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Bringing the Medical Home…Home:A State Specific Model
March 3, 2005
Carol Dorros, MD
Margo Chiappinelli, AuD
First Connections Training and Resource Project for Newborn Hearing Screening
A RI Department of Education and RI Department of Health Collaboration. Supported in Act, Health Resource and Services Administration, Department of Health and Human Services part by project 1 H61 MC 00009 from the Maternal and Child Health program (Title V, Social Security Project funds managed by The Hearing Rehabilitation Foundation.)
Acknowledgements and Thanks
Ellen Kurtzer-White, Au.D.* Project Director, First Connections
Marianne Ahlgren, Ph.D, CCC-A Project Coordinator, First Connections
Mary Catherine Hess, MAAdministrator, RIHAP
Betty Vohr, MDMedical Director, RIHAP
American Academy of Pediatrics * deceased
Presentation Objectives
• Present Rhode Island’s newly developed algorithm for medical home providers
• Present the process of its development
• Discuss gaps identified and opportunities/solutions for strengthening our EHDI system
Background
Literature and the RI experience indicate that the EHDI system needs refinement to better respond to significant issues for families:
The emotional response to diagnosis Availability and access to expert services Increased stress and delays in services
when system is fragmented
Background
• AAP recommends a Medical Home for all children with special health care needs. (AAP position statement RE9902, 1999)
• A medical home is defined as an approach to providing health care services where care is:
- accessible- family-centered- continuous- comprehensive
- coordinated- compassionate- culturally competent
Background
Joint Commission on Infant Hearing recommends a Medical Home for all children with hearing loss.(AAP position statement, SO 60016, 2002)
“Pediatricians and other primary care providers, working in partnership with parents and other health-care professionals, make up the infant’s “medical home.”
RI Medical Home Task Force for Children with Hearing Loss
Goals:
• Identify strengths and barriers in the RI EHDI system
• Refine the system into one that is better informed, competent and linked.
• Develop a medical home model specifically for RI’s infants with hearing loss.
Task Force Development
• Multidisciplinary team of stakeholders
• Met monthly
• Total of approximately 2 years
Initial 1 ½ years examining current system
-Identifying system strengths/barriers
-Defining roles of professionals involved
Algorithm development took 8 months
Task Force Participants
• Audiologists (community and hospital based)• Members of the Deaf Community• Early Intervention Administrators • Family Guidance Providers • Otolaryngologist• Parents• Pediatricians ( PCPs and hospital based)• Rhode Island Hearing Assessment Program Admin.• Rhode Island Dept. of Health Admin.
Working Towards a Solution…
A State Specific Algorithm
Algorithm Goals
Specifically designed for RI PCPs in order to enhance the effectiveness of the medical home and provide a more seamless experience for families.
Physicians requested: One page document Defining flow of the RI EHDI system Defining roles/responsibilities of partners Local resource names and phone numbers
Algorithm Development
• Stakeholders met monthly for a period of about 8 months
• Revised the AAP/NCHAM algorithm to reflect the specific process and resources in RI
• Systematically discussed all language, information
and process for inclusion, exclusion or modification
• Decisions all made by a consensus model
Birth
BirthScreen
RIHAP*(401-277-3700)
Identify a Medical Home for every infant
PCP InformedPhone family to encourage themto follow through with rescreen
Pass
MissedIncomplete
Did Not PassRIHAP contacts family
and schedulesa rescreen
3
Hospital-based Inpatient Screening(OAE/AABR)
Results sent to PCP
At least 2 screeningattempts recommendedprior to discharge
Gap: Unclear language within algorithm
Solutions:
Clarified that screening “results are sent to PCP” rather than the “medical home”
Changed “Refer” to “Did not Pass”to clarify meaning to target audience
A t le a s t 2 s c re e n inga tte m p ts re c o m m e n d e dp rio r to d is ch a rge
H ospital-based Inpatient S creening(O A E /A A B R )
R e s u lts s e n t to P C P
MissedIncomplete
Did Not PassRIHAP contacts family
and schedulesa rescreen
Pass
Gap: Responsibilities/Roles unclear
Solutions:
• Added header line with partners responsible for each stage of process
• For infants who do not pass the initial screen, the algorithm identifies who makes referral for re-screen
RIHAP contacts family and schedulesa re-screen.
• To support the medical home, developed PCP action point
Phone family to encourage them to follow through with re-screen.
Ongoing Care of All Infants
Ongoing Care of All Infants
Provides opportunity to remind PCPs about:
• Elements of comprehensive care related to hearing, vision, speech, language and overall development
• Monitoring for hearing loss that may occur out of the newborn period
• Risk indicators for late-onset hearing loss that require referral for audiologic monitoring
Before 1 Month
Birth
A t le a s t 2 s c re e n inga tte m p ts re c o m m e n d e dp rio r to d is ch a rge
H os pita l-ba sed Inpatient S cree ning( O A E /A A B R )
R es u lts s ent to P C P
Screen RIHAP*(401-277-3700)
Identify a Medical Home for every infant
Before 1 MonthRe-screen
RIHAP
Outpatient Screening
(OAE/AABR*)
Results sent to PCP
PCP Informed
Phone family to encourage themTo follow through with rescreen
Pass
Did not passRIHAP recommendsdiagnostic testing
Home births
Pass
MissedIncomplete
Did Not PassRIHAP contacts family
and schedulesa rescreen
PCP Informed
Phone family to identify an audiologist and support need for
follow-through
Gap: Unclear roles/responsibilities
Solutions:• For infants who do not pass the re-
screen, the algorithm identifies who is responsible for next step RIHAP recommends diagnostic testing
• Added a PCP action point to support the medical home
PCP phones family to identify anAudiologist and support the need for follow-through
Before 3 Months
Before 3 Months Referred for Diagnostics Follow-up Every child with suspected hearing loss Every child identified with a permanent hearing loss
Pediatric Audiologic Evaluation
RIHAP can be contacted for a list of Pediatric Audiologists, 401-277-3700, Fax 401-276-7813
Otoscopic inspection
Child & family history
Middle ear function
OAE*
ABR*
Frequency-specific tone bursts
Air & bone conduction
Audiologist counsels parents about results and recommendations
NormalHearing
HearingLoss
PCP sets up an appointment with family to review the results, intervention
benefits, and follow-up.
Audiologist reports diagnosis to RIHAP (401-277-3700)
Audiologist refers for early intervention and family support:Specific Early Intervention Program ***Family Guidance Program (401-222-4013) PCP initiates medical evaluation
PCP refers to otolaryngologistFor evaluation, to recommend treatment, and to provide clearance for amplification
Partners in Care inform family(Audiologist, ENT, Family Guidance Program, others)about communication, amplification and cochlear implants
Community Audiologist Hearing Loss Professionals and Organizations
Results to PCP
Results Sent to PCPSupport follow-up, with Audiology, EI, and Family Guidance Program.
Pediatric Audiologic Evaluation
Audiologist counsels parents about results and recommendations
HearingLoss
PCP sets up an appointment with family to review the results, intervention
benefits, and follow-up.
Results to PCP
Diagnosis: Hearing LossGap: Lack of family-centered communication
Solution:
• Address emotional distress of family
• Emphasize hope, not necessarily technical information
• Allow the family to indicate how much information they can take in at the time of diagnosis
• Recognize that the family may need time to process information.
Family-centered communication between audiologists & families promotes a more satisfying and successful interaction
Pediatric Audiologic Evaluation
Audiologist counsels parents about results and recommendations
HearingLoss
PCP sets up an appointment with family to review the results, intervention
benefits, and follow-up.
Results to PCP
Diagnosis: Hearing LossGap: Meaningful Communication from Audiologist to PCPReports from the audiologist to the PCP about diagnostic results provide an opportunity for team building and decreased fragmentation of care
Solution:
Communication to PCP should:
• Describe the degree, type of HL & implications for social and academic development
• Use non-technical language
• Specify interventions and services needed
What audiologist has done What PCP needs to do
Diagnosis: Hearing LossGap: Unclear roles/ responsibility for PCP
Solution:
PCP Action Point
• PCP needs to be informed of plans and issues
• Allows PCP to support family & assist in facilitating follow-up
Pediatric Audiologic Evaluation
Audiologist counsels parents about results and recommendations
HearingLoss
PCP sets up an appointment with family to review the results, intervention
benefits, and follow-up.
Results to PCP
Before 3 Months Referred for Diagnostics Follow-up Every child with suspected hearing loss Every child identified with a permanent hearing loss
Pediatric Audiologic Evaluation
RIHAP can be contacted for a list of Pediatric Audiologists, 401-277-3700, Fax 401-276-7813
Otoscopic inspection
Child & family history
Middle ear function
OAE*
ABR*
Frequency-specific tone bursts
Air & bone conduction
Audiologist counsels parents about results and recommendations
NormalHearing
HearingLoss
PCP sets up an appointment with family to review the results, intervention
benefits, and follow-up.
Audiologist reports diagnosis to RIHAP (401-277-3700)
Audiologist refers for early intervention and family support:Specific Early Intervention Program ***Family Guidance Program (401-222-4013) PCP initiates medical evaluation
PCP refers to otolaryngologistFor evaluation, to recommend treatment, and to provide clearance for amplification
Partners in Care inform family(Audiologist, ENT, Family Guidance Program, others)about communication, amplification and cochlear implants
Community Audiologist Hearing Loss Professionals and Organizations
Results to PCP
Results Sent to PCPSupport follow-up, with Audiology, EI, and Family Guidance Program.
Follow-up: Permanent HLGap: Unclear roles and responsibilities
Solutions:
• Identified responsible parties (titles and phone numbers) and expected actions
• Changed “advise family” to “Partners in care inform family”
• Developed PCP action point
Audiologist reports diagnosis to RIHAP (401-277-3700)
Audiologist refers for early intervention and family support:Specific Early Intervention Program ***Family Guidance Program (401-222-4013) PCP initiates medical evaluation
PCP refers to otolaryngologistFor evaluation, to recommend treatment, and to provide clearance for amplification
Partners in Care inform family(Audiologist, ENT, Family Guidance Program, others)about communication, amplification and cochlear implants
Results Sent to PCPSupport follow-up, with Audiology, EI, and Family Guidance Program.
Follow-up: Permanent HLGap: Lack of communication among partners
Solution:
PCP Action Point
• Only if PCP informed, can he/she support the family in their journey
• Ongoing communication among partners in care maximizes the opportunity to create the most effective MH
Audiologist reports diagnosis to RIHAP
Audiologist refers for early intervention and family support: PCP initiates medical evaluation
PCP refers to otolaryngologist
Partners in Care inform family
Results Sent to PCP
Support follow-up with Audiology, Early
Intervention,and Family Guidance Program
Before 6 Months
Before 6 MonthsContinued Follow-up
Every child identified with a permanent hearing loss
Audiologists/Early Intervention Programs/ Medical Specialists
Continued enrollment in Early Intervention and Family Guidance Program
Provide services until transition to school system at 3 years of age
Medical Evaluations
To determine etiology and identify related conditions
Genetic
Ophthalmologic (annually)
Developmental pediatrics, neurology, cardiology, and nephrology (as needed)
Pediatric Audiological Services
Hearing Aid fitting and Monitoring
Behavioral Audiometry (starting at age 6 months)
Ongoing monitoring
RI AlgorithmHow are we using it?
• Distributed to all RI PCPs and partners in care
• To be included with all results sent to PCPs regarding:
– Initial screen “Did Not Pass”
– Infants identified at at birth with risk factors for late onset HL
• Educational programs for partners in care
• A phone survey through RIHAP will be ongoing to document questions or comments regarding the algorithm
Conclusions
Developing a state specific algorithm is a very worthwhile exercise
The process facilitates communication among partners in care
Provides a succinct illustration of state specific EHDI system flow
Defines roles of partners in the medical home
Identifies gaps in the system
Identifies opportunities for improvement
Special ThanksFirst Connections Training and
Resource Project:Project DirectorEllen Kurtzer-White, AuDProject CoordinatorMarianne Ahlgren, PhD, CCC-APrincipal InvestigatorPeter Simon, MD, MPH
Other Medical Home for Hearing Loss in Children Task Force Members:
Robert Burke, MD, MPHMemorial Hospital of RI
Brian Duff, MDUniversity Otolaryngology
Deborah Garneau, MAOffice of Families Raising Children with Special Needs
Ellen Gurney, MD
Providence Community Health Centers
Mary Catherine Hess, MA
RI Hearing Assessment Program
Kerri Hicks
Parent
Mary Jane Johnson, MEd
Family Guidance Program
Jennifer LeComte, MA
Family Guidance Program
Deborah Lyons, MS, CCC-A
RI Hospital Dept of Audiology
Cheryl McDermott, MS, CCC-A
RI Hearing Assessment Program
Courtney O’Neill, MS, CCC-A
RI Hearing Assessment Program
Betty Vohr, MD
RI Hearing Assessment Program