepartmentsSpecial Education Departments Visiting Nurse Service of Newport and Bristol CountiesVisiting Nurse Service of Newport and Bristol Counties

1111

Traditional Pediatric Delivery Traditional Pediatric Delivery SystemSystemFragmented, Hard to Navigate, Fragmented, Hard to Navigate, Episodic, ExpensiveEpisodic, Expensive

Recreation

Child Outreach

Special Education

Schools

Sub-specialists

Emergency Care

Early Intervention

Family

Pediatrician/Family Practitioner

Community SupportGroups/Resources

Mental HealthHealth Plans

Transportation

Family Services

Home Care

Rehab Services

1212

NHPRI

Head Start/Child Care

Special Education

Schools

Sub-specialists

Mental Health Services

Early Intervention

EBCAP

RIPIN/Family Voices

CEDDAR

Newport Hospital

FRCs/FSCs

Child Outreach

Home Care

Rehab Services

Medical Home-Physician

-Family(PPEP)

Parent ConsultantAquidneck Medical

Associates

Comprehensive/CoordinatedComprehensive/Coordinated Family - Centered Medical Family - Centered Medical HomeHome

1313

Physician Practice Physician Practice Training TeamTraining Team

Objectives:Objectives: To develop and offer To develop and offer current, meaningful, and current, meaningful, and community-focused medical home community-focused medical home trainings for pediatricians and trainings for pediatricians and family practitioners and their stafffamily practitioners and their staff

To establish a single point of To establish a single point of contact as a resource for quality contact as a resource for quality improvement (CATCH Coordinator)improvement (CATCH Coordinator)

1414

Physician PracticePhysician PracticeTraining TeamTraining Team

Action StepAction Step: Developed a curriculum which : Developed a curriculum which includesincludes– The history of Newport County CATCHThe history of Newport County CATCH– Community assessment methodology and Community assessment methodology and

findingsfindings– Common elements of a medical homeCommon elements of a medical home– Cost benefits of operating a medical home, Cost benefits of operating a medical home,

particularly for utilizing care coordination particularly for utilizing care coordination servicesservices

– Codes for extended careCodes for extended care– Medical Home indicators (for self-evaluation)Medical Home indicators (for self-evaluation)– Strategies for medical home improvementStrategies for medical home improvement

1515

Community Agencies Community Agencies Training TeamTraining Team Objective 1Objective 1: Share care : Share care

coordination information with the coordination information with the community through medical community through medical home trainings, single point of home trainings, single point of contact and through the contact and through the development of a medical homedevelopment of a medical home

1616

Community Agencies Community Agencies Training TeamTraining Team Action StepAction Step: Provided medical home : Provided medical home

training to approximately forty five training to approximately forty five health care coordinators* at agencies health care coordinators* at agencies throughout Newport County.throughout Newport County.

* Agency care coordinators include * Agency care coordinators include

family service coordinators, mental family service coordinators, mental health workers, nurse/educators, health health workers, nurse/educators, health advocates, case managers, social advocates, case managers, social workers, physicians and practice staff workers, physicians and practice staff (any provider that links families to (any provider that links families to community services)community services)

1717

Community Agencies Community Agencies Training TeamTraining Team Objective 2Objective 2: Identify and document all : Identify and document all

sources of care coordination support sources of care coordination support

Such as PPEP, CEDARR , East Bay Community Action Such as PPEP, CEDARR , East Bay Community Action Program, Child and Family Services, Newport County Program, Child and Family Services, Newport County Mental Health Center, NHPRI Case Management, Mental Health Center, NHPRI Case Management, Housing Authority, Family Service Coordinators, COZ Housing Authority, Family Service Coordinators, COZ Centers, Visiting Nurse Service of Newport and Bristol Centers, Visiting Nurse Service of Newport and Bristol Counties, Head Start, Early Intervention, Newport and Counties, Head Start, Early Intervention, Newport and Regional Special Education, Dr. Martin Luther King Jr. Regional Special Education, Dr. Martin Luther King Jr. Center, CODACCenter, CODAC

1818

Community Agencies Community Agencies Training TeamTraining Team Action StepAction Step: Developed a comprehensive : Developed a comprehensive

list of agencies that provide care list of agencies that provide care coordination by disseminating a care coordination by disseminating a care coordination services surveycoordination services survey . .– Based on returned surveys, developed a Based on returned surveys, developed a

Pediatric Care Coordination Directory that Pediatric Care Coordination Directory that defines the scope of care coordination defines the scope of care coordination provided by each agency (40 Agencies provided by each agency (40 Agencies Represented)Represented)

– Distributed over 120 Directories to Distributed over 120 Directories to agencies and physician practices as part agencies and physician practices as part of Medical Home Trainingsof Medical Home Trainings

1919

Community Agencies Community Agencies Training TeamTraining Team Objective 3Objective 3: Assist in orienting : Assist in orienting

PC’s to community care PC’s to community care coordination services and through coordination services and through the PPEP provides Newport the PPEP provides Newport County CATCH with feedback County CATCH with feedback about gaps or delays in service about gaps or delays in service delivery delivery

2020

Family Training TeamFamily Training Team

Action Step 1Action Step 1: Developed a : Developed a family questionnaire to capture family questionnaire to capture current and specific problems current and specific problems regarding barriers to medical regarding barriers to medical homes and to define the homes and to define the educational needs of the families. educational needs of the families.

2121

Family Training TeamFamily Training Team Action Step 2Action Step 2: Provided medical home : Provided medical home

education for families through focus groups.education for families through focus groups.– Educated over 400 parents on medical home Educated over 400 parents on medical home

concepts during focus groups.concepts during focus groups.– The 400 parents represented parents served by The 400 parents represented parents served by

support groups, Head Start, Even Start, the support groups, Head Start, Even Start, the Newport Hospital Birthing Center, mental health Newport Hospital Birthing Center, mental health parent groups, and the Newport County Regional parent groups, and the Newport County Regional Special Education Advisory Committee, etc.Special Education Advisory Committee, etc.

– Families are instructed on how to advocate for Families are instructed on how to advocate for their child and how to make maximum benefit of their child and how to make maximum benefit of the visit to the medical homethe visit to the medical home

2222

Barriers WorkgroupBarriers Workgroup

Objective: Objective: Identify and Identify and address address barriers to use barriers to use of medical of medical homes, homes, including:including:

1.1. TransportationTransportation

2.2. LanguageLanguage

3.3. Health InsuranceHealth Insurance

Jim's Email.lnk

2323

Barriers WorkgroupBarriers Workgroup Survey findings on Survey findings on

transportationtransportation: : – No bus service on Memorial Blvd. No bus service on Memorial Blvd.

which is the location of the largest which is the location of the largest pediatric practice in Newport Countypediatric practice in Newport County

– Confusion over RIte Care Confusion over RIte Care transportation benefits.transportation benefits.

– Bus routes are unclear. Bus routes are unclear.

2424

Barriers WorkgroupBarriers Workgroup

Transportation Actions TakenTransportation Actions Taken::– Partnered with RIPTA to create a Partnered with RIPTA to create a

medical home bus route map to be medical home bus route map to be distributed at the birthing center, distributed at the birthing center, physicians offices, and to parents in physicians offices, and to parents in medical trainings.medical trainings.

– DHS provided CATCH with an DHS provided CATCH with an explanation of transportation benefits explanation of transportation benefits which will be distributed to parents and which will be distributed to parents and providers.providers.

2525

Barriers WorkgroupBarriers Workgroup

Survey findings on language & Survey findings on language & cultureculture::– Parents don’t understand medical Parents don’t understand medical

jargon.jargon.– Lack of written bilingual information.Lack of written bilingual information.– Parents find it difficult to tell the doctor Parents find it difficult to tell the doctor

they don’t understand their instructions.they don’t understand their instructions.– Cultural sensitivity is lost if a different Cultural sensitivity is lost if a different

doctor is seen at each visit.doctor is seen at each visit.

2626

Barriers WorkgroupBarriers Workgroup

Language recommendations made:Language recommendations made:– Raise awareness of RIte Care interpretation/ Raise awareness of RIte Care interpretation/

translation benefits.translation benefits.– Create flyers in multiple languages describing Create flyers in multiple languages describing

the above benefit to distribute to parents at the above benefit to distribute to parents at medical home trainings.medical home trainings.

– Encourage physicians to assess their practice’s Encourage physicians to assess their practice’s need for interpreters. need for interpreters.

– Ask physicians what bi-lingual information Ask physicians what bi-lingual information would be useful for the practice and help them would be useful for the practice and help them get it.get it.

2727

Barriers Work GroupBarriers Work Group

Health InsuranceHealth Insurance Identify locations where families present Identify locations where families present

without insurance i.e. Newport without insurance i.e. Newport Department of Labor and Training, Department of Labor and Training, Housing Authority Intake Offices, Urgent Housing Authority Intake Offices, Urgent Care Facilities, E.R. etc. Care Facilities, E.R. etc.

Collaborate with Covering Kids to Collaborate with Covering Kids to provide community education provide community education concerning RIte Care/RIte Share concerning RIte Care/RIte Share benefits, eligibility guidelines and benefits, eligibility guidelines and enrollment proceduresenrollment procedures

2828

Newport County CATCHNewport County CATCH Overall Lessons LearnedOverall Lessons Learned::1.1. Simplify medical home jargon. Make it RelevantSimplify medical home jargon. Make it Relevant2.2. One-on-one visits with organizations work best. Use One-on-one visits with organizations work best. Use

visits to learn of services that are or are not available visits to learn of services that are or are not available in the communityin the community

3.3. Plug into existing community organization networks, Plug into existing community organization networks, develop collaborationsdevelop collaborations

4.4. Help stakeholders understand how they benefit from Help stakeholders understand how they benefit from medical homes.medical homes.

5.5. Tailor medical home trainings to your audience ie Tailor medical home trainings to your audience ie families, human service agencies, PCP’sfamilies, human service agencies, PCP’s

6.6. Family input is critical in the development of Family input is critical in the development of curriculums and training strategies curriculums and training strategies

2929

Future InitiativesFuture Initiatives

Collaborate with the PPEP to define access Collaborate with the PPEP to define access barriers and capacity issues & continue barriers and capacity issues & continue collaborative problem solving with providers collaborative problem solving with providers and familiesand families

Collaborate with the RI Lung Association, Collaborate with the RI Lung Association,

Hasbro Children's Hospital and Newport Hasbro Children's Hospital and Newport Hospital to implement community needs Hospital to implement community needs assessment and training for asthmaassessment and training for asthma

Develop Neighborhood Training Teams in Develop Neighborhood Training Teams in collaboration with the Newport Housing collaboration with the Newport Housing AuthorityAuthority

3030

Future InitiativesFuture Initiatives Provide medical home training to school educators, FSC(s) Provide medical home training to school educators, FSC(s)

and health advocates as part of the Train the Trainer and health advocates as part of the Train the Trainer InitiativeInitiative

Collaborate with mental health and special education Collaborate with mental health and special education services to integrate care into the medical Homeservices to integrate care into the medical Home

Develop a Newport County Medical Home web-site for Develop a Newport County Medical Home web-site for families and providersfamilies and providers

Maintain and build upon established medical home services Maintain and build upon established medical home services and productsand products

Obtain funding to sustain Newport County CATCH/Medical Obtain funding to sustain Newport County CATCH/Medical Home InitiativeHome Initiative

3131

Newport County Newport County CATCHCATCH

For more information contact: For more information contact:

James SattelJames SattelNewport County CATCH /Medical Home Initiative Newport County CATCH /Medical Home Initiative

CoordinatorCoordinator

435 Broadway435 BroadwayNewport, RI. 02840Newport, RI. 02840

(401) 847‑2100; ext 223(401) 847‑2100; ext 223

jsattel@ebcap.orgjsattel@ebcap.org

3232

Newport County Newport County CATCHCATCH Question and Answer TimeQuestion and Answer Time