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Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation The Role of the Medical Home in Care of Children with Complex Chronic Conditions Dennis Z. Kuo, MD, MHS, FAAP UAMS / Arkansas Children’s Hospital Jane Sneed, MD, FAAP The Children’s Clinic, Jonesboro, AR June 2, 2011
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Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Dec 25, 2015

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Page 1: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Partnering with Patients and Families

in the Medical Home

2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation

The Role of the Medical Home in Care of Children with Complex Chronic

Conditions

Dennis Z. Kuo, MD, MHS, FAAPUAMS / Arkansas Children’s Hospital

Jane Sneed, MD, FAAPThe Children’s Clinic, Jonesboro, AR

June 2, 2011

Page 2: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Disclosures

Neither Dr. Kuo or Dr. Sneed have any relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

We do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation.

Page 3: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Looking Back…

The first and second webinars of this series:

History of medical home modelHealth care teams, family/professional partnerships, Bright Futures, quality improvementCare management of chronic condition (asthma)

Page 4: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Webinar Objectives

By the end of this webinar, the participant will be able to:

Illustrate the importance of building and maintaining multi-specialty teams in the provision of care for children and youth with complex chronic conditions Explore strategies for enhancing complex co-management working partnerships between specialty and primary care clinicians Explain how to effectively work with clinical teams and patients/families for successful and appropriate care transition planning from pediatric to adult care

Page 5: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Alex (name is changed)

Alex is a 3 month old child you have seen since birth. In the nursery, you noticed dysmorphic facies, low tone, undescended testes, and a heart murmur. He developed heart failure shortly after and required surgery to repair a large VSD.

Today, you suspect craniosynostosis on exam. He is developmentally delayed and small for age.

Page 6: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Alex’s needs

What specialists does he need? Cardiology, neurosurgery, urology, GI, genetics when older: ENT, developmental, neurology

What therapists does he need? Speech, swallowing, OT, PT, developmental

What is the role of his primary care provider? Checkups? Nutrition? Care coordination? Immunizations?

What is the role of his family? Should this have gone at the top of the list?

Page 7: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Complex Chronic Conditions

“Medically fragile” or “Medical Complexity”Usually described by:

Multiple subspecialists Technology dependence for basic health needs Frequent visits to tertiary care centers

High prevalence of neurodevelopmental disabilities and genetic disorders

Srivastava 2005; Cohen 2011, Pediatrics

Page 8: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Why consider these children separately?

Highest risk for adverse outcomes Medical, growth, developmental, social Tend to “fall through the cracks”

Most challengingMost satisfying?

The role of the Medical Home (on steroids?)

Page 9: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Bending the cost curve

Medicaid projected growth rate: 8.8% - higher than Medicare or national health spending Bend the curve: slowing the rate of increase

A small number of children are responsible for a majority of health care costs Medicaid: 10% of children = 72% of costs 0.4-1% of children = 12-15% of total costs, 20-25% of

hospitalized patients, and 45-50% of hospital days

Shortell (2009), JAMA; Kenney (2009), Health Affairs; Neff (2004); Berry (2011) unpublished, by permission

Page 10: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

The high resource utilizers

The vast majority of the high resource utilizers have “complex” and “chronic” conditions Children who “fall through the cracks” Majority of costs are inpatient

Need to coordinate care and improve quality Integrated, organized systems Fundamental payment reform

Neff (2004); Fisher (2009) NEJM; Berry (2011), J Peds; Cohen (2011)

Page 11: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Building and maintaining multi-specialty teams for children with complex chronic

conditions

Consider: The components of care How the components work together The role of the Medical Home

How the Medical Home can initiate and lead co-management

Page 12: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Care components

Perrin et al. (2007) Arch Pediatr Adoles Med

Page 13: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

The world that Alex’s parents see

Ray (1997, 2002)

Page 14: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

The Chronic Care Model

From Wagner EH. Figure from Antonelli R (2005). Adapted from Bodenheimer (2002)

Page 15: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Chronic Care Model components

Care partnership supportDelivery system designDecision supportClinical information systems

Page 16: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

When comprehensive care works

48% decrease in the number of hospital days and a $10.7 million decrease in payments to the tertiary care center Gordon JB Pediatr Adol Med 2007

55% reduction in ED visits Klitzner TS J pediatr 2010

40% reduction in inpatient costs, 27% decrease in hospital stays Casey PH Arch Pediatr Adolesc Med 2011

Courtesy of D. Bergman

Page 17: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Putting it all together: Co-management

Multiple health care professionals partner with families to provide a consistent direction of care

For children with complex chronic conditions: Integrates all components of care Reinforces the active role of the

PCP/Medical Home

Stille (2009)

Page 18: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Partners

Specialty care = straightforward Does not address all needs

Primary care = first point of access, immunizations, continuity Primary care sometimes not fulfilled when

child has multiple visits to specialty services Assumption that needs are being met

Community-based services Not always consistent

Families!Haggerty (2011). Academic Pediatrics

Page 19: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Primary care “Medical Home” as hub of coordination partnership

PCP Family

Specialist

Specialist

Specialist

Medical Home “functions”: explainer, interpreter, advisor, coordinator

PCP= the child’s Primary Care PRACTICE(not just one provider)

Slide courtesy of Chris Stille, MD

Page 20: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Spectrum of co-management

PCP as primary manager, specialist as consultant Less complex, few specialty needs

Specialist as primary manager, PCP less involved Appropriate for high complexity and if comprehensive

service exists at tertiary care centerCo-management

Medical Home has higher responsibility Medical Home acts as care coordinator Some children with complex chronic conditions have no

subspecialty “home”

Hack, Pediatric Annals 1997; Antonelli, 2005; adopted from C. Stille (2009)

Page 21: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Making co-management work

Define your roles Primary care physician has higher

responsibility Specialty provider provides decision

making support

Primary care physician can learn to care for higher complexity over time

Most PCPs welcome co-managementDon’t forget families!

Antonelli (2005); Kuo (2007); Kisker (1997)

Page 22: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Take the initiative

Recognize the components of comprehensive care that only PCP can deliver

PCP determines the additional level of involvement, due to varying experience PCP can provide improved access, continuity, and care

coordination for children and families Higher level of co-management likely improves care

outcomes due to improved accessInitiate communication with specialty colleagues

Determine your roles and be specific for what you needComfort will increase over time

Page 23: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Care partnership: Family-Centered Care

Essential, yet frequently misunderstood

Associated with more efficient use of health care resources for CYSHCN

Principles: Partnership approach to care Respect for diversity Information sharing is open and unbiased Care plans may be negotiated

Kuo (2011) MCHJ; Kuhlthau (2011) Acad Pediatr

Page 24: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Delivery System Design: Define Roles

Medical Home: ALWAYS good primary care First point of contact Anticipatory guidance Immunizations Care hub / care coordination Verify/Initiate Early Intervention

Act as “eyes and ears” for specialty teams Remind families that you can be first point of

contact

Page 25: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Additional roles

With good communication with specialty colleagues, may consider: Labs Medication initiation / adjustment Referrals to community services

Consider designating office staff (such as nurse) to be single point of contact Additional roles for office staff

Help families define their roles Foster children/families likely require extra attention

Kuo (2007). Pediatrics

Page 26: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Decision making support

Clinical care guidelines (e.g. AAP)Be familiar with common issues of

condition(s) High prevalence of neurodevelopmental

disabilities Recognize that many children have

feeding/growth issues, dysphagia, respiratory issues

Learn from specialty colleagues Regular communication; they will teach

you Eyes and ears / red flags

Page 27: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Define communication lines

Keep updated and continuous care plan Consider separate forms and someone to maintain

Methods of communication Email? Fax? Phone call? What will be communicated? – ask specialists Timing and frequency of communication Health care portals

If all else fails, encourage family to contact you and / or schedule regular follow-up visits

Page 28: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Clinical Information Systems

Track your children with special needs Particularly children with complex chronic conditions Quality of care measures

Utilize communication lines, including email, fax, phone

Clinical decision making tools

Page 29: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Conclusions

Comprehensive care can improve health outcomes and reduce utilization

Medical Home must take the lead to develop comprehensive care for children with complex and chronic health conditions

Co-management increases PCP involvement and can lead to improved outcomes

Page 30: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

Thank you!

Questions?

Page 31: Partnering with Patients and Families in the Medical Home 2011 CME Webinar Series brought to you by the National Center for Medical Home Implementation.

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