Bringing Family Back into the Medical Home

Bringing Family Back into the Medical Home

Barry J. Jacobs, PsyD, Crozer-Keystone Family Medicine Residency Program

Maureen P. Davey, PhD, LMFT, Drexel UniversityJennifer L. Hodgson, PhD, East Carolina University

David B. Seaburn, PhD, LMFT, Private PracticeCollaborative Family Healthcare Association 13th Annual Conference

October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #A3October 28, 20113:30 AM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

What is the scientific basis for this talk?

--Review of empirical literature on efficacy of family-based interventions on patient clinical outcomes

--Observations of clinician-educators, as well as outcome studies, of specific family-based healthcare programs in North

Carolina and Philadelphia

Objectives

--Cite 3 key empirical studies that demonstrate the importance of family involvement to patient clinical outcomes

--Describe 2 models for involving family members in the collaborative healthcare team

--Identify core skills, derived from Medical Family Therapy, for healthcare and social service professionals to establish

collaborative relationships with family members--Describe how family systems concepts can improve the

functioning of collaborative healthcare teams

Expected Outcome

What do you plan for this talk to change in the participant’s practice?

--Participants will learn about the importance of involving patients’ family members in the collaborative healthcare

team.--They will learn specific models and skills for integrating family

members into that team.

Learning Assessment

A learning assessment is required for CE credit.

Attention Presenters:Please incorporate audience interaction through a

brief Question & Answer period during or at the conclusion of your presentation.

This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy

accreditation requirements.

TODAY’S TALK

• Introduction on importance of family involvement in the Medical Home

• Research highlights on family-based interventions

• Key concepts of family-centered healthcare• A model of family-centered care for HIV-

infected children• A family-centered, primary care model• Comments and discussion

INTRODUCTION

• Why do we say “back into the Medical Home?”

• Because the hottest trend in American healthcare delivery during the past 5 years—the “Patient-Centered Medical Home”—placed little emphasis on engaging family members in patients’ healthcare, despite a long tradition of family-oriented approaches to health, especially in primary care

THE HOME THAT WAS BUILT

• In 2007, American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, American Osteopathic Association released Joint Principles of Patient-Centered Medical Home (PCMH)

• Cited 7 key principles—personal physician, physician-directed practice, whole person orientation, coordinated/integrated care, enhanced quality, access and payment

• Scant mention of patients’ families

HOME (cont.)

• On basis of these principles, the National Committee for Quality Assurance (NCQA) began accrediting medical practices as “medical homes”

• In many regions, these practices received increased insurance reimbursement for their innovations

• Few of these practices have family-centered care or clinicians with family systems training

THE PENDULUM SWINGS

• The PCMH seemed a rebuff to long tradition of family-centered care

• Within family medicine:• 1977--Geyman: “It is axiomatic that family is

the basic unit of care in family practice…”• 1983--Doherty & Baird: “therapeutic triangle”:

patient-family-physician• 1983—Bloch founds Family Systems Medicine

PENDULUM (cont.)

• 1990—Publication of Family-Oriented Primary Care by McDaniel, Campbell & Seaburn

• 2003—AAFP practice monograph by McBride on 6 principles of family-oriented medical practice

• None of their conceptual frameworks or clinical practices were incorporated into the PCMH

SWINGING BACK?

• 2010—Stille et al—Medical Home in pediatrics should be “family-centered”

• Same emphasis on “family-centered” care in geriatrics (e.g., Gaugler, 2005; NAC, 2009)

• Information systems advances: Patient and family portals—adopted by many healthcare systems in last 2 years—offers new opportunities for involving family members in patients’ care

JACOBS (2010)--FCMH

• Valuing family member’s expertise and engaging them in process of improving quality

• Including family members as full-fledged or quasi-treatment team members

• Family access to information and secure emailing through EMR patient portal

• Family advisory councils, family educator groups, family caregiver mentoring groups

PLACE IN THE HOME?

• Will family-oriented approaches to healthcare regain traction?

• Will depend on evidence-based practices and demonstrated clinical outcomes

• We have to show that involving family improves patient clinical outcomes

• Also show it decreases family member morbidity (e.g., reduce caregiver depression)

SOME OF OUR FAVORITE RESEARCH

• Little research on families and Medical Home• Recent studies from variety of disciplines on family

impact on health and illness:• Having family member present during medical visit

increases patient’s satisfaction with physician (Wolff, Roter, 2008)

• Involving a spouse in care for a chronically ill patient decreases patient’s depression and, in some cases, decreased mortality (Martire et al, 2004)

RESEARCH (cont.)

• Involving family members in an adult’s diabetic care increases family supportive behaviors, improves patient’s knowledge about and attitude toward diabetes (Kang et al, 2010)

• Supporting family caregivers can delay an Alzheimer’s patient’s nursing home placement for nearly 2 years (Mittelman et al, 2006)

• Please see bibliography for more

A FAMILY FRAMEWORK

• Family Social Context

• Family Context of Illness Meaning

• Family Contributor to Problem

• Family Partner in Care

FAMILY AS SOCIAL CONTEXT

No organism can be understood apart from the context in which it was shaped. The family is the first and often the most lasting influence on its members.

FAMILY AS CONTEXT OF MEANING

We create meaning through dialogue in the context of relationships. Family is the first shaper of illness meanings.

FAMILY AS CONTRIBUTOR TO THE PROBLEM

Illness in a family member can be maintained by family dynamics.

FAMILY AS PARTNER IN CARE

• Partnership with the family is essential when working with chronic and terminal illness.

The Dorothy Mann Center for Pediatric & Adolescent HIV at St. Christopher's Hospital for Children/Drexel University College of Medicine:

A Model of Family-Centered Care

Dr. Jill Foster, MD, DirectorMaureen Davey, PhD, LMFT

Drexel UniversityDepartment of Couple and Family Therapy

HIV Affects Families in the US• CDC estimates that more than one million people are living

with HIV in the United States (www.cdc.gov). • One in five (21%) of those people living with HIV is unaware

of their infection.

• In tens of thousands of families,Parents will need to tell their

children that they have HIV

• In thousands of families, Parents will need to tell their children that they too have HIV

Model of Family-Centered Care:

The Dorothy Mann Center for Pediatric & Adolescent HIV at St. Chrisopher’s Hospital for

Children

Demographics of North Philadelphia

• 44% African American, 9% Latino/a, and 5% Asian. • A quarter of the cities’ families live below the federal poverty

level. • 1 in 16 households receive public assistance. • Minority families in Philadelphia with HIV face the associated

co-morbidities of substance abuse, domestic violence, low literacy, and mental health issues

• The median rate of new AIDS cases in Philadelphia is approximately 1,000 per year.

• For Philadelphia, the epidemic is primarily heterosexual and black—44% of the population is black, but 70% of AIDS cases are black.

History of Services at St. ChrisYearYear Type of ProviderType of Provider StrengthsStrengths ChallengesChallenges

1988-1999 Social Workers Case management, Grief counseling

No supervisionNo partnering with parents/familiesShort-term therapy

1999-2000 Child Psychologist for ½ day per week

High level of expertise with children’s mental health issues

Individual child therapyNo adult/family work

2000-Present Child Psychiatrist Medication Evaluations Limited availability for adultsLimited availability for therapyNo family/couples therapy

2000-2002 Individual master’s level therapist for 2 days/week

First time having a therapist dedicated to mental health of all clinic’s patients.

Unable to billLimited Experience with children/teens and familiesUnable to attend weekly team meeting

2002-2006 Community mental health family therapist and a family therapy intern from Drexel’s CFT department

Dedicated therapy services at an agency, separated from patients’ HIV care.

High turn over of therapist at agency (3 therapists over 4 years with gap in services)Two medical records

2006-Present 2 Family therapists on site and family therapy interns from Drexel’s CFT department

Dedicated family therapy and child/youth servicesAttends team meetings and active collaboration with medical staffOne medical record

Funding---Ryan White Titles I Patchwork of funding for services

Current Services at St. Chris• “One Stop Shopping Model” for 160 HIV+ positive

children/youth, 60 HIV + adults, and 300 families affected by HIV:

– Medical Care– Case Management– Nutritional Counseling– Family Therapy (75% patients and increasing)

– Psycho-educational Support Groups– Patchwork of Funding (Ryan White Title I and

Medicaid)

Multidisciplinary Collaboration• Multidisciplinary Clinic Comprised of:

– Physicians and a Part-time Psychiatrist– Midlevel practitioners (e.g., Nurses, Physician Assistants)– Social Workers– Child life specialist– 2 Family Therapists and Family Therapy Interns– Community Based Case Mangers/Action AIDS

• Family-centered Collaborative Model:– One Medical Record and integrative treatment plan– Weekly team meetings and meetings as needed to coordinate care– Leveling of hierarchy (providers ‘speak’ same language)– Co-provision of services– Family support and ongoing psychological assessments to target

treatment

Primary Care (All Patients)

Specialty Care (HIV Positive and Exposed)

ClinicalHealth maintenance visits including routine gynecologic careDevelopmental screening for childrenLaboratory supportAnticipatory Guidance

Routine HIV care including history, physical examination, prescription of HAART and OI prophylaxis; infant testingAdherence support and Risk Reduction Counseling

Social Work Medical Case Management

Basic assistance with housing, insurance, and referrals to other agencies as needed

On site and in collaboration with outside partners including ActionAIDS and Health Federation of Philadelphia

Psychosocial Support

Individual, couples, and family counseling, child life, prevention case management

Support groups for HIV positive youth, family therapy (both on site and in-home services), coordination with partner notification services

Current Clinical Services

Benefits of family-centered care for children/youth coping with HIV• Higher self-esteem• Better coping skills• Helps garner sources of social support• Less depression/anxiety• Improved treatment retention & adherence• Better long-term health

and emotional well-being

Wiener et al., 2007

Benefits of family-centered care for families coping with HIV

• Recent studies1 demonstrate that other family members’ anxiety, depression, and paranoid thoughts impact on the health of HIV positive family members

• Less depression/anxiety among caregivers• Improved trust/attachment with child/youth

– facilitating open family communication– Improving treatment adherence – Increasing family closeness and social support– decreasing feelings of isolation and stigma

1Alexander et al., APHA 2008

GIVEN THAT THERE ARE SO MANY BENEFITS…

Collaborative Family-centered care is the exception rather than the rule for patients coping with HIV

Davey et al, 2008

Barriers:Funding for family-centered careSuccessful collaborative models

Getting Started• Assessment of patient and family

– Biopsychosocial Assessment (1-3 sessions)– Combination of parent/youth individual sessions– Genogram

• Assessing for Family Support– Has the parent/youth disclosed HIV status to anyone?– Do other people in the household know about the

child’s/youth’s diagnosis– Is the living situation stable?– May need to involve another caregiver to support teen,

parent (e.g., fictive kin, aunt, grandmother)

Helping People with HIV– Disclosure & Psychological impact of HIV

• Decrease anxiety, depression• Increase coping skills

– Compliance with medical regimes• Compliance is related to positive affect, adaptive

coping, and social support

– Increasing family support• Reduce stigma, fear, blame• Reduce rejection by others

- Palliative CareJohnson, et al. (2009)

CASE DISCUSSION:

Case: Donna and Family• 30 year old mom (Donna) who has HIV is parenting

2 school-age children– Donna recently developed resistance to her HIV

medications from prior poor adherence and is now progressing to chronic renal failure and dialysis

– Donna has a long trauma history• Infected in her mid-teens through sexual abuse and had an HIV+

baby from that assault who was placed in foster care and eventually adopted by another family

• In her mid-20’s Donna had 2 HIV- children and was a wonderful parent

– Donna was never able to take her HIV meds without experiencing them as a result of the sexual abuse

Donna and Family (Cont’d)• Family Therapy was critical to help Donna make a decision

about whether or not to continue on dialysis or go to hospice and to make a plan for her 2 children.– Home visits with the family therapist began after

consulting with multidisciplinary team, as it became too hard for Donna to come to the clinic

– Donna eventually chose hospice – Family Therapy continued with Donna, 2 children and

her estranged mom (maternal grandmother)• Reconciliation between Donna and her mom• 2 Children moved in with maternal grandmother• Donna died and family therapist continues to work with children

and Donna’s mother on grief counseling and adjustment as a newly formed family

Case Discussion: Palliative Care• Team had many discussions about how to ‘push’ family

therapy on someone who was clearly dying without taking her medication, primarily because of psychological reasons (triggering of childhood trauma)

• How to know when it was time to move to more of a hospice/palliative care model

• How to help Donna choose and plan for her children, knowing she is dying

• How to help Donna say goodbye to her children and help them remember her

• Family-centered care in this case made a tough situation better for the family/children and easier for the staff to work through

• Continuity of care possible with family-model

Greene County Health Care, IncGreene County Health Care, Inc

• Snow Hill Medical Center• Kate B. Reynolds Medical Center• Bernstein Medical Center• Walstonburg Medical Center• Migrant Farm Outreach Clinic• Pamlico Medical Center (NEW!)

OUR POPULATION…

Demographics• 30,235 patients • Age Breakdown:

– 1-19 = 4,256 (male); 4,083 (female)– 20-64 = 12,044 (male); 8,891 (female)– 65 and over = 415 (male); 546 (female)

• Hispanic/Latino = 21,032• Income as % of poverty level:

– 100% and below = 12,744– 101-150% = 1,030– 151-200% = 248– Over 200% = 78– Unknown = 16,135

• Uninsured = 25,093• Migrant or seasonal = 17,751

All people who face barriers in accessing services because they have difficulty paying for services,

because they have language or cultural differences, or because there is an insufficient

number of health professionals/resources available in their community. Underserved populations also include people who have

disparities in their health status.

Health Resources and Services Administration’s Policy Information Notice 98-23: Health Center Programs Expectations (1998) United States Department of Health and Human Services, ¶ 2.

GCHC’s Integrated GCHC’s Integrated Care ProgramCare Program

•Utilize 3 Option Model

•Screening•Assessment•Brief Therapy•Traditional Therapy•Lifestyle Change

Consultation•Medication monitoring•Coordinated team care

Medical Family Therapy Services integrated with Primary Health Care:

Three Option ModelThree Option Model

Consult before provider visit

Consult duringprovider visit

Consult after provider visit

Assess and Screen Patient

Together

BH provider exit room for physical

exam

Coordinate Care

Resume Interaction and

Finalize Plan

Psychosocial screening (PHQ-9)SBIRT screening

Coordinate Care

Resume Interaction and

Finalize Plan

Provider communicates psychosocial concerns and focus for care

Screen, Treat, Coordinate, and

Finalize

Core Skills: Therapists Learning to Core Skills: Therapists Learning to “Insert” Themselves“Insert” Themselves

• Focus on building relationships with staff, providers, and Focus on building relationships with staff, providers, and patients/familiespatients/families

• Provide the level of care they are ready to provide and Provide the level of care they are ready to provide and patient/family ready to receivepatient/family ready to receive

• Review medical provider schedules for the day—anticipate Review medical provider schedules for the day—anticipate patients with more mental health needspatients with more mental health needs

• Approach providers before the start of clinics about patient Approach providers before the start of clinics about patient panel that daypanel that day

• Remain visible in clinic, even when documentingRemain visible in clinic, even when documenting• Use referral list if patient may require more than 4-6 sessions so Use referral list if patient may require more than 4-6 sessions so

available for IC servicesavailable for IC services• Connect with the nursing staff on a regular basisConnect with the nursing staff on a regular basis• Work with Promoturas or local liaisons with minority groups in Work with Promoturas or local liaisons with minority groups in

communitycommunity

Core Skills: Engaging Family/Support Persons in Primary Care

– Attend to Family Life Cycle Stages & Normative Stressors

– Engage patients’ support persons ethically– Balance voices in room respectfully– Promote cultural sensitivity and competency in

working with families – Screen and assess for couple and relational issues

(i.e., family, social, occupational, community)– Make eye contact and acknowledge each person

at beginning, middle, and end– Encourage patients to bring support person(s) in

to each visit

Core Skills: Sample Interventions• Speaker-Listener Technique (Markman, Stanley, Blumberg,

2010)• Circular Questioning (Wright & Leahey, 1994)• Role Play• Motivational Interviewing (Miller & Rollnick, 2002)• Scaling Question (Solution Focused)• Thought Stopping and Thought Insertion• Mindfulness Strategies

* Want to have family leave with some change/thoughts about change with regard to their cognitions, behavior, and/or emotional states individually and/or relationally

Advances in billing for IC

• “Incident to” billing – Services rendered by a behavioral health provider (BHP) as a physician extender. MD’s NPI number is utilized.

• Traditional therapy billing codes by BHP using their National Provider Number (NPI)

Billing Tips

• Education and Medication Management – Can be used by MD when BHP assists in session and 50% or more of the time is spent counseling the patient. MD’s NPI number is utilized

• Health and behavioral codes – potential to bill for medical diagnoses

Issues to consider

*Billing for a BHP’s time is different from typical medical billing and administrative, therefore staff may need training

*BHP should have the ability for independent reimbursement across all payer mixes = maximizes flexibility and increase return

* www.Icarenc.org – Billing and coding tutorials

Case Example• Madi (age 53) was seen for primary care follow up after

being diagnosed with diabetes type 2 in the emergency room. Her husband attended the appointment with her, concerned because his wife was refusing to eat. They spoke limited English and immigrated from Mexico to the US eight years ago. Upon entering the room the patient was crying and laying on her side on the exam table. Her husband was seated in the “one” chair in the room (without wheels): his elbows rested on his knees as he looked at his wife. He popped up and shook the behavioral health provider’s hand, grateful to see him. He pointed to his wife, indicating that she needed help: his hand on her shoulder. He appeared worried. She did not make eye contact or appear to move at all after you entered the room.

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!