# Presentation: 469288

## The Medical Home Model: Caring for Children with Special Health Care Needs

**State, Healthcare Providers and Families as Partners**

## The National Initiative for Children’s Healthcare Quality

## NICHQ’s Mission

- “To eliminate the gap between what is and what can be in health care for all children.”

## About NICHQ

- NICHQ is an action oriented organization dedicated exclusively to improving the quality of children’s health care
- NICHQ is a resource for health care and improvement organizations, foundations, and government agencies seeking to improve care for children
- NICHQ is a national organization:
- Home Office – Cambridge, MA
- National cadre of key advisors
- Geographically distributed staff

## NICHQ’s Success Will Be Gauged By Whether:

- Children achieve
- Their greatest potential with
- No needless harm—injury, pain, suffering, death
- Families
- Are optimally able to provide for, promote, and support their child
- Communities
- Are best able to support healthy children and families
- Society
- Achieves these results with
- Equality
- No waste

## What we do:Change Practice to Improve Care and Outcomes

- Innovate
- Discover, invent, and share “good ideas—ready for use” in children’s health care
- Demonstrate
- Undertake targeted initiatives to demonstrate the feasibility of improving care and outcomes
- Accelerate Adoption
- Work with health care delivery organizations, families,  government, and others so that better models are widely and rapidly adopted

## NICHQ’s Bold Improvement Agenda

- Prevent Childhood **Obesity**
- Provide Seamless, Evidence Based, Family Centered Care for Children with **Chronic Conditions**
- Purge **Harm **from Children’s Health Care
- Promote **Equity **in Care

## Our Services

- Training and Transforming Care
- Learning Collaboratives: In person and across distance
- Action Networks and Spread Initiatives: Accelerating learning, spreading better care
- Annual Children’s Forum
- Toolkits
- Jump Start and Jump Ahead:  Introductory and Advanced QI Methods and Tools for Children’s Health Care
- Setting the National Agenda for Change
- Federal and State Children’s Quality Policy
- Measurement
- Improvement
- Health Information Technology
- Payment
- Creating and Sustaining Improvement Resources
- Local, State, Regional and Federal programs to sustain change

## 7th Annual Forum

- 7th Annual Forum
- March 19-21, 2008
- Miami, Florida
- Intercontinental Hotel

## Our Partners

- Health Care & Improvement Organizations:
- Institute for Healthcare Improvement
- Improving Chronic Illness Care Program
- Center for Health Care Strategies
- Family Voices, Spina Bifida Association, CHADD, Epilepsy Foundation
- Child and Adolescent Health Measurement Initiative
- Foundations
- David and Lucile Packard Foundation
- Robert Wood Johnson Foundation
- Commonwealth Fund
- California Endowment and Health Care Foundations
- Government
- State: NY, California, VT Departments of Health
- Federal: Maternal and Child Health Bureau, AHRQ, CMS

## Together we can make health care better for every child!

## Before we begin....

- This is really hard work... complex...abstract
- Remind you (and me) why we are doing this...
- Patient 1: Infant with complex genetic disorder, skin breakdown, severe developmental delay, Cambodian refugee family, non-English speaking. Foster care.
- Patient 2: Girl with dozens of surgeries for complex congenital anomalies, failure to thrive, mild developmental delay, maternal substance abuse.
- Create a system where any parent, any child, and society knows that that child and family will get the right care, the right way, the right time to efficiently and effectively achieve the best outcome

## Objectives

- Describe core elements necessary for
- full implementation
- spread of the medical home model
- Share how
- Maternal Child Health Bureau (MCHB),
- Title V
- primary care and
- specialty clinicians have worked/can work successfully to implement the medical home

## A Medical Home is

- Accessible
- Family Centered
- Continuous
- Comprehensive
- Coordinated
- Horizontal
- Vertical
- Longitudinal
- Compassionate
- Culturally Effective

## Defining medical home...basic, good, better, ... great

- A medical home is a community-based primary care setting which provides and coordinates high quality, planned:
- family-centered health promotion &
- chronic condition management

## The Patient/Family       & the Community-Based Medical Home – at the crossroads, integrating:

- _Vertically _– Among health care systems/specialists/PCPs/others
- _Horizontally_ – Among supportive community agencies/schools...

**Medical**
**Home**

**Community**
**Supports**

**Health Care**

***Longitudinally....***

## Why Medical Home Spread Slow

- Lack of awareness
- Limited operationalization
- Pragmatic barriers
- Time
- Knowledge
- Role definition
- Reimbursement
- Limited skills in the methodology of changing practice behavior.
*Are there any other obstacles to spread? *

## Other obstacles

- Parents need to be involved
- Infrastructure: training, culture change
- Worry that payers will drive this—to lowest denominator of usual source of care
- Champion-leadership: role of chapters
- Doctor as hero (can’t do it all): Teams, coordinator, resources
- Payment for participation in improvement
- Better to have a partnership team..
- Coding and billing
- Reimbursement for care coordination

## Hypothesis...

- Application of four key concepts
- Medical Home/Care Model for Child Health
- Collaborative Model
- Model for Improvement
- Model for Spread
- Together with support from a capable regional/state/local resource (Title V)
- Will result in acceleration of spread of Medical Home

## Care Model for Child Health in a Medical Home

**Care Model for Child Health in a Medical Home**

**Informed,**
**Activated**
**Patient/Family**

**Prepared,**
**Proactive**
**Practice Team**

**Supportive, **
**Integrated **
**Community**

**Prepared,**
**Proactive**
**Practice Team**

## Aim

- What are we trying to

- accomplish?

- How will we know that a

- change is an improvement?

- What change can we make that

- will result in improvement?

- Model for Improvement

**Act**

**Plan**

**Study**

**Do**

- From:  Associates in
- Process Improvement

- Measures

- Ideas

**Notes:**
Improvement involves a change—not all changes are improvements!

## IHI Breakthrough SeriesTM(12 month time frame)

**Select Topic ****(develop mission)**

**Planning Group**

**Develop **
**Framework **
**Changes **
**Measures**

**Participants ****(10-100 teams)**

**Prework**

**LS 1**

**P**

**S**

**A**

**D**

**P**

**S**

**A**

**D**

**LS 3**

**LS 2**

**Supports**
-  Email  Phone Conferences Visits              Monthly Team Reports

**Dissemination**
- Holding the Gains
- Publications
- Congress
- etc.

**A**

**D**

**P**

**S**

**Expert Meeting**

**AP1**

**AP2**

**AP3**

***LS – Learning Session***
***AP – Action Period***

- Parent Training

- Parent Training

- Parent Training

- Title V Training

- Title V Training

- Title V Training

**Notes:**
Here is a modified form of the diagram. Show’s PDSA continuing after LS3 and other wording changes. Please review and consider using it for all the BTS slides.

## Modifications to BTS Design

- “Participants”=
- State Title V Programs, each of whom recruited
- 2-3 Primary Care Practice Teams
- MHLC II: Broader State Team: AAP/AAFP, Medicaid, Parent
- Faculty=
- Clinical, Title V, and Parent Chair
- Teams=
- Physician, Staff (Nurse/Care Coordinator), Parent
- Topic=
- Medical Home, aka, Chronic Care Model for CYSHCN
- Added emphasis on Cultural Competency (MHLC II)

## IHI Framework for Spread

**Set-up**
**-****Adopter audiences**
**-Successful sites                 -Key partners                    -Infrastructure supports to enable adoption**
**-Initial spread strategy ****(leverage system structure****)**

** **

- IHI Framework for Spread

**Social System**
**-Early adopters          ****-Key messengers**** **
**-Communities                  -Technical support**
**-Transition issues**

**       ****Communication (awareness & technical)**

**          ****Leadership**
**-Topic is a key strategic initiative**
**-Goals and incentives/policies aligned**
**-Executive sponsor assigned**
**-Day-to-day managers identified**
**-Aim developed**

**Better Ideas**
**-****Develop the case**** **
**-Describe the ideas**

## Participant States

- MHLC I
- Connecticut
- Colorado
- Florida
- Ohio
- Oklahoma
- Louisiana
- Michigan
- North Carolina*
- New York
- Utah
- Virginia
- Wisconsin

- MHLC II
- DC
- West Virginia*
- Vermont
- Illinois
- Maine
- Maryland
- Minnesota
- Texas
- Pennsylvania*
- * = practice team, but no State Agency

**Notes:**
community-based: 48%
Tertiary/academic: 29%
hospital-based or network-based: 13%
solo: 10%

## Aim: Medical Home Learning Collaboratives

- To improve care for children with special health care needs/youth by implementing the Medical Home concept
- To foster substantial relationships between Title V programs and their state’s primary care community, enabling Title V to:
- Support improvement in practices and
- Spread improvement across their State

## Participants Teams-Practices

- 3 Teams from each State
- 43% Community Based, Group Practice
- 22% Community Hospital or Network Group Practice (e.g., Marshfield Clinic, Bassett Health)
- 25% Academic Primary Care Sites
- 9% Solo Practice
- Team Members
- Physician, nurse/other office staff/care coordinator, parent partner

**Notes:**
community-based: 48%
Tertiary/academic: 29%
hospital-based or network-based: 13%
solo: 10%

## Measures

- ED visits
- Unplanned Hospitalization rates
- Family worry
- Front office satisfaction
- Medical Home Index
- Care Plans
- Practice Satisfaction

## Medical Home Learning Collaborative IMedical Home Index Pre and Post Measures

## Medical Home Learning Collaborative IIMedical Home Index Pre and Post Measures

## Results MHLC I

## Results-MHLC II

## Results—MHLC II

## Qualitative Results: Title V

- Most valuable activities and insights:
- Conduct walk-through of practices
- Connect teams to state resources
- Assist with care coordination
- Outreach to broad variety of audiences
- Practices need help working with families
- Positive impact on how to implement change and promote adoption of new models
- Additional support, training, infrastructure needed
- Spread Challenging
- Tool developed
- “Internal” collaboratives successful and ongoing

## Qualitative Results-Parents

- Parents can be very effective in this process because they can counter assumptions health care providers make about the way things work"
- "There are things I can do, like pre-register my child for appointments...my pediatric clinic and the hospital are willing to do [many things] to make things better for my family. I never would have known what to ask for, as a new parent, before the medical home training"

## Qualitative Results-Practices

- The MHLC "helped the practice focus on achievable steps to initiate a true medical home“
-  "the small changes have made a world of difference in our practice...
- Specific changes (self-report)
- 70% streamlining access
- 64% have designated care coordinator
- 63% working with community agencies
- 60% partnering with families
- 50% using some form of registry
- Simplification, prioritization needed

## Why Medical Home Spread Slow

- Lack of awareness:
- Not Directly Addressed, Other (ACP, NCQA) Efforts
- New attention provides an opportunity; legislation: CO, MN, IA
- Double edged sword: just pay us more
- Need consistency
- Limited operationalization
- Better, but still complex
- Pragmatic barriers
- Time—Einstein rules!
- Knowledge--Yes
- Role definition--Yes
- Reimbursement—In part. See NCQA/PC Medical Home
- Limited skills in the methodology of changing practice behavior--Yes

## Hypothesis...

- Application of four key concepts
- Medical Home/Care Model for Child Health: *Simplify*
- Collaborative Model:
- Model for Improvement
- Model for Spread— *Not well adopted/applied*
- Together with support from a capable regional/state/local resource (Title V)
*Partners necessary (not sufficient)*
*Training—data, coaching, practice issues*
*Resources and priorities** *
- Will result in acceleration of spread of Medical Home

- Incentives for practices to want to implement
- Recertification

## Step By Step Approach with Simplified Medical Home Model

**A Guide to Assisting Practices**** to Implement Medical Home**
**#1** **Engage parents as partners at practice level**
**#2 Identify, categorize complexity, and create a registry of CYSHCN **
**#3 Use planned encounters **
**#4 Develop strategy and identify specific roles for care coordination and communication at the practice level**

## What can title V do...

- Facilitator
- Infrastructure Builder
- Systems Builder
- Model on Hearing Screening:
- legislation]
- Training
- Systems builder
- Using the same components: FC, Coordinated,
- Information sharing: Connections community of practice—consolidated record (e.g., RI)
- Recruit
- Care Coordination
- System of identification; planned encounters; partnership with families.
- How to operationalize within community, state, region.
- Key leadership characteristics

## Spread Framework—In Words

**Leadership:** Setting the agenda and assigning responsibility for spread
**Set-Up for Spread:** Identifying the target population and the initial strategy to reach all sites in the target population with the new ideas
**Better Ideas:** A description of the new ideas and evidence to “make the case” to others
**Communication:** Methods to share awareness and technical information about the new ideas
**Social System:** Understanding the relationships among the people who will be adopting the new ideas
**Knowledge Management:** Observing and using the best methods for spread as they emerge from the practice of the organization
**Measurement and Feedback:** Collecting and using data about process and outcomes to better monitor and make adjustments to the strategy

## Revised Spread Planner

**Spread Planner for Medical Home****A Tool for Title V and Other State Level Leaders**
- Leadership
- To what extent is spread of the Medical Home model a strategic objective of the key leadership organizations in your state (i.e., Title V, AAP, and Family Voices)?
- Are the goals/incentives of other key stakeholders within the state aligned with Medical Home spread?
- Is there support for Medical Home implementation at a policy level?
*How has the recent focus on medical home affected your efforts?*

## Joint Principles of the Patient-Centered Medical Home 

- Joint Principles of the Patient-Centered Medical Home

- The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate the patient’s family.

- American Academy of Family Physicians (AAFP)
- American Academy of Pediatrics (AAP)
- American College of Physicians (ACP)
- American Osteopathic Association (AOA)

## Joint Principles of the Patient-Centered Medical Home 

- Joint Principles of the Patient-Centered Medical Home

- Personal physician
- Physician directed medical practice
- Whole person orientation
- Care is coordinated and/or integrated
- Quality and safety
- Enhanced access
- Payment

## National Committee for Quality Assurance (NCQA): Physician Practice Connections

- Practice Requirements
- For Certification

- Source: *2006 National Committee for Quality Assurance*

## NCQA – PPC: Standards & Intent

- 1. Access and Communication
- The practice provides patient access during and after regular business hours, and communicates with patients effectively
- 2. Patient Tracking and Registry Functions
- The practice has readily accessible, clinically useful information on patients that enables it to treat patients comprehensively and systematically
- 3. Care Management
- The practice maintains continuous relationships with patients by implementing evidence-based guidelines and applying them to the identified needs of individual patients over time and with the intensity needed by the patients

## NCQA – PPC

- 4. Patient Self-Management Support
- The practice collaborates with patients to pursue their    goals for optimal achievable health
- 5. Electronic Prescribing
- The practice seeks to reduce medical errors and improve efficiency by eliminating handwritten prescriptions and by using drug safety checks and cost information when prescribing
- 6. Test Tracking
- The practice works to improve effectiveness of care, patient safety and efficiency by using timely information on all tests and results

## NCQA – PPC

- 7. Referral Tracking
- The practice seeks to improve effectiveness, timeliness and coordination of care by following through on consultations with other practitioners.
- 8. Performance Reporting and Improvement
- The practice seeks to improve effectiveness, efficiency, timeliness and other aspects of quality by measuring and reporting performance, comparing itself to national benchmarks, giving physicians regular feedback and taking actions to improve
- 9. Interoperability
- The practice maximizes use of electronic communication to improve timeliness, effectiveness, efficiency and coordination of care

## Better ideas

- Can you make the case for adoption of the Medical Home model?
- Set Up
- What is your implementation plan for spread?
- How will you attract new adopters (e.g., use a broad based communication campaign, identify and use opinion leaders, share comparative data)?
- What technology will you need (registries, web sites)?
- Who are the key messengers?

## Measurement and Social System

- How will you measure improvement at the practice level?
- How will you measure improvement at the State level?
- How will you provide feedback?
- Social System
- Are there vehicles to link stakeholders at State and local level?

## Other Health System Components

- Vertical Coordination: Primary and Specialty Care
- Case example: Children with Epilepsy
- Horizontal Coordination: Community/Public Health Resources
- Case example: Handoffs between newborn hearing screening, specialty care, primary care, and early intervention

## Ten Rules for Redesign

- Care is based on continuous healing relationships
- Care is customized according to patient needs and values
- The patient is the source of control
- Knowledge is shared and information flows freely
- Decision making is evidence-based
- Safety is a system property
- Transparency is necessary
- Needs are anticipated
- Waste is continuously decreased
- Cooperation among clinicians is a priority
- Institute of Medicine, Crossing the Quality Chasm (2001)

## Design principles of the Hearing Screening Learning Collaborative

- Newborn and family at center – *family source of control*
- All stakeholders at same table – *information shared freely, cooperation, transparency*
- Create sense that all in same system
- Focus on idealized system design - *safety*
- Used reliability principles -*safety*
- Prevent initial failure
- Identify failure and mitigate
- Critical failure mode functions, redesign
- Focus on handovers and interface of care system -*cooperation*
- Develop integral role of PCP/Medical Home and notion of co-management – *continuous healing relationships*

## Design of change package

- Expert panel preferred change package according to chronology of care
- Phases of process:
- Preparation and planning
- Screening
- Confirmation of diagnosis
- Treatment/amplification
- Enrollment in Early Intervention
- State infrastructure development

## Key change concepts

- Standardization
- Scripts for failed screen
- Fax-back forms to enhance communication
- Process of referral to specialists
- Consideration of failed newborn screen as critical test result
- Consider people as in the same system
- Listen to the customers
- Reduce wait time (for an appointment)
- Give people access to information

## Measurement strategy

- % of newborns who “do not pass” with verified PCP in hospital record
- % of newborns with results of newborn screening available for first newborn visit
- % of infants who “did not pass” the screening phase who get a complete audiologic evaluation by 3 months of age
- Mean age of infants at completion of audiologic evaluation
- Time to “third available new” appointment with the audiologists (in days)
- % of infants with abnormal audiologic evaluation with notification of PCP/MH within 2 days
- % of infants with PHL who are offered amplification/treatment by 3 months of age
- % of infants with PHL with an initial IFSP by 6 months
- % of infants who “did not pass” unable to find through outreach by 3 months of age

## Parent experience of care measures

- Developed by parent partners
- % of parents who were told and got a copy of the results of the newborn screen
- % of PCP’s who had the results of the newborn screen available at the time of the first newborn visit
- % of parents who “always” were able to get the help they needed for questions related to their infant’s hearing loss
- % of parents who “always” were able to get specific information they needed

## Lessons Learned

- Improving handovers with standardized communication tools enhances information transfer across the system
- Conversations about roles, responsibilities and accountability for care management improves care processes for clinicians and families
- Partnering with families in the design and improvement processes accelerates improvement
- Simple ideas work; work out processes on paper while developing larger data systems
- Fax back forms
- Identification of roles and responsibilities
- Structure of the state system matters

## Lessons learned (cont.)

- Identifying a system failure as early as possible helps reduce delays and loss to follow up
- Use every “failure” as an opportunity to learn about your system
- Standardizing processes and providing redundancy in birth hospitals helps to locate parents after discharge
- Changes to the appointment system for the diagnostic evaluation improves completion rates
- All parts of the system should emphasize the importance of establishing early communication approaches with the infant while in the decision process about communication options

## Percent of newborns who “do not pass” with verified PCP in hospital record

## Percent of newborns who “do not pass” the hospital based hearing screening with multiple contacts on the screening form for follow-up

## Time to third available new appointment for ENT/ORL

## Awareness and Access to Care for Children and Youth with Epilepsy--Aim

- To improve systems of care for children and youth with epilepsy, especially those residing in medically underserved areas.
- To design care for children and youth with epilepsy to be timely, effective, safe, patient- and family-centered, and equitable.
- To apply the model and lessons that proved successful in the first Medical Home Learning Collaborative to the care of children with the specific condition of epilepsy.

## Highlights

- Application of Advanced Access concept to specialty care:
- Service Level Agreements, Practice Redesign
- Engagement of parents in learning collaborative process (see video)
- Increased use of home medication lists, attention to comprehensive care

## Aim

- Improve the health and well being of Children and Youth with Special Health Care Needs (CYSHCN) and their families through building the capacity of state Title V programs—in concert with other state based partners—to create and sustain effective community based systems of care...

## Defining System of Care

- ...a family-centered coordinated network of community-based services designed to promote the healthy development and well being of children and their families.

## A well-functioning system of services will coordinate and integrate the full range of needed child and family services, among them health care, education, and social services, with the goal of optimizing outcomes for the children and families it serves...  Perrin at al.

- Through any door...

## Specific Aim

- With a focus on transforming the health care component of the system of care by:
- Spread of the medical home and
- Strengthening co-management relationships between the medical home and specialty care (vertical coordination)

## Three Phases

- Planned innovation program
- Implementation
- Reflection

## Planned Innovation

- Identify successful state level strategies of enhancing health care and other community services
- Synthesize a new framework
- Assess validity of framework through expert review and (limited) field testing.

## Implementation

- Two sequential learning collaboratives
- Each focusing on two categorical programs-- Epilepsy and Newborn Hearing Screening -- while working with State Title V Leadership on applying the system framework.
- State Teams
- “Practice” Teams (Epilepsy, Hearing Screening)

## Reflection

- Analysis of results
- Synthesis
- Recommendations for further action
- Preparation of dissemination materials

## Focus of innovation

- Approaches that work:
- System creation
- Supporting primary care, specialty care, public health system capability—enabling spread
- Addresses financing, quality, population health simultaneously
- Within and outside of Title V

## Help Me Grow- (Connecticut)

- Child Health Provider
- Language/Behavior/Parenting Concerns
- 1-800-Help Me Grow
- Referrals:  Language Eval; Play and Support Groups
- Two Week Follow-Up Contact:  Enrolled
- Feedback to Child Health Provider

## Design Process

- Desired performance characteristics
- Identification potential sites/programs/systems
- Screening, visits, summary
- Synthesis
- Expert review
- Test
- Revise
- Roll out

## What do you think?

- How should Title V support improvement in clinical care?
- Direct coaching and support at practice level?
- Partnership in establishing regional support services?
- Provision of core resources (developmental screening, data systems, care coordination training and support)
- What are the most effective approaches to supporting better care that you have seen? Most innovative?
- How have changes in programs and policies (SCHIP, Medical Home, others) influenced your thinking?

## IHI’s Triple Aim: Optimize the Health System Across Three Dimensions 

## System Components: IHI Triple Aim

- Individuals and families
- Partnership, Joint planning,  Patient controlled record
- Redesign of “primary care” services and structures
- Team, vertical coordination
- Population health management
- Useful segmentation , health info, “public health”
- Cost control platform
- System integration
- Developing workforce,  Strategic planning
- Execution, including spread, of strategic initiatives