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Medical Home in Continuity Clinics – the Indiana Experience Nancy L. Swigonski, MD, MPH Phil Siefken, MD – Continuity Clinics Director Mary Ciccarelli,

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Presentation on theme: "Medical Home in Continuity Clinics – the Indiana Experience Nancy L. Swigonski, MD, MPH Phil Siefken, MD – Continuity Clinics Director Mary Ciccarelli,"— Presentation transcript:

1 Medical Home in Continuity Clinics – the Indiana Experience Nancy L. Swigonski, MD, MPH Phil Siefken, MD – Continuity Clinics Director Mary Ciccarelli, MD – Med Peds Program Director Dawn Haut, MD – Clinic Director Linda Hankins –Parent of CSHCN Doug Roepke, MD – Preceptor

2 Overview Tension Between Medical Home as a Concept and a Reality Tools for Continuity Clinic –Medical Home Index –Case Vignettes

3 Medical Home...“a headquarters for care” that includes –a person as the usual source of care as well as –a place AND a process for the anticipation, coordination, and provision of accessible family-centered continuous comprehensive coordinated compassionate and culturally-effective care Cooley, et al. The Medical Home Index: Devleopment and Validation of a New Practice-level Measure of Implementation of the Medical Home Model. Ambulatory Peds 2003;3:

4 Tension Between Medical Home as a Concept and a Reality “Health care is changing in very fundamental and important ways.” (Academic Health Centers: Leading Change in the 21 st Century IOM;2003)

5 Tension Between Medical Home as a Concept and a Reality “Health care is changing in very fundamental and important ways.” (Academic Health Centers: Leading Change in the 21 st Century. IOM; 2003) “If the most conscientious physician were to keep up with the literature by reading 2 articles / day, in 1 year this individual would be more than 800 years behind.” (Barnett, GO. Computers in Medicine. JAMA. 1990;263: ).

6 Tension Between Medical Home as a Concept and a Reality “Health care is changing in very fundamental and important ways.” (Academic Health Centers: Leading Change in the 21 st Century. IOM; 2003) “If the most conscientious physician were to keep up with the literature by reading 2 articles / day, in 1 year this individual would be more than 800 years behind.” (Barnett, GO. Computers in Medicine. JAMA. 1990;263: ). “Our concepts of medicine, health and preventive care will be fundamentally redefined...” (Academic Health Centers: Leading Change in the 21 st Century. IOM; 2003)

7 Tension Between Medical Home as a Concept and a Reality Olsen DG, Swigonski NL. Transition to Adulthood: The Important Role of the Pediatrician. Pediatrics 2004;113;e “Families and physicians who, historically, had focused on getting a child through one health crisis after another now face a different challenge – that of transitioning the growing child into the world.”

8 Tension Between Medical Home as a Concept and a Reality Olsen DG, Swigonski NL. Transition to Adulthood: The Important Role of the Pediatrician. Pediatrics 2004;113;e “Families and physicians who, historically, had focused on getting a child through one health crisis after another now face a different challenge – that of transitioning the growing child into the world.” Health needs shift from acute illness to management of chronic disease Institute of Medicine Report: Academic Health Centers: Leading Change in the 21st Century July, 2003

9 Tension Between Medical Home as a Concept and a Reality Olsen DG, Swigonski NL. Transition to Adulthood: The Important Role of the Pediatrician. Pediatrics 2004;113;e “Families and physicians who, historically, had focused on getting a child through one health crisis after another now face a different challenge – that of transitioning the growing child into the world.” “Current care systems cannot do the job. Trying harder will not work.” “Changing systems of care will.” Crossing the Quality Chasm; IOM Health needs shift from acute illness to management of chronic disease Institute of Medicine Report: Academic Health Centers: Leading Change in the 21st Century July, 2003

10 Indiana University School of Medicine Pediatric Residency Program 75 categorical pediatrics 11 Emergency Medicine/Pediatrics 5 Psych/Child Psych/Pediatrics 51 combined Med/Peds 21 Continuity sites –11 private –10 clinics

11 Continuity clinic sacred cows* Continuity clinic sacred cows* (aka – barriers to Medical Home quality improvment) It’s not really my practice; I have no ability to make changes These expectations are unrealistic There is not enough time We don’t get paid for doing all these services It’s not my job *sacred cow (1) a plodding, bovine mammal with numerous stomachs and of dubious intelligence, that some regard as holy and immune to usual treatment; (2) an outdated process, policy, assumption, mindset or strategy, often invisible, that inhibits change and prevents responsiveness to new opportunities

12 Medical Home...“a headquarters for care” that includes –a person as the usual source of care as well as –a place AND a process for the anticipation, coordination, and provision of accessible family-centered continuous comprehensive coordinated compassionate and culturally-effective care Cooley, et al. The Medical Home Index: Devleopment and Validation of a New Practice-level Measure of Implementation of the Medical Home Model. Ambulatory Peds 2003;3:

13 National Medical Home Learning Collaborative Center for Medical Home Improvement National Initiative for Children's Healthcare Quality Supported by MCHB “Current care systems cannot do the job. Trying harder will not work.” “Changing systems of care will.” Crossing the Quality Chasm; IOM

14 Medical Home Index Tool Variety of system barriers hamper implementation of Medical Home concept Descriptors in AAP definition do not offer guidance on day-to-day practice Tool measures 6 system domains to accomplish provision of Medical Home –guidance of quality improvement efforts –Benchmarking

15 Medical Home Learning Collaborative 11 states participating Title V director and state-level teams –Two-tiered collaborative 3 practices teams from each state –Physician, office staff member, parent 15 month process with 3 national mtgs Each state conducts learning collaborative within state for 30 more practices (or other spread strategy) Pack up experience for states unable to participate

16 Medical Home Learning Collaborative MHI Pre and Post Measures

17

18 Case Vignettes

19 Sore Throat/Strep Throat Alex Djuricich, MD Indiana University School of Medicine Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

20 Vignette A 5 year old girl presents with her mother to the office with a concern of sore throat. Was well until yesterday evening, when began having sore throat. Had fever today of 102.0, eating not as well, no vomiting or cough Exam shows T 102.2, pharyngeal exudates, beefy red tonsils, swollen and tender anterior cervical lymph nodes Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

21 How do you determine whether the patient has strep throat or a different condition (e.g. viral pharyngitis) that does not warrant antibiotics? Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

22 Clinical Question How do you determine whether the patient has strep throat or a different condition (e.g. viral pharyngitis) that does not warrant antibiotics?

23 Learning points What is the differential diagnosis? How do you diagnose strep throat? What tools can help you differentiate strep throat from other causes of sore throat? What is the accepted treatment? Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

24 Differential Diagnosis Viral50-80% Streptococcal5-36% EBV1-10% Chlamydia/Mycoplasma2-5% Others2% –Candida –STD organisms Post nasal drip in allergic rhinitis Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only. Ebell, MH, et al. Does This Patient Have Strep Throat? JAMA 2000;284(22):

25 Take home point Exam alone is NOT sufficient to rule in or rule out strep throat Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

26 Clinical prediction rules McIsaac Modification of the Centor Strep Score McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ 2000;163:

27 Treatment Penicillin V K –25-50 mg/kg/day DIV q6-8h –750 mg po qday x 10 days IS an acceptable tx Amoxicillin for 10 days –750 mg po qday x 10 days –45 mg/kg/day divided BID For penicillin-allergic patients –clindamycin (25-40 mg/kg day DIV qid) –erythromycin (50 mg/kg/day DIV qid) Azithromycin (still a 3 rd line agent) –12 mg/kg/day x 5 days (MAX: 500 mg/day x 5 days) Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

28 Billing Strep pharyngitisICD-9: Sore throat ICD-9: 462 Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

29 Quality Improvement / Medical Home If rapid screen negative, what do you do? –Withhold antibiotics, and wait for culture or –Give antibiotics, and call patient back if culture negative How does follow-up occur? –What happens on weekends? –Who gets culture results? –What do you do if the phone has been disconnected? Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

30 Physician Resources Ebell, MH, Does this patient have strep throat? JAMA 2000;284(22): Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

31 Toilet Training Gilbert C. Liu, M.D. Nancy Swigonski, MD, MPH Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

32 The Vignette First time parent wonders if his daughter can begin potty training Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

33 Learning points What to expect with potty training When to start potty training How to do potty training Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

34 What is potty training? A multi-step process May have starts and stops Different for every child –Development –Temperament Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

35 When 1 yo WCC re: parental expectations Between 18 mos & 3 years most children show signs of readiness: – stays d ry 2-3 hours at a time – follows simple d irections – pulls pants up and d own – Shows awareness that she has had, is about to have, or is having a bowel movement ( d irty) – uses a few words to express nee d s and wants Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

36 How to Potty Train Buy a potty chair that sits on the floor Help child get used to the chair –letting her sit on it with clothes on –if she’s not interested - try again tomorrow When the diaper is wet, or dirty, talk about using the potty When child has a dirty diaper –dump the stool in the toilet together –tell that this is where the poop goes Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

37 How to Potty Train Place child on the potty at routine times during the day and also Ask if child needs to go potty Use consistent toileting words PRAISE child for attempts and successes Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

38 How to Toilet Train When a regular pattern of going to the potty is detected – say goodbye to diapers –some people believe that diapers and pull- ups confuse children Take time, be patient, and keep a sense of humor! Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

39 Quality Improvement / Medical Home How might this process differ for a child with developmental delay? When and how might you help parents set expectations? How does toilet training differ among cultures? How do you elicit this information? Where would you go for resources for families?

40 Resources Family –http://familydoctor.org/handouts/179.html Physicians –PEDIATRICS Vol. 103 No. 6 Supplement June 1999, pp Copyright 2004 by IU School of Medicine, Children’s Health Services Research, Partnerships for Change-Dyson Initiative. May be used, with attribution, for non-profit purposes only.

41 Summary Systems changes need to be implemented in continuity clinics to make them a Medical Home reality Medical Home improvement can be integrated into clinical primary care teaching


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