Medical Home Key Clinical Activity Session 2: Family Centered Care

Jill Rinehart, MD FAAPAssociate Clinical Professor PediatricsUniversity 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.

Our Medical Home Program Burlington, Vermont

Three pediatricians, Dr. Joseph Hagan, Dr. Jill Rinehart, Dr. Gregory Connolly

Two Pediatric Nurse Practitioners, Maryann Lisak & Tonya Wilkinson

One main RN Care Coordinator KristyOffice manager, Accounts manager, one office assistant,

four additional part-time nurses, three medical assistants~4000 Active Patient ListDr. H 1991, Dr. R 1999, Dr. C 2010 Insurance mix: 35% Mcaid, 60% Private,<5% uninsured

Family Centered Care: What?

Provides care that is “whole-person” oriented, consistent with unique needs and preferences of the families

Partners with patients and families to make treatment decisions

Has open communication between patients and care team, access to resources to help when communication is strained

Family Centered Care

Accessible 24/7 Accessible (universal design) After Hours coverage Admit to children’s hospital

Family Centered Care: Why?

“Increasing evidence that the care experience (which encompasses how health care practitioners communicate with patients and families and invite their active participation in clinical care) affects outcomes. The better the experience--relationship and communication with the provider--the better the outcome.”

Mackean, G.L., Thurston, W.E., Scott, C.M. (2005) Bridging the Divide between families and health professionals’ perspectives on family-centered care. Health Expectations, 8, 74-85

National Study-CSHN, 2005-6

Surveyed 40,840 ChildrenMeasured 5 core medical home components:

1) Having a usual source of care2) Having a personal doctor or nurse3) Receiving all needed referrals for specialty care4) Receiving help as needed in coordinating health-

related care5) Receiving family-centered care

“New Findings from the 2005-06 NS-CSHN,” Strickland, B.et.al.Pediatrics, June 26, 2009 Vol. 123

National Study-CSHN 2005-6

Good News:• 90% of CSHN and their peers had “usual source

of care” and a personal MD or nurseBUT only half of CSHN and peers had access to

medical home in all 5 aspects• As family income increases, access to medical

home increases• Access is affected by race/ethnicity, health

insurance status, severity of child’s condition

“New Findings from the 2005-2006 NS-CSHN,” B.Strickland, et.al.Pediatrics, June 26, 2009Vol. 123

Access to Medical Home

• Parents of CSHN who do have medical homes report less delayed or forgone care and significantly fewer unmet needs for health care and family support services

• But limited improvements since success rates first measured in 2001 NS-CSHN

“New Findings from the 2005-2006 NS-CSHN,” B.Strickland, et.al., Pediatrics, June 26, 2009 Vol. 123

Family Centered Care: How?

Interdisciplinary Teams Care Conferences Discharge Rounds at Vermont Children’s

Hospital Co-located Psychologist, psychiatry consultation

twice a month Pediatric Subspecialists are collaborating more

with one another (ENT, Pulmonary, GI)--> connecting to medical homes

Interdisciplinary

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

Family Centered Care

Coordinates across settings and services

Family-Centered

McKayla is a 12 year old with Nonketotic Hyperglycinemia

Developmental DelayChoreoathetosisSeizuresDysphagia (G-Tube)Friend, classmate,

daughter, niece

Compassionate

Admitted for aspiration pneumonia

Comprehensive

• Physician facilitates essentially all aspects of care

• Pediatric Resident communicates with neurometabolism program to adjust feedings/meds

• Family as experts: provides medication lists, dietary history, clinical expertise:“She’s herself again!”

Family Centered Care

Coordinates a patient’s health care access across care settings and services, over time, in consultation and collaboration with patient and family understand the families’ strengths identify gaps in services

What the Julius Medical Home Was at HRC

Incredible reputationAmazing Physicians24/7 CoverageNurses that were

lactation specialistsIntegrated approach and

interest in Matt’s whole life

Our Medical Home Until 1:30pm 2/15/01

SupportFamily &

Friends

FAMILYFAMILY

MEDICALHOMEPRIMARY DOCTOR CARE COORDINATOR

DAYCARE

And Then…Along Came the Amazing Miss Kate

Congenital Hydrocephalus

Multiple revisions, infections, complications

Cerebral Palsy, Epilepsy

Downright remarkable

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

FAMILYFAMILY

MEDICALHOMEPRIMARY DOCTOR

CARE COORDINATOR

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

SpecialistsNeurosurgeryNeurologyPhysiatristEndocrinology

FundingInsurersMedicaidFITCSHN

CSHNClinicsFundingEquipment

RespiteMedicaid ArisFIT

SupportFamily,

Friends, Groups, Advocacy

Family Centered Care

Provides care that is “whole-person” oriented, consistent with unique needs and preferences of the families We get to know our patients, prepare prior to

visit (C.C.) Strengths based (S. family) “Flags” in the EHR Registry “Reminders” section

Family Centered Care

Partners with patients and families to make treatment decisions Especially with subspecialty recommendations,

medical home often “sells” the intervention

Family Centered Care

Has open communication between patients and care team, access to resources to help when communication is strained Access to pediatric ethicist Co-located child psychologist

Building Medical Home Teams

• Care Coordinator

• Team Huddles

• Provider Meetings

• Staff Meetings

• Co-located Psychologist

• Pediatric Psychiatrist-Case consults every 2-3 weeks

• New alliances: Community Health Team, Medical social worker, Pediatric Registered Dietician

Family Centered Care: Specific Strategies

Mission Statement of your Medical Home “Our practice partners with families and

community to build relationships that nurture children's physical and emotional health and well-being.”

Identify Care Coordinator RolePhone follow up after dischargeRegistry of CSHN“Reminders” Box

Engaging Patients and Families

• Family Centered Care

•Motivational Interviewing

• Team building

• Empowering parents as experts and partners

• Medical Home Index

• Family Advisory Board

Practice Organization

• Preparing for Office Visits (pre-visit forms)parent, youth

• Patient Registry-flag in E.H.R. for CSHN, or “more time needed”

• Access to clinical guidelines: (Bright Futures, ADHD, Asthma)

• Care coordinator(nurse): connects with families with newborns, after ED visits, discharge from NICU, or Children’s Hospital

• Care Conferences: brings families, communities together

Quality Improvement Strategies

• Practice Improvement Partnerships (Blueprint for Health, NCQA)

• Medical Home EQIPP Course

• Bright Futures EQIPP Course

• PDSA cycles on building a team, ways to engage families, implementing clinical guidelines (Bright Futures, acute conditions, implementing a recall/reminder system)

• Self-assessment! (Medical Home Index, FCC Self-Assessment)

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Thank You to Our Parent Partners

Carolyn Brennan Kimberly CooksonSandy JuliusScott MetevierPeggy Mann Rinehart Wendy RugglesTheresa 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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ResourcesResources

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

Family as Expert