Transcript Medical Home Information Sharing Webinar for AAP Leaders

MEDICAL HOME INFORMATION
SHARING FOR AAP LEADERS
November 3, 2010

Fan Tait, MD, FAAP, Associate Executive Director
Director, AAP Department of Community and Specialty Pediatrics

Robert Hall, JD, MPAff, Associate Director
AAP Department of Federal Affairs

Dan Walter, Senior Policy and Government Affairs Analyst
AAP Division of State Government Affairs

W. Carl Cooley, MD, FAAP, Chairperson
AAP Transitions Clinical Report Authoring Group

Jeanne W. McAllister, BSN, MS, MHA, Co-Principal Investigator
National Healthcare Transition Center
Webinar Overview

Update and Overview of AAP Efforts Related to Medical
Home—Focus on Medical Home Education and Training

Accountable Care Act—Medical Home Components and
Priorities, Federally and In States

Transitions and Medical Home—What’s on the Horizon
for the AAP

National Healthcare Transition Center
2
Medical Home
Education and Training
Fan Tait, MD, FAAP
Associate Executive Director
Director, Department of Community and Specialty Pediatrics
American Academy of Pediatrics
EQIPP: Medical Home for
Pediatric Primary Care

Pediatric health care providers create plans for
improvement to address gaps identified in key activities
of the medical home

ABP-approved Performance in Practice Quality
Improvement Activity (Part 4 MOC)

CME credit is available

Medical home course available now!
www.eqipp.org
4
EQIPP: Medical Home for
Pediatric Primary Care
 Key
Clinical Activities
Developing a high functioning, multidisciplinary
quality improvement team
 Knowing and managing your patient population
 Enhancing access to care
 Providing family-centered care
 Providing and documenting planned, proactive,
comprehensive care
 Coordinating care across all settings

5
LEND Programs—
Medical Home Initiative
Background on Leadership Education in
Neurodevelopmental and Related Disabilities
(LEND) Medical Home Initiative
 Support
from the Maternal and Child Health Bureau
(MCHB)
 LEND
Directors, AAP / National Center for Medical
Home Implementation staff
 Began
development of medical home
competencies, January 2009
7
Background, LEND Programs

Provide long-term, graduate, and post-graduate level
interdisciplinary training as well as interdisciplinary
services and care

Purpose: To improve the health of infants, children, and
adolescents with disabilities, prepare trainees from
diverse professional disciplines to assume leadership
roles in their respective fields and to ensuring high levels
of interdisciplinary clinical competence

Currently 39 LEND programs in 32 states and the District
of Columbia
8
Background, LEND Programs (cont’d)

Knowledge and skills of all child health professionals to
improve health care delivery systems for children with
developmental disabilities;

High-quality interdisciplinary education, emphasizes
integration of services from state and local agencies and
organizations, private providers, and communities;

Skills that foster community-based partnerships; and

Innovative practices to enhance cultural competency,
family-centered care and interdisciplinary partnerships.
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Creating the LEND Medical Home
Competencies

Created in 2009-2010

Partnership with AAP, Association of University Centers
on Disabilities (AUCD)

Rationale: Created out of a perceived need for trainees
in LEND programs

to receive additional training regarding their future role(s)
in medical home—as part of the medical home team
10
Goal of LEND Medical Home Initiative
 To
focus on the interdisciplinary work LEND
trainees will be engaged in
 To
assist trainees in their understanding of the
core tenets of medical home and how they
apply to their respective fields of expertise
11
LEND Medical Home Competencies
Organized in 3 Major Areas
 Area
One: Basic Characteristic of the Medical Home
Family-centered
Family/Professional Partnerships
Coordinated Services
Comprehensive
Culturally Effective
Accessible
Community-centered
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LEND Medical Home Competencies
 Area
Two: Organizational capacity for CYSHCN
and their families
Eligibility and tracking in a medical home
Importance of family advocate and/or family input
Quality improvement
Payment structure
13
LEND Medical Home Competencies
 Area
Three: Transitions
Family to youth focus in providing transition services
Link to appropriate adult health care services and supports
14
Next Steps
Fall 2010: Competencies available to all LEND programs
to test and pilot locally
 Do NOT anticipate that LEND programs will adopt all
competencies/activities. Choose those that will be
integrated best into their curricula.
 Feedback requested summer 2011
 Revisions will be made based on feedback
 Goal: Final set of medical home competencies for LEND
trainees available fall 2011

For additional information about
the LEND Medical Home
Initiative, contact Michelle
Esquivel ([email protected] or
847/434-4989)
15
Medical Home Resident Education
Initiative
Medical Home Resident Education
Initiative Work Group (REIWG)
The REIWG has been convened under the auspices of the AAP /
National Center for Medical Home Implementation
Goal
 Provide direction, tools, and resources to residency program
directors, faculty, and others in their efforts to educate trainees
regarding the core tenets of medical home
Objective
 Assess and address the needs in the area of resident education
related to medical home for all children—including children with
special health care needs; specific emphasis on care coordination
and family-centered care, respectively
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Medical Home Resident Education
Initiative Work Group (REIWG)
REIWG Members
Renee Turchi, MD, MPH, FAAP Chairperson
Richard Antonelli, MD, MS, FAAP
Matthew D. Garber, MD, FAAP
H. Garry Gardner, MD, FAAP
Aditee P. Narayan, MD, MPH, FAAP
Umbereen S. Nehal, MD, MPH, FAAP
Thomas S. Klitzner, MD, PhD, FAAP
Jennifer M. LeComte, DO
Robyn Nolan, MD
Eugene Rich, MD, FACP
Janet Serwint, MD, FAAP
Scott Shipman, MD, FAAP
Dennis Vickers, MD, MPH, FAAP
Susan Wiley, MD, FAAP
Family Representative
Juno Duenas, Executive Director of
Support for Families
Instructional Designer
Marcia Jackson, PhD
Staff
Michelle Z. Esquivel, MPH
Heather Stob
Angela Tobin, AM, LSW
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Medical Home Resident Education
Initiative
Needs Assessment
 Developed for dissemination to all Pediatric Program Directors to
assess and identify the current curricular components in teaching
medical home across residency training programs
Curriculum Development
 Structured around the six building blocks of the Building Your
Medical Home toolkit






Care Partnership Support
Clinical Care Information and Organization
Care Delivery Management
Practice Performance Measurement
Resources and Linkages
Payment and Finance
Targeted Project Pilot
 Summer/Fall 2011
For additional information on the
medical home resident education
initiative, contact Heather Stob
([email protected] or 847/434-4902)
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2011 Webinar Series:
“Implementation and Application
of Medical Home in Practice”
“Implementation and Application of
Medical Home in Practice” Webinar Series
 Up
to four 60-minute webinars between February
and June 2011
 Slated
for CME application and approval
 Planning
Group members represent a variety of
professional backgrounds including pediatric
primary and specialty care, family medicine,
pediatric nursing and public health administration
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“Implementation and Application of Medical
Home in Practice” Webinar Series
Planning Group
Planning Group Members
Thomas S. Klitzner, MD, PhD, FAAP
Marie Y. Mann, MD, MPH, FAAP
Linda Lindeke, PhD, RN, CNP
William Schwab, MD, FAAFP
Staff
Angela Tobin, AM, LSW
Corrie Pierce
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Focus of Webinar Series

How the medical home model successfully addresses
specific child health issues from preventive, acute and
chronic care perspective(s);

State and/or practice level case studies highlighting the
infrastructure and support utilized for effective
implementation of medical home, including quality
improvement, information technology, and payment
strategies;

Practical tools available from the National Center to help
develop medical home teams, coordinate care, and
improve communication across the health care system.
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For More Information...
 For
more information on the webinar series,
contact Angela Tobin at [email protected] or
847/434-7621
 Additional
information will be available at
www.medicalhomeinfo.org in the near future
24
Joint Principles: Medical Education of
Physicians as Preparation for Practice
in the PCMH
History of Medical Student Joint Principles
 June
2010 Series of Conference Calls
 AAFP,
AAP, ACP, AOA
 Discussed
possible development of joint
principles for medical education of physicians as
preparation for practice in the patient-centered
medical home (PCMH)
26
Details of Project

Used in work with medical student education leaders (associations,
programs, etc)

Work framed around the key tenets of the medical home joint
principles

Summarizes the attributes and/or competencies needed as well as
corresponding educational sub-principles

Crosswalks the principles, attributes/competencies and subprinciples with the core competencies required in medical
education.
For additional information about
the medical student education
effort, contact Michelle Esquivel
([email protected] or 847/4344989)
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Accountable Care Act—Medical Home
Components and Priorities, Federally and
In States
Children’s Access to Care:
Policy Challenges and Advocacy
Opportunities
Robert Hall, JD, MPAff
Associate Director
Department of Federal Affairs
American Academy of Pediatrics
Structure of the Affordable Care Act (ACA)

Ten Titles of HR 3590




Titles I-VII are the guts
Title VIII is CLASS Act
Title IX is revenue/tax provisions
Title X is the Senate floor amendment
Floor amendment with Sec. numbers like 10101-10102
 Two Other Titles in HR 4872




Sec. 1202 is Medicaid payment increase
Affordability provisions also improved (sec. 1001)
Title II was student loan repayment
29
AAP Priorities for Health Reform

Coverage – Quality health insurance for all children

Benefits – Age-appropriate benefits in a medical home for
all children

Access – Payment rates and workforce support to provide
real access once children are insured
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Academy Priorities:
Coverage

Number of children covered is not projected, but the mandate and
coordination between the Exchanges and Medicaid/CHIP should
improve enrollment

Continuation of CHIP
How well will the Exchanges work for children?
 Significant uncertainty regarding actuarial value/cost sharing
protections


Immigrant Issues
CHIPRA lifted the five year bar for legal immigrant children
at state option
 Immigrants barred from Exchange

31
32
Academy Priorities:
Benefits in a Medical Home

Preventive and well child services in Bright Futures
guidelines with no co-pay for ALL non-grandfathered
group and individual insurance packages

Pediatric-specific benefits including well baby/child,
rehabilitative, habilitative, mental/behavioral health,
vision, oral, “Pediatric Services” in Exchange
33
Academy Priorities:
Medical Home in Health Reform

Grant program to establish community-based health
teams to support primary care providers
Will provide PMPM payments to providers
 Separate payment to “health teams”


Unfunded Pediatric Medicaid Accountable Care
Organization demonstration
Performance guidelines; if lower cost, share savings
 Secretary must work in consultation with pediatric providers
to establish guidelines

34
Academy Priorities:
Access - Payment
 Medicaid
pays pediatricians on average 72% of
Medicare rates
Only 53% of physicians are willing to see new Medicaid
patients
 New and traditional Medicaid enrollees are in danger of
having a Medicaid insurance card that provides no real
access to care

 Reconciliation
law: $8.3 billion over ten years
that will increase payments to Medicaid primary
care providers
35
Academy Priorities: Access - Workforce

Primary Care




Workforce funding, tied to NHSC and HPSA (Title VII, etc.)
Commissions to recommend priorities
Reform GME to increase supply of primary care, others
Subspecialty



$30 million per year for loan repayment for ped. subspecialty,
surgical specialty and child and adolescent mental and
behavioral health care
Eligible for $35k/year for 3 years
Not appropriated
36
Implementation Timeline: 2010

After September 23, 2010 (as a new health plan year begins):
New plans must provide all Bright Futures services to all enrollees with
no cost sharing
 Young adults can remain on their parents’ health plan until age 26
 Children with insurance can no longer be denied coverage for preexisting conditions
 Insurance plans can no longer impose lifetime caps or restrictive annual
limits on coverage, and cannot rescind coverage when a person
becomes sick



Small employers receive tax credits to purchase employee
health care premiums
By July 1, 2010, a temporary, high-risk pool is established for
qualified uninsured persons with pre-existing conditions (in
place until 2014)
37
Health Home in HCR: Specifics



Sec. 2703: $25 million in state planning grants to develop Medicaid
State Plan Amendments to provide “health homes”
90% FMAP for 2 years thereafter
Health homes:
The term health home services means comprehensive and timely
high-quality services …
 Provide services that include







(i) comprehensive care management;
(ii) care coordination and health promotion;
(iii) comprehensive transitional care, including appropriate follow-up, from
inpatient to other settings;
(iv) patient and family support (including authorized representatives);
(v) referral to community and social support services, if relevant; and
(vi) use of health information technology to link services, as feasible and
appropriate.
38
Medical Home and HCR: Training
 Title

VII amendments
New competencies with attention to:
Training in providing care in medical home
 Development of tools/curricula related to PCMH
 CME for PCPs re: PCMH
 Capacity-building awards to those that provide innovative
approaches to clinical teaching using models of primary
care including PCMH

39
Center for Medicare and
Medicaid Innovation (§3021)





“The purpose of the CMI is to test innovative payment and service
delivery models to reduce program expenditures…while preserving or
enhancing the quality of care...”
Must consult with other relevant federal agencies and clinical and
analytical experts
Secretary must select models for testing where there is evidence that
the model addresses a defined population for which there are deficits
in care leading to poor clinical outcomes or potentially avoidable
expenditures
Statute includes a menu of 20 possible models
Secretary may, through rulemaking, expand the duration and scope of a
model (even go nationwide) if:



Model reduces spending without reducing quality, or model improves care
without increasing spending
No waiver authority for expansion phase
Funding: $5m in FY 2010; $10b in FYs 2011-2019
40
Models for CMMI Testing

Contracting directly with groups of providers and suppliers, such as
through risk-based comprehensive payment or salary-based payment

Supporting care coordination for individuals at high risk of
hospitalization through an HIT-enabled provider network that includes
home tele-health technology

Varying payment to physicians who order advanced diagnostic imaging
based on their adherence to appropriateness criteria

Paying providers and suppliers for using patient decision-support tools

Allowing states to test all-payer payment reform

Aligning guidelines of cancer care with payment incentives under
Medicare in the areas of treatment planning and follow-up care
planning
41
Models for CMI Testing





Developing a collaborative of high-quality, low-cost health care
institutions responsible for developing and implementing best
practices, and assisting other institutions in adopting such best
practices
Testing the use of electronic monitoring by specialists, including
intensivists and critical care specialists, based at integrated health
systems
Allowing direct access to certain health professionals or services, such
as outpatient physical therapy (that is, without requiring a physician
order or referral)
Health Innovation Zones: consisting of groups of providers that include
a teaching hospital, physicians, and other clinical entities that, through
their structure, operations, and joint-activities deliver a full spectrum of
integrated and comprehensive health care services to applicable
individuals
Using tele-health services, especially in medically underserved areas
and facilities of the Indian Health Service
42
Pediatric ACO Demonstration Project





Included in §2706 of the law
References Medicare ACO Demonstration Project (§3022)
2012-2016
Incentive payments if exceed specified minimal savings
level
Authorizes such sums as necessary, but not otherwise
funded
43
Update on the Patient Protection
and Affordable Care Act (ACA) and
Medical Homes
Dan Walter
Senior Policy and Government Affairs Analyst
Division of State Government Affairs
American Academy of Pediatrics
The 2010 Election
45
Medical Home and the ACA
3
sections of ACA specifically include medical
homes:
State Medicaid ‘health homes’ option for persons
with chronic conditions (Section 2703)
 Centers for Medicare and Medicaid Innovation
(CMMI) (Section 3021)
 Community health teams to support patient-centered
medical homes (Section 3502)

46
State Health Homes Option
Medicaid health homes option a state plan amendment
 Begins January 1, 2011
 State designates health care home or health care home
team
 To be eligible to participate, enrollees must either have:




2 chronic conditions
1 chronic condition and be at risk for a second chronic
condition, or
1 serious mental health condition
47
State Health Homes Option

Secretary of HHS will establish standards

Federal match of 90% for care management, care
coordination and health promotion, transitional care, referral
to community resources, HIT use to link services

Designated provider:
Physician, practice, rural clinic, community health or mental health
center, home health agency, or any other entity or provider
determined by the state and approved by the Secretary of HHS to
be qualified to be a health home
 Beneficiaries choose


CMS will be issuing regulation and State Medicaid Director
Letter
48
State ACA Implementation:
Who’s Involved





State legislators, governors,
state commissions or offices of
implementation, state
agencies
HHS/CMS
HHS Office of Consumer
Information and Oversight
State Insurance
Commissioners
National Association of
Insurance Commissioners
(NAIC)





Medicaid/CHIP
National Association of State
Medicaid Directors (NASMD)
National Conference of State
Legislatures (NCSL)
National Governors
Association (NGA)
AAP chapters
49
Child-Only Policies
 September
23, 2010: consumer protections took
effect
 Child-only
plans in individual market: HHS issues
guidance, states react


California enacts legislation to protect children
Other states take varying approaches
50
State Exchange Development
 48
states and District of Columbia have received
planning grants
 HHS
announces early innovators grants
 Different
possible models
51
NAIC: Medical Loss Ratio
 October
21 NAIC regulation recommendation
finalized
 HHS
to issue regulation
52
Rate Review
 August
16: HHS grants awarded to 45 states and
District of Columbia
 States

reviewing existing authority
New legislation required?
 Reviews
begin
53
Funding Opportunities
 Prevention
and Public Health Fund
 Primary care workforce grants
 Medicaid Quality and Demonstration Programs
 Center for Medicare and Medicaid Innovation
 Maternal, Infant, and Early Childhood Home Visiting
Program
 State alternatives to tort litigation
54
State Challenges
 State
lawsuits
 Establishing exchanges and 16 million new
Medicaid patients by 2014
 State budgets and political environment
 Medicaid underpayment
 Grant timetables
55
AAP Division of State Government Affairs
www.aap.org/moc/stgovaffairs
56
AAP Division of State Government Affairs
[email protected]
800/433-9016 ext 7799
57
Transitions and Medical Home—
What’s on the Horizon for AAP
W. Carl Cooley, MD, FAAP
Chairperson
Transitions Clinical Report Authoring Group
American Academy of Pediatrics
Health Care Transition for All Youth
(with and without special health care needs)
Why this? Why now?

Less than half of US youth with special health care
needs get the transition support they need

Positive transitions begin with prepared youth and
families

For planned and successful health care transitions,
pediatricians and adult primary care providers need
tools and concrete methods to address barriers and
improve care
59
Help is on the way...
AAP Health Care Transition agenda
 National health care reform efforts affecting youth and
young adults
 Health care transition remains one of six performance
priorities for national maternal and child health policy
 Got Transition – new National Health Care Transition
Center

www.gottransition.org
60
AAP Health Care Transition Agenda




2007 – Improving health care transitions for youth is a “top ten”
AAP priority
2008 – National survey of AAP fellows on health care transition
issues revealed the need for more information and support
2008 – AAP/National Center for Medical Home Implementation
commissioned a review of health care transition practices, models,
and evidence base
2008 – AAP/National Center for Medical Home Implementation
Transition Advisory Meeting advised a four part agenda:
New clinical report on best practices in health care transition
2. Promote improved reimbursement and financing for Health Care
Transition (HCT)
3. Develop training and medical education resources
4. Advance health care transition research
1.
61
AAP Transitions Clinical Report Authoring Group
(TAG)
Members
W. Carl Cooley, MD, FAAP
Paul Sagerman, MD, FAAP
Michael Barr, MD, MBA – American College of Physicians
Mary Ciccarelli, MD, FAAP
Albert Hergenroeder, MD, FAAP
Thomas S. Klitzner, MD, PhD, FAAP
Laura Pickler, MD, MPH – American Academy of Family Physicians
Brad Thompson, MA
Patience White, MD, FAAP
Nicholas C. Wilkie, MA
Stuart T. Weinberg, MD, FAAP
For additional information on health
AAP Staff
Stephanie Skipper, MPH
care transitions, contact Stephanie
Skipper ([email protected] or
847/434-4918)
62
Health Care Transition Clinical Report –
2010 - 2011
Serve as basis for the four AAP HCT agenda items (best
practice, financing, education, research)
 Developed by an expert authoring group including youth
and families
 Joint endorsement by AAP, AAFP and ACP
 Reviewed by large and diverse constituency
 Planned publication in Pediatrics in early 2011
 Planned simultaneous commentary in AAFP and ACP
journals

63
Health Care Transition Clinical Report
Targets all youth
 Provides algorithm-based logical framework

Branches for youth with special health care needs
 Provides framework for future condition or specialty
specific applications

Outlines concrete elements of practice structure and
process beginning at the 12 year check-up
 Extends through the transfer of care to an adult medical
home and adult specialists

64
Health Care Transition Milestones
(from the algorithm)
Age 12 – Youth and family aware of practice’s health
care transition and transfer policy
 Age 14 – Health Care Transition Plan initiated
 Age 16 – Youth and parental expectations and
preferences regarding adult health care identified
 Age 18 – Transition to adult model of care



(as appropriate for cognitive ability)
Age 18 – 22 – Transfer of care to adult medical home
and specialists
65
Health Care Transition in Your Practice
 Three



primary elements
Preparation – assuring that young adults are ready to
manage their own health care as independently as
possible and families are ready to support this
Planning – assuring that health care transition needs
are anticipated and responsibility is clear about who
will do what and when (youth, parent,
physicians/providers)
Implementation – assuring the smooth and seamless
transition and transfer from pediatric to adult health
care
66
National Health Care Transition
Center
Jeanne W. McAllister, BSN, MS, MHA
Co-Principal Investigator
Internal Team
W. Carl Cooley, MD, co-PI
Jeanne W. McAllister, BSN, MS, MHA, co-PI
Mallory Cyr, Youth Manager
Ann Walls, MEd, Program Manager
Guided and Advised by:
A National “HCT Cabinet” meets 2X/month
A National Advisory meets 2x/year
68
Got Transition is a program of the Center for Medical Home Improvement (CMHI) of the Crotched Mountain Foundation
www.medicalhomeimprovement.org and is supported by cooperative agreement U39MC18176 HRSA/US MCHB
National Health Care Transition Center
Targets youth and young adults with special health care
needs
 Works with primary care medical homes and specialty
settings
 Aims to help these partners to implement and
disseminate health care transition best practices

69
Got Transition? – Getting to “Yes”
70
Getting to “Yes!”
These two photos courtesy of Colorado's Children and Youth with Special Health Care Needs Unit

Got Transition? Helping state and national partners measure their
progress and develop health care transition policies and initiatives

Got Transition? Hosting conversations using social media technology as
the “go to” resource for health care transition information and networking
(youth/family directed)

Got Transition? Assuring health care transition implementation in health
care practices as a result of quality improvement learning collaboratives
(Washington, DC; Denver, and Boston)

Got Transition? Providing easy access to proven health care transition
tools for professionals, youth, and families (website, dissemination
professional organization, integration current toolkits )

Got Transition? Promoting policy changes for better access to health care
transition services including improved health care provider reimbursement
71
Support for pediatric transformation leads to 30% improvement overall in 3 years, n=10.
72
Medical Home Index HCT Measure CYSHCN (1-8 scale)
Current and 2004 Sample of 12 Pediatric Medical Home Practices
“Basic” 1-2; “Responsive” 3-4; “Proactive” 5-6; “Comprehensive” 7-8
73
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Change Package (steps/tools)
Pediatric Health Care Setting
Adult Health Care Setting
Policy & Education
Policy
Transition Registry
Registry
Transition Preparation
Transition Preparation
(counterpart)
Transition Planning
Transition Planning (counterpart)
Transition/Transfer of Care
Transition/Transfer of Care
Transition Closure (achieve)
Transition Closure (declare)
75
National Health Care Transition Center
Coming soon!
www.gottransition.org
Contact… Ann Walls, MEd, Program Manager
[email protected]
76
Next Information Sharing Webinar
 Save

the Date!
Next medical home leadership webinar tentatively
scheduled for February/March 2011
 Webinar

Recordings
All medical home leadership webinars will be recorded
and posted on the National Center Web site:
http://medicalhomeinfo.org/training/webinars.aspx
77
NEW National Center for Medical Home
Implementation Facebook Page
Facebook has quickly become one of the top search engines on the Web and a
valuable source for building a sense of community amongst followers.
Goals
 Expand the reach and diversity of audience
 Create awareness of the National Center and its available resources
 Drive traffic back to Web site
Features
 Wall of posts spotlighting the timely
news and resources available from the
National Center and our partners
 Medical Home overview tab
 AAP YouTube Channel tab featuring the
Medical Home Child Health Day video
 AAP Twitter feed tab highlighting the
latest news from the AAP
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Thank You!
Questions?
Contact:
Suzi Montasir, MPH
Program Manager,
AAP Division of Children with Special Needs
800/433-9016, ext 4311
[email protected]
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