Presentation on theme: "The Medical Home in Practice"— Presentation transcript:
1 The Medical Home in Practice Workshop #33 - The Medical Home in Practice - Rural Community-Based and Tertiary Care Center ModelsThe Medical Home in PracticeRural Community-BasedAndTertiary Care Center ModelsJuly 17, 2004
2 CHILDREN’S HOSPITAL OF WISCONSIN (CHW) SPECIAL NEEDS PROGRAM A PRIMARY CARE/TERTIARY CAREMEDICAL HOMEPARTNERSHIPHolly Colby, RN, MS
3 EVOLUTION OF THE SPECIAL NEEDS PROGRAM (SNP) In 1998 the SNP was developed from a contract with WI Medicaid for case management services.Physician joined the program in January 2003 as Medical Director and Care CoordinatorDevelopment of physician care coordination in collaboration with nurse case manager (CM) for high intensity/medically fragile children
4 Special Needs Program Goals Provide exceptional care coordination servicesAdvocate for improved care coordination for all children with special health care needs (CSHCN)Educate and assist other providers and programs in providing care coordination services for their patientsMedically Fragile children require a Medical Home to promote safe, coordinated care to optimize clinical and related outcomes and decrease parental stress
5 What do Families Say They Want People (doctors, nurses, therapist, et al) who help them negotiate the medical and non-medical maze of services
6 OUR VISION Care coordination at Children’s Hospital of Wisconsin will: Facilitate high quality, comprehensive, cost effective care
7 VISION Promote optimal quality of life for children and families Meet and exceed theexpectations of all customers
8 Children’s Hospital of Wisconsin SNP Description In children in SNP with an average of 7 physicians and mean hospital charges of $157,576/yrTarget population:974 patients had 3 major specialists and mean charges of $27,860/yr.193 patients had 5 or more specialists and mean charges of $83,940/yr.SNP staff: 3 Nurse Case Managers, 1 part-time Clinical Nurse Specialist, 2 part-time physicians, program manager and part-time administrative assistant
9 Criteria for SNP enrollment Family desires to work with Case Manager (CM). Program is voluntary.Highly complex medical conditionAt least five sub-specialistsMultiple and/or uncertain diagnosesPatient is not already followed by a CM
10 Criteria for SNP enrollment Medical condition requires frequent care and monitoringPeriods of medical instabilitySocially complex situationPCP requests care coordination assistance
11 REFERRAL SOURCES 2003 Specialty physicians at CHW-23% Population-specific programs at CHW-17%Inpatient Case Managers-12%Parents/Guardians-7%Primary Care Physicians-5%Birth to Three Programs-5%Others (Schools, Social Workers, Dieticians, Health Departments, Family Centers)-26%149 referrals in 2003 (66 enrolled)
12 INTAKE PROCESSWeekly intake rounds attended by SNP team, Social Work, Rehab Physician, and a staff member of the Special Needs Family CenterReferrals reviewed using established program criteriaRecommendations made re: who or what program can best meet patient/family needsAcuity determined using SNP Intensity Scoring tool to predict CM effort/patientCommunication with PCP, family and referral source re: team recommendation
13 THE SCOPE OF SNP CARE COORDINATION SERVICES Case plans and clinical summariesCommunication link between families, PCP, sub-specialists, and other providersFacilitate and coordinate health care delivery, appointments, care conferences, referralsAttend IEPs, clinic appointments, home visits
14 SCOPE OF CARE Provide psychosocial support and advocacy Provide health and resource informationAverage case loads: complex CSHCN
15 BENEFITS OF SPECIAL NEEDS PROGRAM TO FAMILIESAssists with establishing a plan of careFacilitates communication between providersCoordinates appointmentsProvides a single point of contactFacilitates access to community resourcesTo PCPInitiates a clinical summaryKeeps PCP in the loopFacilitates communication with specialistsOne-stop shopping (call CM for appointments, results, etc)Comment from a PCP:“You’ve made it so much easier to follow my patients”
16 PROGRAM EVALUATION Patient/family satisfaction (Ireys and Perry) Cost and reimbursement data evaluatedAnecdotal feedback from primary care physicians and other providersOutcomes including Quality of Life, Functional Status, and resource utilization will be measured
17 Patient Satisfaction Survey 2003 ResultsCoordinating care: 8% very good, 80% excellentReferring to other specialties: 12 % very good, 78% ExcellentCommunication with professionals: 12% very good,78% ExcellentParent comments:“CM services have been the greatest plus that has ever happened to us““The CM has been a wonderful asset to our family and has taken much of the stress out of our child’s health care”“Our CM saves me so much time and reduces my stress level greatly. I can be mom, not her nurse and case manager too”
18 REIMBURSEMENT STRATEGIES WI Medicaid program: targeted case managementCommercial Payers for nurse case managementPhysician billing for care coordinationOther grants and funding
19 ISSUES/CHALLENGES Funding for care coordination services Increasing demand for case managersLimited capacity for current staff to increase caseloadsInadequate reimbursement adversely affects ability to add more case managers to program
20 FUTURE DIRECTIONS OF THE SNP PROGRAM Prove to payers and administrators that care coordination of CSHCN makes a difference-MEASURE PERTINENT OUTCOMES!Validate intensity/acuity scoring toolRefine identification of the target populationPerform needs assessment of families of CSHCN, PCPs, and sub-specialistsSeek funding opportunities for continuing program development and outcomes studiesSpread Medical Home partnerships in WIContinue collaboration with the resident teaching program
21 SUMMARYOne parent comments: “The CM has been a life-saving asset to our family, our sanity and our child’s medical team.”The SNP is considered by families, physicians, and other healthcare professionals to provide optimal care for medically fragile children. The SNP is uniquely able to work with families and the PCP to improve quality of care, eliminate inefficiencies, and improve family satisfaction.
22 Together Everyone Achieves More A Children with Special Health Care Needs rotation for third year (PL-3) Residents at Children’s Hospital of WisconsinAnne K. Juhlmann RN, BSN
23 BACKGROUNDChildren with special health care needs (CSHCN) make up 15-18% of the U.S. pediatric populationSpecial health care needs impact development, function, and well-being of children, families and communities.Pediatricians are expected to successfully serve the growing population of CSHCN and their families.
24 BACKGROUND“Is there nothing that medical faculty …can do to stay in more open, feeling contact with their own humanity and that of their patient?Renée Fox
25 REALITYGreater than 70% of practicing pediatricians report feeling unprepared to provide care to CSHCN and their families.
26 The bridge between vision and provision REALITY:The typical Pediatric Residency does not focus on how to provide a medical home to CSHCN and families.Vision:Every child deserves a medical home and by 2010 every child will have one.EDUCATIONThe bridge between vision and provision
27 OVERALL GOALImprove health care for CSHCN by developing a CSHCN rotation for third year Pediatric Resident that is fun, practical and focuses on:The impact of chronic disease and disability on the child, family, community, and health care providers.The importance of providing medical homes for these children and their families.
28 INTENTION OF ROTATIONGive residents the opportunity to appreciate the challenges, rewards, needs, beliefs, hopes and perspectives of families of CSHCNTeach residents that serving CSHCN and their families requires a TEAM approach utilizing community, primary and tertiary care providers and resources.
29 INTENTION OF ROTATIONTeach residents about the potential benefits, challenges and opportunities inherent in providing medical homes for CSHCN.Provide residents with practical approaches to caring for CSHCN and their families.
30 Description of CSHCN Rotation In Jan the Children with Special Health Care Needs Rotation was added to the curriculum’s required third year Behavior and Development Rotation.Residents participate in approximately 14 half day experiences in hospital, outpatient clinic and community settings.Teachers are physicians, nurses, physical, occupational and speech therapists, community providers and most importantly - families
31 Workshop #33 - The Medical Home in Practice - Rural Community-Based and Tertiary Care Center Models THE FOCUSAll experiences focus on the IMPACT of special health care needs on children, their families and the community AND the need for an interdisciplinary TEAM approach to caring for CSHCN.July 17, 2004
32 FOCUS OF CARE COORDINATION EXERCISES and TEAM MEETINGS How to prepare clinical summaries and strategies for providing care coordination to CSHCNIdentifying and mobilizing resources for CSHCN and families.“It seems so many things get missed when no one is coordinating care”“I plan to start clinical summaries for the CSHCN in my practice. What an asset to families & providers!”
33 FOCUS OF HOME PROVIDER EXPERIENCES Durable Medical Equipment (DME) Provider:The expertise and activities of DME Providers.Home Care Agency:The pivotal role of home care providers and how pediatricians can help them serve CSHCN.“I never knew how much preparation went into even a single day at home for a single complex patient!”Sam Juhlmann“It made me realize that there are many more people behind the scenes that help me to care for a CSHCN.”
34 FOCUS OF FAMILYHOME VISITThe focus is on daily life for the child and the family and the family’s ability to find quality of life despite their many challenges.“I was inspired to become the physician they spoke so highly of.”“After two hours I was exhausted – mentally and emotionally. It is hard to imagine living with the daily routines this family has established.”“The positive attitudes of parents is a true inspiration!”
35 This was my best experience to truly understand a CSHCN! FOCUS OF FAMILY HOME VISIT How kids can be kids and families can be families despite special health care needs.“This mom helped me to understand that she still has hopes and dreams for her child to lead the best life that she can. Isn’t that really the hope that all parents have for their children?This was my best experience to truly understand a CSHCN!
36 FOCUS OF OUTPATIENT CLINIC EXPERIENCES Cerebral Palsy, Muscular Dystrophy, Spina Bifida, Palliative Care, Tracheostomy/VentilatorImpact of pediatric disorders and technology on CSHCN and their families.Importance of home nurses in the lives of these children and families.“Functionality is really what families care about and want to talk about. Something most doctors do not consider”
37 FOCUS OF SEATING & EQUIPMENT CLINIC Improving mobility and quality of life for children who require custom wheelchairs and adaptive equipment.“It is crucial to maximize the mobility of the family rather than just the mobility of the child.“
38 FOCUS OF PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY SESSIONS. The impact of developmental delays on the child, family and community.When and how to request, monitor and advocate for various types of therapeutic intervention.“therapy does not just end in clinic but is a way of life at home. “
39 Needs, challenges, barriers and opportunities for CSHCN in school. FOCUS OF SCHOOL VISITNeeds, challenges, barriers and opportunities for CSHCN in school.How physicians can support and advocate for accessible, individualized and appropriate education.
40 FOCUS OF CSHCN REGIONAL CENTERS IN WISCONSIN The crucial role of community and statewide resources for CSHCN and families.“”As a physician I can advocate for more resources”“People who know resources are a substantial and invaluable resource.”“Families are a great support for each other!”
43 ASSESSING RESIDENT LEARNING THROUGH DAILY JOURNAL ENTIRES Residents were required to record their thoughts and reflections upon completion of each of their experiences.“Reflective writing enables doctors to examine their practice critically from a wide perspective, and to increase their understanding and empathy.”“Writing keeps us alert, alive and flexible. It keeps us questioning: questioning medical practice, our patients and ourselves.”Gillie Bolton
44 ASSESSING RESIDENT LEARNING THROUGH FORMAL PRESENTATIONS All residents prepared a formal presentation at the end of his/her rotation that focused on the challenges faced by families caring for CSHCN, the benefits of a medical home and how they will deal with the barriers to implementing a medical home for CSHCN in their practice.
45 FAMILY (TEACHER) VIEWS “Talking with the resident made me feel like all of our experiences could be used to help the resident be a better doctor for other children and families like ours.”“I was touched at the resident’s genuine amazement at all we do. It made me feel like she was beginning to get it.”
46 FAMILY (TEACHER) VIEWS “The resident said, ‘I never knew how much fun your child had at home. I used towonder why you continued to care for him. Now I know why.”The resident shared some of the feelings she had as an intern caring for my child. I shared my sense feelings during hospitalizations. I felt as if we began to build a bridge of understanding tonight.”
51 “With every child’s brain is a mind teeming with ideas and dreams and abilities unrealized. The greatest thing we can do as parents, teachers, physicians, friends is to nourish that potential, both intellectual and humanitarian, so that each mind can fulfill its promise to the benefit of mankind.”Dr. Ben Carson