The Child Health Accountable Care Collaborative (CHACC): Strengthening the Bond Between the Pediatric Subspecialist and the Patient- Centered Medical Home Mary Jones, RN, CHACC Coordinator

Disclosures I have no conflicts of interest or financial disclosures

Goals Briefly describe Community Care of North Carolina (CCNC) & Medicaid Describe the program goals for the Children’s Health Accountable Care Collaborative Discuss the challenges of care for children with chronic and complex diseases and the role of care coordination Discuss the creation and use of specific treatment and referral guidelines in the care of children with special healthcare needs

Community Care of NC  Statewide primary care medical home & care management system  Rests on foundation of Carolina Access in which Medicaid patients are linked to a primary care home  Provides resources to improve access to, quality of and coordination of care across the different segments of the local health care system and decrease cost of care  Private-public partnership (all savings stay in NC)  Provides ready access to data  Community based, locally driven, provider led

CCNC Goals  Evolving towards “Wellness” based case versus “Illness” based care.  Consolidation of hospitals, practices, and health care systems into larger integrated systems (shared responsibility of care by physicians and hospitals) is now the norm  Health care is evolving toward patient-centered using medical home (a single site or home for coordination of a patient’s health care) as the focus of the care structure  Technology allows access to and new approaches to data

6 What is a “Medical Home?”  A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. (American Academy of Pediatrics)  “My doctor is….”

Childhood Accountable Care Collaborative How it started..  Started in 2013 as Federal CMMI Award for 2 years to improve care for children with Medicaid & complex medical conditions ($9.3 million over 3 years)  Statewide initiative involving local CCNC network primary care homes, 5 academic medical centers, 7 tertiary hospitals, and Pediatric Subspecialists- 7/2015 has been continued in local areas by Community Care Plan of NC or Hospitals

Program Goals  Engage primary care providers and pediatric subspecialists across the state to share responsibility and accountability for pediatric primary, subspecialty, and hospital care.  Primary care providers and peds subspecialists jointly develop and utilize evidence-based guidelines of care for pediatric chronic illnesses and high volume referrals to peds subspecialists. Actively engage in co- management of these children.  Provide active care management to children under the care of pediatric subspecialists through embedded care managers and patient coordinators at tertiary hospitals and provide a warm hand-off to CCNC network care managers.  Reduce costs of care for this patient population (target is 2%)

9 Outcome Targets of Program  Provide a model for medical home-medical center collaboration in care of children with special health care needs  Develop statewide evidence based management schemes for complex and chronic illnesses in children  Establish referral guidelines to streamline consultation  Reduce cost of care for children with special health care needs  Improved access to necessary pediatric subspecialty care in a timely and efficient way

Who are the NC children with Chronic or Complex illnesses and what are the challenges in their care?

Background  FACT: 5% of Children under 18 incur 54% of the cost for children’s care in Medicaid Who are these children and what can be saved on cost while maintaining or improving quality of care? 11

12 Issues for Children with Chronic and Complex Illness in NC  Location of and Access to the subspecialists (long waits for appointments-up to 4 months or more)  Communication with PCPs and co-management  Where is the Medical Home? Family confusion (My doctor is….)  Coordination of access to services

CHACC vs C5  Who is a C5 patient? Medically complex, often requiring technology (trach/vent), needing active care coordination. C5 makes home visits and hosts patients in a weekly referral clinic with link back to primary care medical home  Who is a CHACC patient? High cost, chronically ill patient seen in a specialty clinic, needing care coordination and link to primary care medical home; often various social concerns

CHACC goals  Provide continuity of care for patients who see our subspecialists  Enhance what is done in the primary care setting at the time of referral before the patient sees the subspecialist  Improve communication with the family and the medical home after the visit- CHACC Care plans  Better meet the needs of the PCMHs and the subspecialists  Decrease unnecessary referrals and return visits to subspecialists to reduce wait time for new referrals

CHACC goals cont.  Reduce hospitalizations and ED visits  Help with medication compliance and education  Ensure community f/u in the home (HV in Pitt County)

Care Coordination & Case Management  CHACC embeds pediatric specialty care managers in specialist clinics  Develop the “CHACC Care Plan” to facilitate collaboration between pediatric sub-specialists and primary care physician  Support families with Co-Management.

CHACC Care Plan

CHACC Care Plan pg2

CHACC Care Plan pg3

CHACC care plan pg4

21 Case Management at Subspecialty Care location  Case Manager Role: coordinate care and medical needs of patients with CCNC case manager, subspecialty providers, and PCP.  Patient Advocate Role: provide assistance for family with social needs, appts, and transportation; assist case manager

Who are we?  Our Vidant based Center for Children with Complex and Chronic Conditions (C5): Medical directors from BSOM (Drs Willson and Zepeda), A Nurse Practioner (Clay Parker, NP), and 3 care coordinators (Kathy, Tieranny,and Rhonda)  Our CHACC program is supported through the Community Care Plan of Eastern Carolina (CCPEC) and Vidant Medical Center: Medical champion (Dr. Willson), 2 care coordinators (Mary, Cierra), and 2 patient navigators (Michael, Davey Ann)

23 Co-Management Guidelines for Primary Care Physicians and Subspecialists  Develop CME for PCPs and Subspecialists about the guidelines  Track outcomes by ED and hospital utilization  Repeat cycles with appropriate “expert panels” to cover a series of diseases and disorders where co- management is needed.  Available now are guidelines for GERD management Constipation, Sickle Cell, and Abdominal Pain  initiatives/child-health-accountable-care- collaborative/chacc-gi/ initiatives/child-health-accountable-care- collaborative/chacc-gi/

24 Co-Management Guidelines for Primary Care Physicians and Subspecialists  Joint development of co-management guidelines with PCPs and Subspecialists  Process: Evidence-based review of literature around the subject and published guidelines for referral, pediatric endocrinologists, obesity center directors, and PCPs from CCNC invited to attend, discussion of the review, development of consensus on management by PCP and Subspecialists-web site initiated with NC Medicaid to publish the guidelines

Referral Sources  Pediatric Specialists  Hospital  NICU  PICU  Pediatric Floor  Primary Care Providers  CDSA  CC4C

ECU Clinics Where CHACC Patients Are Followed  Nephrology  Gastrointestinal  Healthy Weight  Endocrine  Surgery  Behavior/Develop.  Neurosurgery  Hematology  Cardiac  Physical Medicine & Rehab  Pulmonary  Infectious Disease  Neurology  Adult Transition Clinic

CHACC Referral Sources Referral SourceQuantity%age ECU Peds Nephro % Vidant-NICU279.32% Vidant-SW258.47% List-CHACC ADT158.47% ECU Peds Specialty-SW128.47% List-TCP % List-Vidant Hospital85.93% CC4C CM75.93% CCPEC CM75.08% List-ECU Peds Specialty62.54% ECU Neurology42.54% ECU Peds Endo41.69% ECU Peds Cardiolgy31.69% ECU APHC21.69% ECU Peds Pulmonary20.85% ECU Peds Surgery20.85% C510.85% CHACC- Duke10.85% CHACC- UNC10.85% CHACC-CCWJC10.85% Cumberland Hospital-VA10.85% ECU Peds ID10.85% Total %

Specialist Referrals

PCP Referrals PCPQuantity %age ECU Pediatrics % Eastern Carolina Pediatrics % Kinston Pediatrics147.63% Goldsboro Pediatrics125.93% ECU APHC115.93% Washington Pediatrics105.08% Boice Willis Clinic95.08% Greenville Pediatric Services84.24% Jacksonville Children's Clinic83.39% MTW County Health Dept83.39% Mt Olive Pediatrics72.54% Benson Area Medical Center52.54% Kinston Community Health Center52.54% Vidant Chowan Pediatrics51.69% Carolina East IM Pediatrics41.69% Children's Health Services41.69% Park Avenue Pediatrics40.85% Halifax Pediatrics40.85% Coastal Childrens Clinic30.85% Craven County Health Dept30.85% Vidant MultiSpecialty Clinic Tarboro30.85% Goshen Medical Center30.85% Vidant Chowan Family Practice30.85% Kate B Reynolds20.85% Our Childrens Clinic20.85% ECU Family Medicine20.85% ECU Firetower Clinic20.85% Kinston Medical Specialist Pink Hill20.85% Vidant Family Medicine Allen Street20.85% Carolina Pediatrics10.85% Eastern North Carolina Medical Group10.85% KidsCare Pediatrics10.85% Vidant Pediatrics Kenansville10.85% Total100.00%

PCP Referrals

CHACC/CCPEC Co- Management Process CHACC Care ManagerCCNC Care Managers Patient Coordinators CCNC Networks--Medical Home/Primary Care Providers Children with complex, chronic Illnesses Co-management Specialty Care Primary Care CC4C Care Managers

Case Studies  Patient A-Chronic kidney disease, abnormal GU anatomy, recurrent UTIs, significant social barriers  Hospital visits 2014:14, then 2015:5  CHACC involvement has been crucial in coordination of patient’s care as family is hesitant to work with new providers.  CHACC assistance with medical supplies, appt coordination, and compliance

Case Studies cont.  Patient B-nephrotic syndrome, HTN, extreme social barriers (language, compliance, literacy)  Hospital visits increased due to condition over time  CHACC has arranged for medications delivered to home, medication calendars in Spanish, home visits set up with CCNC-all have increased compliance and kept patient in remission for longer bursts

Case Studies cont.  Patient C-diabetes insipidus, Gtube, social concerns  Hospital visits 2013:3, to present-0  CHACC has assisted with getting Gtube feeds done at patient’s school and daycare; patient has gained weight appropriately and labs have normalized