1. The Pediatric Medical Home: Building a Strong Foundation R.J. Gillespie, MD, MHPE, FAAP Medical Director Oregon Pediatric Improvement Partnership

2. Roadmap BEING a medical home – What does it look like? BECOMING a medical home – How does my practice get there?

3. Medical Home Fervor

4. What’s actually happening…

5. Factors Influencing Health Status

6. BEING A MEDICAL HOME

7. A Medical Home Is a community-based primary care setting which provides and coordinates high quality, planned, family-centered health promotion and prevention, acute illness care, and chronic condition management — across the lifespan.

8. Medical Home – AAP definition Accessible Family-Centered Continuous Comprehensive Coordinated Compassionate Culturally Effective

9. Primary Medical Home Model Preventive Care Well visits Screening for risk factors Health promotion & Anticipatory Guidance Immunizations Chronic Condition Management Identification & Monitoring Care plans / care coordination Co- management with specialists Acute Illnesses Telephone triage and advice Office visits Coordination with ER / Urgent Care Coordination with hospitals

10. General Activities of the Medical Home Anticipatory guidance – prevention and developmental promotion Identification of risk factors – physical, mental, social Understanding family strengths and protective factors Helping families set goals and priorities for self- management Management / referral to medical and community resources Ensuring follow-up – was the patient able to follow recommendations, complete referrals? Planning for future encounters ahead of time (instead of reacting to problems as they are presented)

11. Delivery of Patient & Family-Centered Care Coordination Services

12. Lessons of the National MHLC If you do nothing else… – Identify your population of CSHCN – Develop the capacity for practice-based care coordination and the use of care plans – Gain family participation/feedback From Carl Cooley’s presentation to the T-CHIC Annual Meeting, June 2012

13. In order to improve care for CYSHCN…you have to know who they are Identifying CYSHCN is different than identifying adults with special health care needs – chronic conditions vary considerably in severity, degree of impairment and service needs – a complete condition list would be unwieldy and include many children who do not require special services – a functional status approach would not capture children who function well but need special services to maintain function – the inherent difficulties in measuring functioning of very young children and infants Why worry about identifying CYSHCN?

14. How Identification is Done Three general techniques: – Provider “gestalt” – Running diagnostic codes – Using a consequences-based screener like the CAHMI screener Most practices do a combination, depending on goals and purposes for identification

15. Shared Care Plans…Background “Every patient can benefit from a care plan (or medical summary) that includes all pertinent current and historic, medical, and social aspects of a child and family's needs. It also includes key interventions, each partner in care, and contact information. A provider and family may decide together to also create an action plan, which lists imminent next health care steps while detailing who is responsible for each referral, test, evaluation or other follow up.” From www.medicalhomeinfo.orgwww.medicalhomeinfo.org

16. Shared Care Plans for CYSHCN Developed collaboratively with child and family, incorporates child and family goals Effective way to support self-advocacy and self- determination Types of care plans Medical summary/transition summary Emergency care plan Working care plan or action plan Individual Health Care Plan for educational setting

17. Name, DOB Parents/Guardians Primary Diagnosis Secondary diagnosis(es) Original Date of Plan, Updated last Main concerns/goals – Current plans/actions – Person(s) responsible – Date to be completed Signatures Key Elements in Shared Care Plans

18. Maxims of Patient Centered Care The needs of the patient come first Nothing about me without me Every patient is the only patient From: D. Berwick. What ‘Patient-Centered’ Should Mean: Confessions of an Extremist. Health Affairs, 28, no.4 (2009): w555-565.

19. Patient-Provider Encounter ProviderPatient Micro-system ClinicHospital Macro-system Health PlanDelivery System Environmental Context Policy

20. Engaging families and/or youth In working with practices, this is difficult but meaningful in many ways Some ideas for how to engage families: – Recruiting families for QI teams or standing clinic committees – Focus Groups Recruit a group of parents to discuss specific topics Example: focus group to review service needs for CYSHCN – Parent Advisory Group Can also be subject-specific, or have the agenda driven by the parents – Survey patients and families about their experience of care Formal surveys Shorter surveys of topics of interest

21. BECOMING A MEDICAL HOME

22. Adaptive Reserve What’s predictive of medical home transformation is the characteristics of the practice themselves…specifically adaptive reserve The ability of a practice to be resilient, to bend, and thrive survive under force. Facilitates adaptation during times of dramatic change.

23. Initial Steps Understand your practice’s culture Create a team Set priorities Decide on accountabilities Measure your progress

24. As the Project Starts Understanding Clinic’s Change Culture Knowing who the clinic needs to be engaged Getting the backing of clinic leadership Key thought: Understanding how your practice typically addresses change and decision- making will facilitate project spread.

25. As the Project is Underway Developing QI skills as a practice (aim statements, PDSA cycles) Engaging patients and families in QI efforts Key thought: QI skills and knowledge can’t live in the brain of a single individual (or small group of individuals) if change is to be sustained.

26. As the Project Finishes Creating a multi-disciplinary team for ongoing QI work Developing a clinic-wide strategic plan for QI Creating systems for tracking and sharing performance measures Key thought: Ongoing sustainability requires a permanent infrastructure for QI.

27. Food for thought Given that medical home transformation is a flexible, long-term process… How can you build your project team and do your project-level work in a way that sustains the work beyond the timeframe of the learning collaborative?

28. Key Questions: Understanding Your Clinic’s Change Culture How are changes made in your practice? Who holds decision-making authority in your practice? How can you engage other providers to participate in changes being made? What are the structural supports needed to maintain continued growth as a medical home?

29. Simple Steps to Implement Now Working on team identity and function – Are you meeting regularly? Do you create an agenda? Are you dividing accountabilities? Finding ways to share project information, goals, aim statements with others – What are the avenues for sharing information with other providers and staff? Are there standing meetings that you need to get yourself on the agenda for? Publicizing project data with other staff members, providers and patients – How is performance data shared with others in the practice?

30. Structural Supports Implementing large scale change calls for dedicated support structures – Many highly functioning medical homes have created QI Teams and are working on a Strategic Plan for Quality Success increases if multiple tactics for change are used

31. Final Thoughts… Start small. One small change can make a big difference. Use existing medical home tools to prioritize your efforts. Know which patients are in most need of your help. Involve your patients in improving their own care as well as your practice.