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The Medical Home Leadership Network:

Family, Health Care and Community Collaboration for Children with Special Health Care Needs

Kate Orville, MPHCo-Director

Washington State

Medical Home Leadership Network

Center on Human Development & Disability

University of Washington

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January 23, 2004

Community Health Plan of Washington

2004 Clinical Operations Meeting

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Overview

What is a medical home? The Medical Home Leadership

Network Community medical home team

activities How to get involved

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What is a Medical Home?NOT a building

but way of providing health care services that are:

Family-centered Coordinated Comprehensive Continuous Accessible Compassionate & Culturally Sensitive

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In a Medical Home… Children and their families receive

the care that they need from a physician or other primary health care provider whom they know and trust.

The pediatric health care professionals and parents act as partners to identify and access all the medical and non- medical services needed to help children and their families achieve their maximum potential.

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Medical Home Basics

Primary care and acute care Links/collaboration/referral with

specialty care Maintenance of comprehensive

central record of info about child Links to community programs Care coordination Assistance with transition

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The Family Perspective

“A 24/7 relationship with my physician and/or office staff who know my child and know her needs– who I can call any hour of the day, who are responsible, who listen and who care, who help me to feel competent about my knowledge and expertise when it comes to her care, who always ask “What can I do for you today?”.

-- Mom of child with special needs

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While all children can benefit from a medical home, it is particularly important for children with special health care needs and their families

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Children with Special Health Care Needs

“Children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”

Adopted by the AAP (October 1998). McPherson M, Arango P, Fox HB, A new definition of children with special health care needs. Pediatrics 1998; 102:137-140

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It Takes a Village to Build a Medical Home

Families and primary health care providers don’t have to do everything themselves

Office staff, community partners, specialists, and health care administrators are available to help…

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Medical Home and the Chronic Care Model

Active, empowered patient/family Proactive practice team Supportive health care organization

(information systems to ID patients, provide clinical support, reminders, incentives etc.)

Links to and collaboration with community services and supports (family-to family support, public health etc)

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How Do We Achieve a Medical Home for Every Child by 2010? MCHB/AAP: Need for state-

based, systematic approach National Medical Home

Mentorship Network Washington State Medical Home

Plan -Title V, WCAAP, Families,MHLN

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WA State Medical Home Goals Families, providers, insurers,

policymakers and others will understand and endorse the medical home concept

Health care providers will have the skills and knowledge to provide medical homes

Families will have the skills and knowledge to provide medical homes

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Medical Home Leadership Network Statewide network of families and

professionals who promote the availability and accessibility of medical homes for children and youth with special needs in their communities

Supported by DOH MCHB CSHCN Program and US MCHB since 1994

Large, active advisory board Housed at UW Center on Human

Development & Disability- Dr. Forrest C. Bennett, MHLN Director

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MHLN Teams

Volunteer

Interdisciplinary- PHN, FRC, MD, Family+

Community-based

Strengthen and leverage existing networks and activities

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Washington StateMedical Home Leadership Network

Teams

Northwest

Regions

King & Pierce

Southwest

CentralEast

Regional Resource Teams(by MD team member)

CHPW Member Center

CHPW Affiliate Center

Non-CHPW affiliate

COWLITZCOWLITZWAHKIAKUMWAHKIAKUM

PACIFICPACIFIC

GRAYSHARBORGRAYSHARBOR

JEFFERSONJEFFERSON

CLALLAMCLALLAM

WHATCOMWHATCOM

SKAGITSKAGIT

MASONMASON

LEWISLEWIS

THURSTONTHURSTON

SAN JUANSAN JUAN

ISLAND

SNOHOMISHSNOHOMISH

KITSAPKITSAP

KINGKING

PIERCEPIERCE

KLICKITATKLICKITAT

BENTONBENTONWALLAWALLAWALLAWALLA

COLUMBIACOLUMBIA

GARFIELDGARFIELD

ASOTINASOTIN

WHITMANWHITMAN

FRANKLINFRANKLIN

YAKIMAYAKIMA

SKAMANIASKAMANIA

CLARKCLARK

OKANOGANOKANOGANFERRYFERRY

STEVENSSTEVENS

PENDOREILLEPEND

OREILLE

SPOKANESPOKANE

LINCOLNLINCOLN

ADAMSADAMSGRANTGRANTKITTITASKITTITAS

DOUGLASDOUGLAS

CHELANCHELAN

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MHLN Team Members :

Promote the medical home concept and strategies to support medical homes

Are well-informed, experienced resources for community colleagues

Collaborate with other interested groups and provide technical assistance and consultation as time permits

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MHLN Teams, with Support of Project Staff: Recruit team members Identify one or more barriers to

medical homes to address Develop plan Identify needed technical

assistance Implement plan Monitor activities Report at annual conference

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Yakima Team Activities

MHLN team active in development of Children’s Village – CV set up on medical home principles

Presentations to local PCPs Family focus group on medical homes Co-developed medical home brochure

in English and Spanish Local autism diagnostic team Early hearing and screening outreach

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Kitsap County Team Activities

Development of local resource packets for services for CSHCN

Presentations to community primary care providers on community resources

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Adams County Team Activities “Child Health Notes” Chart review of client charts at quarterly

MH team meetings Presentations for parents and for

physicians on medical homes Physician collaborating with CHPW on

piloting new CSHCN program Presentation at AAP/Shriners “Every

Child Deserves a Medical Home”

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Add’l Team Activities

Pilot parent advisory group in MD’s practice (Skagit)

Down syndrome & EI presentation (Stevens)

Newborn Hearing Screening Follow Up (Walla Walla, Yakima, Kitsap)

Increase EI referrals for children with speech/language or autism concerns (Snohomish)

Develop rotating list of pediatricians to accept CSHCN with no PCP (Clark)

ID #s CSHCN by diagnosis in the county (Cowlitz)

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Team Collaboration Benefits (1999 evaluation)

Greater awareness of and use of community resources “It’s increased my access and it’s

increased my referral a lot, probably close to 100%” (MD)

“I feel more organized and competent that I know where to direct people” (MD)

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Benefits cont.

Greater access to MD community (PHNs, FRCs)

Increased referrals (PHNs, FRCs)

Enhanced credibility (all) Access to information &

grant opportunities (all) Expanded sense of

community and momentum (all)

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DOH CSHCN Program Support for Collaboration between Medical Home Contractors - Examples

Medical Home Toolkit & County Resource Lists (CCSN)

Collaboration between family and professional organizations

Adolescent Health Transition Notebook CHDD/CTU, Children’s Hospital, and

Mary Bridge increase own “medical homeness” then share lessons learned with other

tertiary care centers

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Upcoming Activities

Continue to identify and promote simple key activities and strategies to providers and families: Care notebooks/organizers for families Parent Advisory Groups Care plans/written instructions for

families

How to make medical homes work for families from diverse backgrounds?

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More activities

Medical Home Website- links to: community resources, diagnosis specific care guidelines patient handouts, tips on setting up a family-friendly

practice etc… Collaborate with health care plans to

pilot ideas – teams very interested Develop new grants Annual Medical Home conference

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Interested in Getting Involved? Contact your nearest local MHLN team

www.medicalhome.org, under “community teams”

Talk to Dawn Davis, CHPW 206-613-8917 Kate Orville, WA Medical Home Leadership

Network, University of Washington

orville@u.washington.edu, 206-685-1279

WA CSHCN Program reps Leslie Carroll and Stacey DeFries

See national medical home website: www.medicalhomeinfo.org

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Together we can do it—

EVERY CHILD DESERVES A MEDICAL HOME !!