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Coordinating Care between Home Visiting and the Primary Care Medical Home An interprofessional approach.

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Presentation on theme: "Coordinating Care between Home Visiting and the Primary Care Medical Home An interprofessional approach."— Presentation transcript:

1 Coordinating Care between Home Visiting and the Primary Care Medical Home An interprofessional approach

2 Learning Objectives Understand the importance of care coordination between the home visitor and the medical home Recognize the value of documentation to standardize the referral and care coordination process Effectively communicate with families by using messaging tools Learn elements of an organizational protocol for care coordination within the medical home

3 Please Note This training is specific to care coordination between home visitors and medical homes. Our primary goal in this project is to encourage the use of the medical home as opposed to use of the emergency room. Currently, ICAAP works in the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program communities to promote Care Coordination between home visitors and medical homes using materials and techniques introduced in this presentation.

4 Illinois MIECHV Communities Englewood, West Englewood, and Greater Grand Crossing Cicero Township City of Elgin City of Rockford Macon County Vermilion County

5 MIECHV Benchmarks Improved maternal and newborn health Prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits Improvement in school readiness and achievement Reduction in crime or domestic violence Improvements in family economic self-sufficiency Improvements in the coordination and referrals for other community resources and supports

6 Importance Of Care Coordination Between The Home Visitor And The Medical Home

7 What is a Medical Home? Comprehensive and continuous medical care is provided to patients with the goal of obtaining maximized health outcomes in a culturally and linguistically appropriate manner A health care setting that facilitates partnerships between individual patients, and their medical professional, and when appropriate, the patient’s family Care is supported by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need it

8 Who are Home Visitors? They are interprofessionals who have experience related to child development and family strengthening. They have also received extensive training in their agency’s home visiting model as well as core knowledge and skills relating to domestic violence, substance abuse, developmental disabilities, and maternal depression. They provide families with social support built on the development of a trusting relationship between the home visitor and parents. These relationships are designed to promote parent effectiveness and help engender strong bonds between the adults and children within families.

9 What is Care Coordination? Care Coordination is a client-centered, assessment- based, interdisciplinary approach to integrating health care and social support services. With care coordination, an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an identified care coordinator following evidence- based standards of care.

10 What does care coordination look like? Documented information sharing among interprofessionals Consistent messaging to the family about health related issues Established medical home protocol that supports care coordination

11 “The Role of Preschool Home- Visiting Programs in Improving Children’s Developmental and Health Outcomes”

12 In this policy statement, the AAP: Recommends that pediatricians become aware of and participate in development of home-visiting programs in their communities States that there is ample reason to believe that the synergy of home visitors working with pediatric clinicians could have positive effects on child health and development Calls for free-flowing communication between home visitors and pediatricians.

13 The value of the relationship Connection with a home visitor gives the medical professional a view into the family’s home life and can be critical to the ability to provide care Home visitors can encourage the use of the Medical Home, not ER, for primary care services The home visitor can share valuable information to reinforce anticipatory guidance and help shape care plans and recommendations The home visitor can coach families for well-child visits and other medical appointments

14 Who benefits from Care Coordination? Home visitors Contribute to more comprehensive care for families Informed communication about family’s health needs and risk factors to medical home Increase opportunities for referral to additional services Medical homes Can provide more comprehensive care to patients Increase knowledge of/and access to resources not typically known More appropriate referrals for families Families/patients Less burden for communicating information between home visitor and medical home Expanded opportunity for access to other important services and supports

15 Care Coordination: Successful Partnerships For both the medical home and home visitor, this requires: Cooperation and open communication Documentation using care coordination tools Contribution of data that informs medical care Consistent messaging

16 Care Coordination: Effective Information Sharing… Demonstrates cooperation and open communication Increases accurate and timely data sharing Encourages consistent communication and messaging between the home visitor and the medical home Lessens family burden for communicating information between home visitor and medical home Expands family opportunity for access to other important services and supports

17 The MIECHV Referral and Care Coordination Process: An overview

18 The MIECHV Referral and Care Coordination Process The Coordinated Intake Office: Contacts the family referred by the medical home Completes the Coordinated Intake Assessment Tool (CIAT) Refers all positive screens within 24 hours If all home visiting providers are at capacity, refers to appropriate community resources and places client on waiting list Provides immediate referrals to community resources for all clients presenting with emergency needs Refers all negative screens to other community and parenting services as indicated Notifies the client’s medical home of referral outcome using the Coordinated Intake Office Referral Fax Back Form The home visitor: Completes all case management Completes the following screening: o 4P’s Plus (substance abuse screening) o Relationship Assessment Tool (domestic violence screening) o Edinburgh Assessment (maternal depression) o ASQ-3 Assessment (child cognitive development) o ASQ-SE Assessment (child socio-emotional development) Refers to appropriate services as indicated by screening results Shares pertinent information with the medical home using the Care Coordination Form (CCF) Using the Care Coordination Form, the medical home and the home visitor share: screening results information about referrals made to resources concerns related to the client/patient/family’s well-being pertinent medical information regarding the client/patient The medical home completes the Medical Home Referral Form to MIECHV Coordinated Intake Office

19 Getting started: Completing the medical home referral form

20 Why use the Medical Home Referral Form Contains contact information that allows CI office to connect with the family Initiates the process for referring a patient/family to a MIECHV Coordinated Intake Office, with patient/family consent. Creates an intentional opportunity for the medical home to: have a conversation with the patient/family about significant observations, concerns, etc. Indicate the reason you are making a referral to determine eligibility for home visiting services

21 Section 1: Family Contact Information It is important to provide accurate information about the patient/family as completely as you are able Section 1. Family Contact Information Patient Name: __________________________________________ AKA_______________________ Patient is (check one) ☐ child ☐ mother Parent/Guardian Name (if patient is under 18): ___________________________________________AKA________________________________ Street Address: __________________________________________________________________________________________ City: ___________________________________ State: __________ Zip: ______________ County: _____________________ Patient Date of Birth: _____/_____/_____ Patient Gender: M F Race: _________________________________________ Type of Insurance Coverage:  Medicaid  Private Insurance Medical card # _____________________________________ Name of Previous Healthcare Provider: __________________________________________________ Primary Language: ___________________________ Home Phone: _____/_____-_______ Other Phone: _____/_____-_______ Alternate or Emergency Contact Person: _____________________________________________ Phone: _____/_____-_______

22 Section 2: Reason(s) for Referral Inform the CI office of referrals made to other resources (e.g. Early Intervention) Indicate reason(s) for referral to CI office Section 2. Reason(s) for Referral Reason(s) for referral to Coordinated Intake Office (Please check all that apply):  At-Risk (Please describe risk factors): _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________  Identified area[s] of concern: ___Motor/Physical ___Cognitive ___Social/Emotional ___Speech ___Language/Communication ___Behavior ___Vision/Hearing ___Adaptive/Self-help Skills ___Maternal Mental Health ___Substance Use ___Relationship Assessment ___Other, specify______________ Comments: _______________________________________________________________________________________________________ _________________________________________________________________________________________________________________  Referral made to ________________________________________________________________________________(e.g. Early Intervention)  Family is aware of reason for referral

23 Section 3: PCP Contact Information Share your organization contact information with the CI office Section 3. Primary Care Provider Contact Information Name of Patient’s Primary Care Provider: ___ __________________________________ _____________________________________________ Street Address: ____________________________________________________ ____ _______________________ City: _____ __ _____________________________________ State: __________ Zip Code: _____________ Office Phone: _____/_____-_______ Office Fax: _____/_____-_______ _____________________________________________________ Contact Person at Primary Care Provider Office: ________________________________________________________ This enables the family to know that there is a care coordination team in place for them and relieves the family of the burden of information sharing among service providers.

24 Section 4: Office Referral Location Section 4. Office Referral Location Referral Date: _____/_____/_____ Please indicate the CI office referral location and fax to: ATTN Coordinated Intake Worker:  Cicero : Family Services & Mental Health P : 708/ F : 708/  Elgin: Kane County Health Department P : 630/ F : 630/  Englewood/ West Englewood/ Greater Grand Crossing: Children’s Home and Aid Society P : 773/ x224 F : 773/  Macon: Macon County Health Department P : 217/ x1140 F : 217/  Rockford: Winnebago County Health Department P : 815/ F : 815/  Vermilion: Aunt Martha’s Youth Service Center P : 217/ F : 217/ Indicate the date the referral is made Indicate the CI office referral location

25 Section 5: Authorization to Release Information Clause a. Referral to Coordinated Intake Office provides the opportunity for the patient or parent/guardian (if patient is under 18) to consent to referral whereby the medical home can share reason(s) for referral as indicated under Section 2. Reason(s) for Referral with the CI Office Section 5. Authorization to Release Information a. Referral to Coordinated Intake Office. The purpose of this disclosure is to refer __________________________________ (print name of patient) to a Coordinated Intake Office to determine eligibility for home visiting services. I, _____________________________________ (print name of patient or name of parent/guardian if patient is under 18), give my permission for the primary care provider, __________________________________ (print name of provider), to share pertinent information about, __________________________________ (print name of patient), regarding reason(s) for referral as indicated under Section 2. Reason(s) for Referral of this form with the Coordinated Intake Office. I understand that I may withdraw this consent by written request to the primary care provider listed in Section 3. Primary Care Provider Contact Information of this form, except to the extent it has already been acted upon. b. Release Home Visiting Services Eligibility Determination to Primary Healthcare Provider. The purpose of this disclosure is to release information from the Coordinated Intake office to the primary care provider about _________________________(print name of patient), including name, date of birth, and information about eligibility for home visiting services, including other referrals made by the Coordinated Intake Office. This consent allows the Coordinated Intake Office to share information with the assigned primary care provider (doctor) and treating doctors within the group, for care coordination. Care coordination allows the primary care provider (doctor) to be notified of patient eligibility for home visiting services and/or other referrals received. I give my permission for the Coordinated Intake Office to share outcomes related to this referral with the primary health care provider (doctor) listed above. Initial______ (of patient or of parent/guardian if patient is under 18). I understand that I may withdraw this consent by written request to the Coordinated Intake Office, except to the extent it already has been acted upon. I certify that this Authorization to Release Information has been given freely and voluntarily. Information collected hereunder may not be re-disclosed unless the person who consented to this disclosure specifically consents to such re-disclosure and or the re-disclosure is allowed by law. I understand I have a right to inspect and copy the information to be disclosed. Patient or Parent/Legal Guardian Signature (if patient is under 18)*_____________________________________ Date:_______/_______/_______ *Consent is effective for a period of 12 months from the date of patient signature or parent/legal guardian (if patient is under 18) signature on this release. Clause b. Release Home Visiting Services Eligibility Determination to Primary Care Provider provides the opportunity for the patient or parent/guardian (if patient is under 18) to consent to the release of information (including name, DOB, home visiting services eligibility determination, and other referrals made) from the CI Office to the PCP Consent is effective for a period of 12 months from the date of release

26 Important to know This consent form has been vetted for HIPAA and FERPA requirements Information sharing (as indicated under Section 2) consent is effective for a period of 12 months from the date of release If clause a. is not signed by the patient or parent/ guardian the medical home CANNOT share ANY information with the Coordinated Intake Office If clause b. is not signed by the patient or parent/guardian the Coordinated Intake Office CANNOT share information with the medical home

27 Sharing information with the medical home using the Care Coordination Form

28 Why use the Care Coordination Form (CCF) share important information including health concerns and referrals encourages the use of consistent anticipatory guidance and messaging incorporates family consent enables all providers to offer additional support to the family relieves the family of the burden of information sharing among providers

29 Section 2: Reason(s) for Contact Formally introduce yourself to the medical home as a professional service provider who is an important member of the care coordination team for the family Based on both your professional training and the fact that you are seeing the family routinely, provides an opportunity to inform the medical home about validated concerns you may have Share important family updates and/or status changes with the medical home Initiate a conversation with the family about significant observations or concerns, and why sharing this with the medical home is beneficial Inform the medical home of referrals made to other resources (e.g. Early Intervention) Request patient medical information from the medical home (e.g. immunization schedule)

30 Section 5: Authorization to Release Information Clause a. provides the opportunity for the patient or parent/ guardian (if patient is under 18) to consent to information sharing whereby you can share indicated reason(s) for contact under Section 2. Reason(s) for Contact with the medical home Clause b. provides the opportunity for the patient or parent/guardian (if patient is under 18) to consent to information sharing as specified under Section 2. Reason(s) for Contact whereby the medical home can share information with you Consent is effective for a period of 12 months from the date of release

31 Important to know This consent form has been vetted for HIPAA and FERPA requirements Information sharing (as indicated under Section 2) consent is effective for a period of 12 months from the date of release If clause a. is not signed by the patient or parent/guardian the home visitor CANNOT share ANY information with the medical home If clause b. is not signed by the patient or parent/guardian the medical home CANNOT share information with the home visitor

32 Communicating with families

33 Messaging Needs to be consistent specifically related to: o Why you screen o When Screening results are of concern o When there is a need for further assessment and referral Supports the mutual goal of medical homes and home visitors to provide comprehensive health care. Messaging is both about what you say and how you say it.

34 Why you Screen Explain that screening is an opportunity to learn what is expected next in a child’s development Make clear that screening is a form of preventative care and the earlier it is done, the better the opportunity for addressing concerns Describe to the family what to expect during screening Let the family know that you will conduct screenings routinely to assure the child’s continued healthy development.

35 When screening results are of concern Find helpful and encouraging words if the screening results are of concern Work with the parents to find helpful ways to communicate screening results with others Before addressing areas of potential concern, affirm to the family that screening results are not a reflection of their parenting skills

36 When there is a need for further assessment or referr al Let the family know that you are making a recommendation for further assessment or referral to support them in promoting their child’s optimal development Encourage the family to read or play with their child (using specific skill tools) with intentionality while they await further assessment or referral eligibility Let families know what will happen next, and who will be contacting them

37 Finding the Words Do not use diagnostic language such as “developmental delay.” Consider using phrases such as: “children develop differently, and some need extra attention and support during their earliest years” Emphasize that screening results indicate whether or not there is a potential concern

38 Consider: Your own non-verbal behaviors such as: body language and gestures eye contact facial expressions The culture of the family in their reactions and responses to information: primary language spoken in home cultural understanding of developmental concerns family history of developmental concerns

39 Tactics for Communication Normalize the conversation Acknowledge parent’s concerns and respond to their questions Point out the child’s positive areas of development or areas of temperament Discuss the family’s supports and resiliency ‘Demystify’ the referral process. Let families know what will happen next, and who will be contacting them

40 Elements Of A Care Coordination Protocol

41 An organizational care coordination protocol includes: Knowledge of community resources A standardized referral process to community resources Managing the Care Coordination Form (CCF) Messaging tools Medical home team responsibility

42 Medical Home Team Responsibility Promote and implement the care coordination protocols in the practice Responsible for managing the care coordination protocol of the medical home Prepare chart prior to office visit, insert appropriate screening tool(s) Offer families the screening tool form(s), explain purpose Offer assistance with completing form Score the screening tools form(s) Involve in screening, scoring, and discussing child developmental/behavioral concerns with caregivers Offer assistance with referrals to community resources Responsible for reviewing all completed forms If necessary, administer follow-up screening Discuss results and concerns with families Make appropriate referrals to community resources Plan for a follow-up appointment Order, reproduce, reorder supplies Formulate a plan on where to store materials and how to distribute and collect materials

43 Care Coordination Resources For forms shared in this presentation, as well as additional resource information for families and home visitors, visit: development-initiatives/home-visiting

44 Project Contact Information Cherie Estrada, Practice Management Consultant Illinois Chapter, American Academy of Pediatrics Elise Groenewegen, Project Coordinator Illinois Chapter, American Academy of Pediatrics 312/ ext. 204


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