1. Scarritt Bennett Internet Access Code: BellTower

2. Care Coordination in Pediatric Primary Care DEANNA BELL, M.D., F.A.A.P MEDICAL DIRECTOR, MHIP TENNESSEE CHAPTER OF THE AMERICAN ACADEMY OF PEDIATRICS

3. www.tennesseemedicalhome.com www.tnaap.com

4. Goals of D70 Grant “... to improve medical home provision for children and youth with special healthcare needs by promoting systems and service integration for children through education of parents and providers on medial home concepts of team-based care, care coordination, and disease management.”

5. Who are CYSHCN in Tennessee?

6. Tennessee CYSHCN 82% are under 200% of the FPL 78% are fully covered or supported by Medicaid 54% do not have access to a medical home 12% have no usual source of care 61% had access to care coordination when needed 23% had any help arranging or coordinating care

7. Anderson Behavioral Framework Coordination of health services relates to : 1.Providers predisposition to coordinate care 2.Resources enabling or impeding care coordination 3.Participant’s perceived need for coordination

8. Cost Trends for CYSHCN Top 10% most costly children lead to 70% of pediatric medical expenditures. 49% of top decile in 2000 were in the top decile in 2001. Cost Predictors:older age special needs functional limitations higher psychosocial morbidity

9. MCHB/AAP definition CYSHCN “... those who 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.” McPherson M, Arango P, Fox H, et al. “A new definition of children with special health care needs”, Pediatrics, 1998; 102 : 137 ‐ 140.

10. What is Care Coordination?

11. “There does not seem to be a clear, universally accepted definition of coordinated care for chronic illness.” Chen, et al. Best Practices in Coordinated Care. Mathematica Policy Research, Inc. 2000.

12. AHRQ – Closing the Quality Gap, Vol.7 Definition Systematic Reviews Health Benefits Costs Gaps in evidence base

13. Care Coordination Descriptions  Over 50 different definitions in the published literature  Approaches varied greatly  Benchmarks not well described  Positive health impacts reported  Cost savings reported  Few cost trends

14. Identified Need: Standardized care coordination system that can be applied across disease states and patient severity ratings.

15. Care Coordination Terminology  Case Management  Disease Management  Teamwork  Information Management  Collaboration  Continuity of Care  Patient Navigator  Chronic Care Model

16. Consistent elements  Numerous participants in team  Occurs when dependency on multiple skill-sets  All participants have knowledge about team members and available resources  Participants rely on information exchange  Goal of facilitation is delivery of appropriate healthcare services.

17. Essential Tasks Assess patient and determine likely coordination challenges Plan for coordination challenges with care plan Identify participants in care – specify roles Communicate to all participants Execute care plan Link to community resources Support self management Evaluate health outcomes Monitor and adjust care

18. AHRQ Definition “...the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.”

19. Care coordination “A process that facilitates linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health.” Pediatrics 104:4, p 978

20. Care Coordination Measures Atlas. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long- term-care/resources/coordination/atlas/index.html

21.  Social  Recreational  Housing  Utilities  Nutrition  Transportation/Mobility  Health Literacy  Transition to adult life  Access: economic or geographic  Medical Health  Mental Health  Dental Health  Reproductive Health  Developmental  Educational/Vocational  Child care/respite care Pediatric Life Domains

22. Considerations Specific to Pediatrics  Very few high volume disease cohorts  Developmental nature of impact on disease  Dependence of children on adults for resources/compliance  Children are the poorest segment of our population

23.  Clinical  Adherence  Functional Capacity  Patient satisfaction/perception of coordination  Utilization/Cost  Care delivery process  Coordination mechanism measures Common Measurements

24.  4 deal with those 65 years of age or older  Acute hospitalizations or ER visits from home health  Timely initiation of home health  3 deal with transition of records after hospital or ER discharge  Medication reconciliation  NCQA PCMH Survey Tool- MOC participants will fill out pre-and post-implementation surveys NQF Care Coordination Measures

25. What is the impact of care coordination?

26. What we do know Higher Medical Home Index scores result in significantly fewer hospitalizations Chronic condition management leads to fewer ER visits and hospitalizations Lower overall costs Reduction in health disparities Improved patient/family satisfaction Improved staff satisfaction

27. Kara Adams, Family Consultant Family Voices of Tennessee

28. Curriculum Framework

29. Care Coordination Framework Patient Disease management Case Management Team-based Communication

30. Care Coordination Framework Patient Disease management Case Management Team-based Communication

31. “A collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost effective outcomes.” Case Management Society of America. Definition of case management. [Accessed: January 28, 2006];available from http://www.cmsa.org/ABOUTUS/definitionofCaseManagement/tabid/104/Default.aspx Case Management

32. Case Manager Functions  Overcome barriers to compliance  Focus is on linkage with resources  Must have exhaustive knowledge base of available community resources to be maximally effective  Tracks compliance  Works with MD and disease manager to optimize compliance and communication

33. Case Management in the PCMH  Fosters relationship with team  Accountability of roles reinforced  More thorough/customized evaluation  Takes patients through an individualized PDSA process.

34. Case Management Tasks  Follows up on positive screens  Creates care plan based on patient risks and needs  Assists with entry into public health insurance/CSS  Navigates patient/payer issues with insurance case manager such as DME, special therapies, etc.  Assists with linkage to services to meet needs in all life domains  Tracks compliance with case management plan of care  Augments communication by communicating with team

35. QI Aim #1 Identifying Barriers to Compliance

37. MOC Aim #1 Measurements  Measure baseline of 20 patients from the practice population for objective screening for barriers to compliance.  Administer screening to patient population  Monthly, select 10 charts from patient population seen that month and audit cart for objective screening to compliance barriers

38. QI Aim #2 Overcoming Barriers to Compliance

40. MOC Aim #2 Measurements  Measure baseline of 20 patients with positive objective screening for barriers to compliance who are linked with a resource to mitigate a barrier. (May be 0 if your practice has not used a screening)  Administer screening and intervention to patient population  Monthly, select 10 charts from population with positive screens and audit chart for case management plan of care documenting linkage of patient with resources to mitigate barriers

41. Kelly Burlison, MPH Program Manager, Quality Improvement Projects American Academy of Pediatrics

42. Requirements for MOC participation  Summit Participation  Baseline/follow-up NCQA PCMH Medical Home Survey  Baseline/monthly (4 month) data entry/analysis for QIDA parameters  Participation in 2 of 4 technical assistance webinars/conference calls  Participation in final QI Program Synopsis call/meeting