1 Minnesota Medical Home Project: Evaluation Feasibility Study Saturday, June 7, 2008 SHRIG Meeting, Academy Health

DRAFT 2 What is a Medical Home Model of Care? Healthy People 2010 Measures Family/Professional Partnership Comprehensive Health Care Access to Health Insurance/Financing Early/Continuous Screening Access to Community Services Transition to Adult Life Minnesota Medical Home Project Coordination of Care

DRAFT 3 Who are Children with Special Health Care Needs (CSHCN)? EraTerminologyScope 1930s-60sCrippled Children Orthopedic impairments 1970s-80sHandicapped Children Above plus developmental disabilities, other physical conditions 1990s (Newacheck PW, 2007) Children with Special Health Care Needs Above plus emotional and behavioral conditions

DRAFT 4 Children with Special Health Care Needs…….. ”…have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally (DHHS, 2004).”

DRAFT 5 What is the Minnesota Medical Home Project (MMHP)? Goal: provide comprehensive patient- centered care to children with special health care needs MNCSHN Section, MN Department of Health + partners Formed in 2004 with 11 primary care teams from practices around Minnesota Healthy People 2010 Objective 16-23

6 Slide credit: Carolyn Allshouse, MCSHCN/MDH

DRAFT 7 MMHP Evaluation Components: 1) Family Perception Survey 2) Medical Home Index - MDH/MCSHN 3) Time Study - DHS/PMQI 4) 2001/2005 National CSHCN Survey 5) Evaluation Feasibility Study – DHS/PMQI

DRAFT 8 What is an Evaluation Feasibility Study? Determine whether the impact of the medical home model of care on the health service utilization and costs of care of Medicaid-enrolled children with special health care needs is feasible to assess. Impact = More Appropriate Care

DRAFT 9 Study Participants Medical Home children (n = 513) intervention group; identified by providers 9 clinics throughout Minnesota Two comparison groups of CSHCN identified from Minnesota Medicaid administrative data “Internal”: same clinics, different MDs (n = 732) “External”: no contact with Project (n = 15,042)

DRAFT 10 Study Inclusion Criteria 0-18 years old CSHCN status identified by a Project provider or by Minnesota Health Care Programs’ (MHCP) administrative claims data enrolled for a minimum of one month per year in MHCP; all 3 years of the study

DRAFT 11 Analysis Methods Repeated measure mixed design multivariate regression analysis Re-run analysis on random sample of the comparison groups All statistical models controlled for differences in age, gender, race/ethnicity, metro/non-metro status, parental marital status, and health status across study groups.

DRAFT 12 Preliminary Results

DRAFT 13

DRAFT 14

DRAFT 15

DRAFT 16

DRAFT 17 Health Condition Over Time Association with Intervention Status Odds Ratio (95% CI) Measure: Health Condition Worsening Between Baseline Year and Year 2 Results: Total Population Comparison Group0.4 (0.3 to 0.5) Medical Home GroupReference (Odds Ratio = 1) Results: Only the “Healthy” Children in the Baseline Year Comparison Group0.3 (0.2 to 0.4) Medical Home GroupReference (Odds Ratio = 1)

DRAFT 18 Medical Home Children: PMPM Inpatient Admissions Hypothesized effect of the intervention  Observed direction  Year 2 – Baseline admissions per 1000 member months Significant? yes, p = <.0001

DRAFT 19 Inpatient Admissions by Study Group (PMPM Adjusted Rate) Baseline (03/1/03- 02/29/04) Year 1 (03/01/04- 02/28/05) Year 2 (03/01/05- 02/28/06) Study Period PMPM Adjusted Rate External Sample n=513 Internal Sample n=513 Medical Home Sample n=513

DRAFT 20 Medical Home Children: PMPM Emergency Department Visits Hypothesized effect of the intervention  Observed direction  Year 2 – Baseline -8.0 visits per 1000 member months Significant? no, p =.418

DRAFT 21 Emergency Department Visits by Study Group (PMPM Adjusted Rate)

DRAFT 22 Medical Home Children: PMPM Well Child Visits Hypothesized effect of the intervention  Observed direction  Year 2 – Baseline visits per 1000 member months Significant? yes, p = <.0001

DRAFT 23 Well Child Visits by Study Group (PMPM Adjusted Rate)

DRAFT 24 Medical Home Children: PMPM Dental Visits Hypothesized effect of the intervention  Observed direction  Year 2 – Baseline visits per 1000 member months Significant? no, p =.813

DRAFT 25 Dental Visits by Study Group (PMPM Adjusted Rate)

DRAFT 26 Any Well Child Year 2 Visit: Predictors Odds Ratio (95% CI) Intervention Status External Controls0.9 (0.8 to 1.10) Internal Controls1.0 (0.8 to 1.3) Medical HomeReference (Odds Ratio = 1) Baseline PMPM Rate 8.5 (6.7 to 11.0) Interaction Terms Study Group X Age GroupWald Chi-Sq p=.004 Study Group X Baseline PMPMWald Chi-Sq p=.05

DRAFT 27 Any Well Child Year 2 Visit: Intervention Effect by Age Odds Ratio (95% CI) Intervention effect for ages 0 – 24 months External Controls0.5 (0.4 to 0.9) Internal Controls0.6 (0.3 to 1.02) Medical HomeReference (Odds Ratio = 1) Intervention effect for ages 2 – 6 years External Controls0.7 (0.5 to 0.998) Internal Controls1.06 (0.7 to 1.7) Medical HomeReference (Odds Ratio = 1)

DRAFT 28 Any Dental Year 2 Visit: Predictors Odds Ratio (95% CI) Intervention Status External Controls0.8 (0.6 to 0.9) Internal Controls0.8 (0.6 to 1.06) Medical HomeReference (Odds Ratio = 1) Baseline PMPM Rate 25.5 (19.2 to 40.0) Race/Ethnicity All other0.7 (0.7 to 0.8) White, Non-HispanicReference (Odds Ratio = 1)

DRAFT 29 Inpatient Admissions by Enrollee Care Plan Status PMPM rate over time; medical home participants only; overall PMPM rate is not adjusted

DRAFT 30 Emergency Department Visits by Enrollee Care Plan Status PMPM rate over time; medical home participants only; overall PMPM rate is not adjusted

DRAFT 31 Fee-For-Service PMPM Costs: All Study Groups Percent by Category of Service March 1, February 28, 2006 *Only children with 4+ months FFS enrollment in each study year

DRAFT 32 Fee-For-Service PMPM Costs by Category of Service and Study Group March 1, February 28, 2006 *Only children with 4+ months FFS enrollment in each study year.

DRAFT 33 Fee-For-Service PMPM Costs: All Study Groups By Age of Child at Baseline * All Categories of Service except long-term care *Only children with 4+ months FFS enrollment in each study year.

DRAFT 34 Fee-For-Service PMPM Costs: All Study Groups By Severity of Condition at Baseline *All Categories of Service except long-term care *Only children with 4+ months FFS enrollment in each study year.

DRAFT 35 Any Year 2 Health Services: Association with Medical Home Clinics Any Inpatient Admissions Any Emergency Department Visits Medical Home Site Care Coordinator Hours Odds Ratio(95% CI) Odds Ratio(95% CI) Clinic A04.72(1.35to 16.58)0.60(0.15to 2.36) Clinic B43.65(1.75to 7.61)1.19(0.66to 2.13) Clinic C52.62(0.97to 7.03)0.42(0.16to 1.09) Clinic D161.85(1.13to 3.03)1.33(0.98to 1.81) Clinic Eno CC1.52(0.33to 7.11)0.94(0.32to 2.73) Clinic Fno CC1.16(0.14to 9.56)0.48(0.11to 2.17) Clinic G240.95(0.32to 2.78)1.70(0.89to 3.27) Clinic H00.78(0.36to 1.65)1.74(1.23to 2.45) Clinic Ino CC (0.28to 2.87) All Non-MMHP SitesReference

DRAFT 36 Inpatient Admissions by Medical Home Status of Clinics *overall PMPM rates are not adjusted

DRAFT 37 Emergency Department PMPM Visits by Medical Home Status of Clinics *overall PMPM rates are not adjusted

38 Preliminary Results: Potential Impact Rates decreased over time  IP Admissions  Medical supply claims (steepest for MH) Increased likelihood of any Year 2  dental visits  well-child visits for 0-6 year olds Care plans associated with decreased IP admissions

39 Preliminary Results: Learnings “Appropriate care” measures  multiple categories of service  do not look at utilization/cost in isolation CSHCN ascertainment methodology  initial comparison group analysis More standardization and/or data needed from the medical home teams

40 Preliminary Analysis: Limitations Selection Bias Outcomes defined as cost and/or utilization offsets rather than quality of life, other externalities Exposure Misclassification and Measurement Error Administrative Data

41 Preliminary Results: Feasibility? Can the medical home program be evaluated using administrative data? Answer: Only provides a partial picture…..

42 Future Research Directions Revise control group ascertainment method Relative weight analysis to better evaluate the overall impact of the MMHP Develop CSHCN-specific performance measures Standardize and measure medical home “exposure” Evaluate the sensitivity/specificity of administrative data for CSHCN

43 Acknowledgements Funding Source/Grant Number MNDHS and MCSHCN/MDH staff (Jon Huus, Jeff Tenney, Greg Gifford) Medical home teams and participants Tonga Nfor, MD

44 Authors: Muree Larson-Bright, PhD Susan Castellano Susan Castellano Tonga Nfor, MD Tonga Nfor, MD Minnesota Department of Human Services Performance Measurement and Quality Improvement Maternal and Child Health Assurance