Transcript Medical home project data

What is the Medical Home for
Children with Chronic Medical
Conditions?
Insights for Improvement
Elisabeth Dellon, MD, MPH: Pediatric Pulmonology
Michael Steiner, MD: General Pediatrics and
Adolescent Medicine
Rachael Carr, BA
Healthcare for Children with
Special Healthcare Needs
 Children and families with special
healthcare needs (CSHCN) often straddle
primary (PCP) and subspecialty care
 Understanding and improving that interplay
has the potential to simultaneously improve
health outcomes and lower the cost of care
Healthcare for Children with
Special Healthcare Needs
 Primary care medical homes and
subspecialty physician shortage
 Right care, right time
– Ideally high quality, accessible care would occur
in medical homes when possible
– Subspecialty care would be accessible, and
used by PCPs and families only when needed
Study
 Objective: Examine the interplay between
families, PCP, and specialty care for CSHCN
from multiple perspectives.
 Goal: To identify variables that impact
where and when families use PCP or
specialist for care
– Eventually be able to ‘turn-up’ or ‘turn-down’
important variables so that care is pursued
where quality will be highest and cost lowest
Methods
 3 phase study, mixed methods study
 1st Phase
– Survey and interview families of CSHCN as they
return for specialty care
•Explore perspectives on child’s health
•Medical home qualities of both PCP and specialty
care setting
•Why they decide to seek care at specialist or PCP for
a discrete problem
Methods
 2nd Phase
– Survey subjects’ PCP offices about practice
characteristics
– Catalog a series of patient contacts with
subspecialty nurses or administrators
– Review PCP clinical notes for those subjects
past 12 months
– Review specialist clinical notes for past 12
months
Methods
 3rd Phase---preparing to enroll
– Brief survey to large volume of children seeking
specialty care to better understand how
demographic variables impact specialty v. PCP
decisions
Results: Caregiver Survey and Interview
Characteristic
Age of child receiving specialty care
Health care coverage
NC Medicaid
Distance to UNC from home
N (%) or Median (range)
8 years (1-17 years)
50 (100%)
24 (48%)
49.6 miles (12-220 miles)
Number of chronic medical conditions
2 (1-8)
Number of specialists seen in past year
4 (1-12)
Caregiver rating of child’s health
Excellent/very good
Good
Fair/poor
15 (30%)
20 (40%)
15 (30%)
Caregiver rating of child’s health now compared
with one year ago
Better
Same
Worse
16 (32%)
24 (49%)
9 (18%)
Results: Caregiver Survey and Interview
Characteristic
N (%) or Median (range)
Caregiver age
38 years (23-55 years)
Female gender
45 (92%)
Relationship to child
Parent
Grandparent
Legal guardian
46 (94%)
2 (4%)
1 (2%)
Caregiver educational level
Less than high school
High school or GED
Some college or 2-year degree
College graduate
Post-graduate degree
3 (6%)
5 (10%)
21 (43%)
16 (33%)
4 (8%)
Percent of Subjects with Varying
Chronic medical conditions
Sickle cell disease
Permanent deformity of…
Muscular dystrophy
HIV/AIDS
Hemophilia
Spina bifida
Severe scoliosis
Recurrent urinary tract…
Overweight
Inflammatory bowel disease
Down Syndrome
Cleft lip/palate
Autism/spectrum disorder
Dermatologic
Metabolic disorder
Kidney disease
Hypothyroidism
Diabetes
Chronic ear infection
Cerebral palsy
Heart disease or heart…
Eating disorder
Depression
Cystic fibrosis
Arthritis
Severe allergies
Leukemia or other cancer
Other condition
Deafness/trouble hearing
Blindness/trouble seeing
Attention…
Seizure disorder
Asthma
Developmental Delay
0
5
10
15
20
25
30
35
Percent of Subjects Seeing Each
Specialist Type
Neurosurgery
Neonatology/special infant care
Plastic surgery
Craniofacial
Urology
Orthopedics
Infectious diseases
Hematology
Developmental/behavioral
Psychology
Immunology
Psychiatry
Rheumatology
Nephrology
Dermatology
Surgery
Pulmonology
Genetics/metabolism
Cardiology
Allergy
Physical medicine/rehabilitation
Endocrine
Otorhinolaryngology/ENT
Gastroenterology
Neurology
Ophthalmology
0
5
10
15
20
25
30
35
40
Healthcare Utilization During
Past Year
Seen by PCP
Seen by specialist
Not at all
1-2 times
3-5 times
6-12 times
13+ times
ER visit
Hospital stay
Caregiver missed work
0%
20%
40%
60%
80%
100%
Who Do Parents Call When Child
Has An Acute Health Problem
Regular Business
Hours
Provider
PCP
Specialist
Emergency room
None (wait until
morning)
Primary
Typical
Chronic Childhood
Condition
Illness
15 (30%) 41 (85%)
35 (70%)
7 (15%)
----
n/a
After Hours/
Weekends
Primary
Chronic
Condition
14 (30%)
25 (53%)
8 (17%)
Typical
Childhoo
d Illness
27 (61%)
8 (18%)
7 (16%)
--
2 (5%)
Why Parents Report They Make
Those Call Decisions
Regular Business
Hours
Reason Given
Trust provider more than others
Provider returns my calls quickly
Provider listens to my concerns
Provider is respectful of child and family
Provider knows more about child’s
condition than others
Provider will see child same day
Good relationship with provider
Good relationship with staff
Costs less than other providers
Insurance dictates who to call
Provider lets me know about results
Provider values my opinion
Don’t have a long wait
Convenient location
Usually seen by same provider
Provider requested we contact them first
After Hours/
Weekends
Primary
Chronic
Condition
23 (46%)
7 (14%)
11 (22%)
4 (8%)
42 (84%)
Typical
Childhood
Illness
12 (24%)
9 (18%)
7 (14%)
4 (8%)
16 (32%)
Primary
Chronic
Condition
16 (32%)
13 (26%)
10 (20%)
6 (12%)
25 (50%)
Typical
Childhood
Illness
10 (20%)
12 (24%)
9 (18%)
1 (4%)
13 (26%)
13 (26%)
12 (24%)
11 (22%)
1 (2%)
2 (4%)
3 (6%)
10 (20%)
4 (8%)
6 (12%)
3 (6%)
8 (16%)
26 (52%)
12 (24%)
5 (10%)
1 (2%)
8 (16%)
2 (4%)
6 (12%)
6 (12%)
20 (40%)
2 (4%)
7 (14%)
11 (22%)
12 (24%)
6 (12%)
1 (2%)
4 (8%)
5 (10%)
6 (12%)
5 (10%)
11 (22%)
1 (2%)
7 (14%)
14 (28%)
10 (20%)
2 (4%)
2 (4%)
5 (10%)
-3 (6%)
3 (6%)
14 (28%)
-5 (10%)
Reasons For Calls to Specialty Nurses
 Total of 866 calls
logged by 15
specialty nurses
 704 calls (81%) were
related to the
medical condition
addressed by the
specialist
Reason for call
Request clinic appointment
Medication question
Test results
Medication refill request
Follow-up
Sick call
Procedure appointment
Request to speak to MD
Forms for school/camp
Need referral
Insurance question
Appeal prior authorization
Adverse medication reaction
School/work excuse
Transportation concern
Results from other specialty
Other
N (%)
173 (20%)
153 (18%)
95 (11%)
77 (9%)
79 (9%)
79 (9%)
60 (7%)
29 (3%)
27 (3%)
20 (2%)
16 (2%)
18 (2%)
21 (2%)
19 (2%)
6 (1%)
8 (1%)
100 (12%)
Family Perception of Medical Home
Characteristics of PCP Care
100
90
80
70
60
50
40
30
20
10
0
Parent
Perception of
PCP, Always
Responses
PCP Report of Medical Home
Characteristics of PCP Practice
 75% response rate
 19% Medical home designation by NCQA
PCP Report of Medical Home
Characteristics of PCP Practice
100
90
80
70
60
50
40
30
20
10
0
Parent
Perception of
PCP
PCP
Response
Family Perception of Medical Home
Characteristics of Specialty Care
100
90
80
70
60
50
40
30
20
10
0
Parent Perception
of PCP
PCP Response
Parent Perception
of Specialist
Next Steps
 Analyze and compare chart extraction data
from PCP and specialist clinical notes
 Examine documented communication
between those
 Large sample to further examine
sociodemographic characteristics
Summary
 CSHCN have multiple problems & see multiple
specialists
 Report more specialty visits per year than PCP
visits
 Parents contact their specialists for care of the
chronic medical problems, and PCP for typical
childhood illnesses
 Many parent contacts to specialists could be
handled at PCP office
Summary
 Parental decisions of who to call for questions
seem most influenced by
– Provider who knows child best
– Access to appointments and convenient location
– Trust
 Families perceive less medical home characteristics at
PCP than reported by those practices
 Families perceive more medical home characteristics in
specialty care than PCP
Discussion
 Current care for CSHCN likely maldistributed, with
too high of a proportion of care done at specialists
– Changing family decision about care seeking for CSHCN
could dramatically affect this
– Could increase contact with PCP, lower contact with
specialist which would improve specialist access
 Need to increase parent sense that PCP has
– Knowledge of child’s condition
– Access and convenience
– Trustworthy
Discussion
 Do PCPs help create this problem by not actively
managing chronic problems where specialist has
seen child?
– Eg “You need to call UNC for that”
 Do specialists worsen this by
– Too many F/U appointments instead of transferring
care back to PCP
– Not communicating to PCP
– Giving family message that only a specialist should care
for this problem
Questions
 Questions
 [email protected]
 [email protected]
 Thank you to Access Care/Medicaid for
funding study
 Thank you to Steve Wegner and Alan Stiles
for guidance and supervision of project
Hidden Slides
Medical care during past year
Not at all
1-2 times
3-5 times
6-12 times 13+ times
Seen by PCP
1 (2%)
16 (32%)
14 (29%)
11 (22%)
7 (14%)
Seen by specialist
--
7 (14%)
15 (31%)
13 (27%)
14 (29%)
Required ER visit
27 (55%)
11 (22%)
7 (14%)
4 (8%)
--
Separate hospital stays 27 (56%)
12 (25%)
7 (15%)
1 (2%)
1 (2%)
Missed work*
8 (17%)
9 (18%)
14 (29%)
6 (13%)
11 (23%)
PCP practice demographics
Characteristic
N (%) or median (range)
Practice type
Pediatrics
Family medicine
26 (84%)
5 (16%)
Practice established
< 5 years ago
6-10 years ago
11-20 years ago
>20 years ago
1 (3%)
8 (25%)
11 (36%)
11 (35%)
Percent of patients with Medicaid
35 (8-95%)
Regular practice hours
< 40 per week
40-50 per week
> 50 per week
4 (13%)
20 (64%)
7 (23%)
“Extra” availability
Weekend hours
Morning walk-in
Evening walk-in
26 (84%)
14 (45)
14 (45)
Share call with other practices
8 (26%)
Response time to calls during regular business hours
Within the hour
Same half day
By end of same day
By next business day
19 (61%)
4 (13%)
3 (10%
3 (10%)
Other features of primary care
practices
N (%)
Nurse coordinator available
25 (81%)
E-mail communication available
9 (29%)
Non-English written materials available
26 (84%)
Spanish interpreter used
28 (90%)
Patients charged for phone calls
0 (--)
Patients charged for appointment no-shows
11 (35%)
Patients charged for late cancellations
4 (13%)