Transcript Managed Care for People with Disabilities Purchasing Institute

Medical Home: Just What the Doctor
Ordered to Fix American Healthcare?
GIH Teleconference
Richard C. Antonelli, MD, MS
Associate Professor of Pediatrics
Univ of Connecticut School of Medicine
Senior Fellow Child Health and Development Institute
September 29, 2008
Learning Objectives
• Articulate the key components of pediatric
Medical Home
• Understand primary care-based pediatric care
coordination and how it is different than adult CC
• Articulate a process to measure care
coordination in the pediatric primary care setting
• Describe the different challenges and
opportunities to provide care coordination to
children and youth with special health care
needs
“Care coordination is the
answer!”…
…“What’s the question?”
Carolyn Clancy, MD,
Director, AHRQ
Definition of Medical Home
• Care that is:
– Accessible
– Family-centered
– Comprehensive
– Continuous
– Coordinated
– Compassionate
– Culturally-effective
Definition of Medical Home
• And for which the primary care provider
shares responsibility with the family.
AAP/ AAFP/ NAPNAP/
ACP/ AOA
Patient-Centered Medical Home
Joint Principles Statement
• Major Focus of Advocacy for All Primary Care
Specialties
• Relationship between PCP and patient (adult
MH) versus family (pediatric MH)
• Quality
• Access
• Equity
• Financing
Care Model for Child Health in a Medical Home
Health System
Community
Resources
and
Policies
Health Care Organization (Medical Home)
Care
Partnership
Support
Supportive,
Integrated
Community
Family centered
Delivery
System
Design
Decision
Support
Informed,
Activated
Patient/Family
Timely &
efficient
Evidence-based &
safe
Clinical
Information
Systems
Prepared,
Prepared,
Proactive
Proactive
Practice
PracticeTeam
Team
Coordinated and Equitable
Functional and Clinical Outcomes
What is Care Coordination?
• Depends who you ask.
• A process that facilitates the linkage of
children and their families with appropriate
services and resources in a coordinated
effort to achieve good health.
AAP 2005
What Is Case Management?
• Began in era of managed care as
mechanism of ensuring access to
appropriate benefits package of services:
utilization review approach.
• Any effective, sustainable communitybased Medical Home system must support
linkages between practice-based CC and
community-based CM!
What Constitutes CC in a
Pediatric Medical Home?
Medical Home Care Coordination Measurement Tool©
Patient Name
Date
Patient Study Code
And Age
Patient
Level
Patient Level
Focus
Care Coordination
Needs
Activity Code(s)
Care Coordination Needs
(choose all that apply)
Site Code: ___
Outcome(s)
Prevented
Occurred
Activity to Fulfill Needs
(choose all that apply)
Level Description
I
Non-CSHCN, Without Complicating
Family or Social Issues
II
Non-CSHCN, With Complicating
Family or Social Issues
III
CSHCN, Without Complicating
Family or Social Issues
IV
CSHCN, With Complicating Family
or Social Issues
Focus of Encounter (choose ONLY ONE)
1. Mental Health
2. Developmental / Behavioral
3. Educational / School
4. Legal / Judicial
5. Growth / Nutrition
6. Referral Management
7. Clinical / Medical Management
8. Social Services (ie. housing, food, clothing, ins., trans.)
Rev-03/20/03
1. Make Appointments
2. Follow-Up Referrals
3. Order Prescriptions, Supplies,
Services, etc.
4. Reconcile Discrepancies
5. Coordination Services (schools,
agencies, payers etc.)
Time Spent
1 – less than 5 minutes
2–
5 to 9 minutes
3 – 10 to 19 minutes
4 – 20 to 29 minutes
5 – 30 to 39 minutes
6 – 40 to 49 minutes
7 – 50 minutes and greater*
( *Please NOTE actual minutes
if greater than 50)
Staff
RN, LPN, MD, NP, PA, MA, SW, Cler
Clinical Competence
C= Clinical Competence required
NC= Clinical Competence not
Required
1. Telephone discussion with:
a.
b.
c.
d.
Patient
Parent/family
School
Agency
e. Hospital/Clinic
f. Payer
g. Voc. / training
h. Pharmacy
2. Electronic (E-Mail) Contact with:
a.
b.
c.
d.
Patient e. Hospital/Clinic
Parent
f. Payer
School g. Voc. / training
Agency h. Pharmacy
3. Contact with Consultant
a. Telephone c. Letter
b. Meeting d. E-Mail
4. Form Processing: (eg. school, camp, or
complex record release)
5. Confer with Primary Care Physician
6. Written Report to Agency: (eg. SSI)
7. Written Communication
a. E-Mail
b. Letter
8. Chart Review
9. Patient-focused Research
10. Contact with Home Care Personnel
a. Telephone c. Letter
b. Meeting d. E-Mail
11. Develop / Modify Written Care Plan
12. Meeting/Case Conference
Form # ___ of ___
Time Spent*
1 2 3 4 5 6 7
Staff
Clinical
Comp.
Initials
Outcome(s)
1. As a result of this care coordination activity, the following was
PREVENTED (choose ONLY ONE, if applicable):
1a. ER visit
1b. Subspecialist visit
1c. Hospitalization
1d. Visit to Pediatric Office/Clinic
1e. Lab / X-ray
1f. Specialized Therapies (PT, OT, etc)
2. As a result of this care coordination activity, the following
OCCURRED (choose all that apply):
2a. Advised family/patient on home management
2b. Referral to ER
2c. Referral to subspecialist
2d. Referral for hospitalization
2e. Referral for pediatric sick office visit
2f. Referral to lab / X-ray
2g. Referral to community agency
2h. Referral to Specialized Therapies
2i. Ordered prescription, equipment, diapers, taxi, etc.
2j. Reconciled discrepancies (including missing data,
miscommunications, compliance issues)
2k. Reviewed labs, specialist reports, IEP’s, etc.
2l. Advocacy for family/patient
2m. Met family’s immediate needs, questions, concerns
2n. Unmet needs (PLEASE SPECIFY)
2o. Not Applicable / Don’t Know
2p. Outcome Pending
R. Antonelli, MD, FAAP
Supported by grant HRSA-02-MCHB-25A-AB
National Study of Care Coordination Measurement in Medical Homes
Antonelli, Stille, and Antonelli, 2008
Focus of Encounter – Aggregate Data –
Primary Focus
% Encounters
Clinical / Medical Management
67%
Referral Management
13%
Social Services (ie. Housing, food, clothing…)
7%
Educational / School
4%
Developmental / Behavioral
3%
Mental Health
3%
Growth / Nutrition
2%
Legal / Judicial
1%
Outcome Prevented – Aggregate Data
Antonelli, Stille, and Antonelli, 2008
The CCMT allows only one outcome prevented per encounter.
32% of total 3855 CC encounters prevented something.
Of the 1232 CC Encounters where prevention was noted as an outcome:
Outcome Prevented
Visit to Pediatric Office / Clinic
Emergency Department Visit
Subspecialist Visit
Hospitalization
Lab / X-Ray
Specialized Therapies
# CC Encounters
714
323
124
47
16
8
Percentage
58%
26%
10%
4%
1%
1%
62% of RN CC Encounters prevented something.
33% of MD CC Encounters prevented something.
RNs are responsible for coding 81% of the Emergency Department preventions and
63% of the sick office visit preventions.
Health Outreach for Medical Equality (HOME)
• Pilot Project to Assess Feasibility and Outcomes
of Co-Located CC model in an urban pediatric
setting
• CC provided by Community-based partner
(Hispanic Health Council) with clinic and
community-based CC
• Funded by Hartford Foundation for Public
Giving, Children’s Fund of CT/ Child Health and
Development Institute, Conn Children’s Medical
Center, and CT Medicaid agency
Implications for Policy and
Practice
• With the advent of Patient-Centered Medical
Home, all primary care provider organizations are
focusing on CC as critical function
• Payers and purchasers are looking at P4P to
incentivize CC
• CC for adult chronic condition CC is very different
from pediatric CC
Implications for Policy and Practice
• Pediatric disease-specific CC (aka, chronic
condition management/ CCM) should be quite
implementable
• However, comprehensive pediatric CC is not the
same as CCM
• Mechanisms of operationalizing and measuring
CC functionality at MH practice level must be
developed
• CC as a discipline must be developed in order to
achieve high performing health care system
Transition for Youth
You think pediatrics or adult CC is
difficult, what about Transitioning
youth with chronic conditions from
one side of the chasm to the
other?
Outcome Realities YSHCN
• 90% of YSHCN reach their 21st birthday
• Nearly 40% cannot identify a primary care
physician
• 20% consider their pediatric specialist to be their
‘regular’ physician
• Significant numbers have extensive primary
health concerns that are not being met
• Fewer work opportunities, lower high school
grad rates and high drop out from college
CHOICES Survey, 1997; NOD/Harris Poll, 2000; KY TEACH, 2002
What Can Be Measured re:
CC?
• Pediatric Medical Home
– Parent/ youth partners in QI at practice level
– Developmental and behavioral screening
– Screening for secondary disabilities (much less
prevalent than adult practice)
– Presence of registry and its utilization
– Development and deployment of Care Plans (these
have CPT codes already)
– Mechanism for linkage from practice-based CC to
community-based CM
– Training opportunities for CC’ers
– ED and in-patient utilization for patients with chronic
conditions
How Can We Improve Quality and
Increase Capacity?
• Co-Management as means of increasing
access and quality:
Targeted Child Psychiatric Services
Connor, Antonelli, et al (Clinical Pediatrics, June, 2006)
What Will Incentivize Change In
Primary Care?
• Patient-Centered Primary Care
Collaborative (PCPCC)
• Medicare Medical Home Pilots (2009)
• State Level Medicaid Medical Home
Projects
– North Carolina
– Minnesota
• NCQA
PCMH-PPC: NCQA, AAFP,
ACP, AAP and AOA
Medical Home Qualifying Criteria
Linked to Reimbursement
NCQA
Standard 1: Access and Communication
A. Has written standards for patient access and patient
communication**
B. Uses data to show it meets its standards for patient
access and communication**
Pt
4
5
9
Standard 2: Patient Tracking and Registry Functions
A. Uses data system for basic patient information
(mostly non-clinical data)
B. Has clinical data system with clinical data in
searchable data fields
C. Uses the clinical data system
D. Uses paper or electronic-based charting tools to
organize clinical information**
E. Uses data to identify important diagnoses and
conditions in practice**
F. Generates lists of patients and reminds patients
and clinicians of services needed (population
management)
Pt
Standard 3: Care Management
A. Adopts and implements evidence-based guidelines
for three conditions **
B. Generates reminders about preventive services
for clinicians
C. Uses non-physician staff to manage patient care
D. Conducts care management, including care
plans, assessing progress, addressing barriers
E. Coordinates care//follow-up for patients who
receive care in inpatient and outpatient facilities
Pt
2
3
3
6
4
3
21
3
4
3
5
5
20
Standard 4: Patient Self-Management Support
A. Assesses language preference and other
communication barriers
B. Actively supports patient self-management**
Pt
2
4
Standard 5: Electronic Prescribing
s A. Uses electronic system to write prescriptions
B. Has electronic prescription writer with safety
checks
C. Has electronic prescription writer with cost
checks
Pts
3
3
Standard 6: Test Tracking
s A. Tracks tests and identifies abnormal results
systematically**
B. Uses electronic systems to order and
retrieve tests and flag duplicate tests
Pts
7
2
8
6
13
Standard 7: Referral Tracking
A. Tracks referrals using paper-based or electronic
system**
PT
4
Standard 8: Performance Reporting and
Improvement
A. Measures clinical and/or service performance by
physician or across the practice**
B. Survey of patients’ care experience
s C. Reports performance across the practice or by
physician **
D. Sets goals and takes action to improve
performance
E. Produces reports using standardized
measures
F. Transmits reports with standardized
measures electronically to external entities
Pts
Standard 9: Advanced Electronic
Communications
A. Availability of Interactive Website
s B. Electronic Patient Identification
C. Electronic Care Management Support
Pts
1
2
1
4
3
3
3
3
2
1
15
4
Useful Websites
• http://www.medicalhomeinfo.org: American
Academy of Pediatrics hosted site that provides
many useful tools and resources for families and
providers
• http://www.medicalhomeimprovement.org: tools
for assessing and improving quality of care
delivery, including the Medical Home Index, and
Medical Home Family Index
References
•
•
•
•
•
•
Antonelli, RC, Stille, C, and Antonelli, DM, Care coordination for children and
youth with special health care needs: a descriptive, multisite study of activities,
personnel costs, and outcomes. Pediatrics. 2008 Jul;122(1):e209-16
Turchi, R, Gatto, M, and Antonelli, R, Children and Youth with Special Health
Care Needs: There is No Place Like (a Medical) Home, Curr Opin Pediatr
2007, 19: 503.
Connor, D, McLaughlin, T, Jeffers-Terry, M, O’Brien, W, Stille, C, Young, L, and
Antonelli, R, Targeted Child Psychiatric Primary Clinician-Child Psychiatry
Collaborative Care, Clin Pediatr. 2006; 45:423-434.
Antonelli, R., Stille, C., Freeman, L.,Enhancing Collaboration: Roles of Primary
and Subspecialty Care Physicians in Providing a MH for CYSHCN, MCHB,
Georgetown Univ, 2005.
Stille, C and Antonelli, R, Coordination of care for children with special health
care needs, Curr Opin Pediatr 2004;16:700-705.
Antonelli, R and Antonelli, D, Providing a medical home: the cost of care
coordination services in a community-based, general pediatric practice,
Pediatrics 2004; 113:1522-1528
References (continued)
•
McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with
special health care
needs. Pediatrics, 102,137–140
• Committee on Children with Disabilities, American Academy of Pediatrics. (1999).
Care coordination:
Integrating health and related systems of care for children with special needs.
Pediatrics, 104(4, Part 1),
978–981
• Committee on Quality of Health Care in America, Institute of Medicine. (2001).
Crossing the quality chasm:
A new health system for the 21st century
•
Friedman, Mark, “Trying hard is not enough”; excellent reference on “Results-Based
Accountability”.