“Building Your Own Pediatric

Medical Home for CSHCN”

Jennifer Lail, M.D. Jacksonville, FL

October 16, 2010

With Help From:

Blue Cross Blue Shield of NC Foundation

Division of Medical Assistance of NC, Quality Management Dept.

NC Title V Program Joseph, Christina

and Teresa

Disclosures “I have no relevant financial

relationships with the manufacturer(s) of any commercial products and/or provider of commercial services discussed in this CME activity.”

“I do not intend to discuss an unapproved or investigative use of a commercial product/device in my presentation.”

Objectives

Identify Medical Home adaptations to pediatric practice that support patient-centered care for all, esp.

CYSHCN

Discuss how patient-centered and planned care promotes communication between patients and multiple providers and facilitates all medical transitions

Understand new initiatives that link Medical Home practices to reimbursement

“I want to try that!” ideas

What is a Medical Home? “The Medical Home is the model for 21st

century primary care, with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated and family-centered manner.”

-American Academy of Pediatrics www.pediatricmedhome.org/

“Crossing the Quality Chasm: A New Health System for the 21st Century”

-New Performance Expectations for care that is:

PATIENT-CENTERED SAFE EFFECTIVE TIMELY EFFICIENT EQUITABLE

-Institute of Medicine, Committee on

Quality of Health Care in America, 2001

Quality Chasm Rules for Practice Redesign 1. Care is based on continuous healing relationships

2. Care is customized according to patient needs and values.

3. The patient is the source of control.

4. Knowledge is shared and information flows freely.

5. Decision making is evidence-based.

6. Safety is a system property.

7. Transparency is necessary.

8. Needs are anticipated.

9. Waste is continuously decreased.

10. Cooperation among clinicians is a priority.

“System Changes? I have patients to see!”

One in 5 families has a CSHCN

Survival/Longevity among CSHCN is increasing

Design is for 1 problem in 10 minutes

Retail-based Clinics erode our acute care base

Reimbursement will be linked to system change

Welcome to Our Medical Home!

Suburban Private Practice, 2 offices, self-owned

Duke University and University of NC Medical Centers within 15 miles

12 MD providers, 9 F.T.E.

74% Managed Care

13% Self Pay (incl. HSA) 13% Medicaid + SCHIP

>30 year history of collaboration with both medical centers

Office hours 365 d/year

Evening/weekend office hours

Nighttime Nurse triage and daytime Advice Nurses

Transition to EMR in fall 2007

Around 50,000 visits/year at 2 sites; 12,233 physicals

See til 21, 43% in registry are 12 and older

Age 12-21 = 24% of 2009 physicals; 4% > age 18

27% CSHCN in registry are Medicaid-insured

Imagine: Staff recognizing a parent when

appt. is made Adequate time scheduled for that child Specialist’s records in your hands prior to the visit,

including lab and X-ray results Parent concerns identified before the visit; multiple

tasks completed Lab slips ready, and EMLA cream on child prior to

visit Help by your staff for families with referrals,

resources, equipment Followup to assure completion of tasks

Essential Components of a Medical Home System

Relationships/RespectReady AccessRegistry and RecordsResourcesReimbursementRecruitment

Relationships Youth and family Supportive staff Care coordinators Specialty Providers

and their staff Schools Insurers Community Providers

Ready Access

Accept Medicaid, many insurers

Evening, Weekend and Holiday office hours

24-hour advice nurses Care til age 21 Translation Phone Privacy protection for

Teens ADA accessible physical

plant Handicapped parking

spaces Identified Adult

Providers

Registry & Care Coordination Program

“The Left Ventricle of the Medical Home”

Identifies who needs more help

Separate from Advice Nurses

Direct Phone Extension Brochures and Business

Cards Care Coordinators Link to

Other Care Coordinators!

Care Coordinators: -Maintain registry of 1434 pts.; data entry, annual purge, data enquiries

-Referrals: 1690 in 2008, 1800 in 2009-contact parent-assure referral data is at specialist

-obtain and scan notes from specialist appt.-referrals directly from parent after familiar with CC system

-Pre-Visit Contacts: 298 in 2008, 473 in 2009 -Transition Care:

-Hospital and ED fup, locating records, calling family, scan to EMR-Newborn entry to practice; discharge summary, NBS results-New pts: obtain old med records, PVC’s with families-Capture of episodic care and return to care system-Bridge of information for parents between school/Medical Home

-Pre-authorizations-radiology procedures-insurance authorizations for specialists

-Medical Necessities:-durable med. eqpt-mattress/pillow covers-Bipap machinery-authorizations for CAP-C, CAP MR/DD

-Medicaid Interface:-capture of episodic care-collaboration with Medicaid Case Managers-Followup on missed primary and specialty appts.

Registry: Knowing Who Needs Care

Maintained by Care Coordinators

Notebooks Excel Access EMR

Alerts schedulers to need for more time

Assures key data to specialist for consult

Track referrals and specialist reports

Prompt Pre-visit contacts

Risk Stratification = Complexity Scores More time? Communication

devices? Technological

support? Translator? Pre-Visit

Contact?

REGISTER YOUR PATIENT WITH SPECIAL HEALTH CARE NEEDS-completed form to Peggy Name:_______________________________Race___________ Sex__________Birthdate________________Chart #________________ Insurer:________________________________ Primary CHP Provider: SBH MI CM JO AD SVH RMC KS JL RSW KM Diagnoses: 1) 2) 3) 4) CSHCN Complexity Rating

Description

Examples

1

1 chronic condition, well-controlled OR Significant PMH, quiescent or resolved

Asthma, mild per. Repaired VSD

2

1 evolving chronic condition, unstable OR 2 chronic conditions, both well-controlled

Asthma PCOS +Type 2 DM Asthma +ADHD

3

2 or more chronic conditions, with either unstable

GERD Asthma w/ER visit

4

Any tech. dependent pt. Mod./severe cognitive delays

(wheelchair, walker, GT, Trach) MR, Autism, Group Home res.

+1

Language barrier

Non-English speaker

+1

Behavioral Disorder

OCD, Anxiety in addition to above

+1

Family/Social Complications

Divorce, Horizons

Total complexity score

DO YOU WANT A PVC DONE? YES NO

Registry-Helps Document Care

Permits data collection for negotiation with insurers

Permits recall by dx for research, parent-to-parent

Aids in NCQA certification process for PCMH

Assists with chart retro-fit for EMR

Risk-stratification for Care-Planning

Population-based care (flu, Synagis, etc.)

Registry permits Planned CarePVC = Productive Visit

Care Coordinator identifies for

Pre-visit contact

MD visit, referrals

made, resources

found

CC helps parent with referrals, resources

CC calls parent, notes

concerns, and interim encounters

CC gathers specialty reports, assures

adeq. time

PVC, spec. data to MD for Preview

MD previews

chart, requests

more info or time

Parent calls for physical

appt. for CSHCN

“Special”

Lab and XR slips are created, EMLA cream made available

PVC’s streamline care Parent survey of

PVC’s- 93% rate as “very helpful”

“it shows you care about my child”

“makes my visit more useful and efficient”

“less reviewing, more looking forward”

MH Services aid Collaboration/Comanagement with

Specialists

Care coordinators as facilitators Assure that referral data sent and visit

accomplished Access to Specialist records (letter, fax-back,

electronic) Phone/email dialogue re: care Specialty followup at PCP office (weight

checks, labs) Synthesis of thought from multiple specialists

Our Parents/Families as Resources Education!

Parent-to-Parent Collaboration

Advocacy Groups

Personal Knowledge of Local Providers and Services

Word-of-mouth referrals

Physical Plant walk-through

Boardmaker

Community Resources Directory “answers in our pockets”

Ask MD’s to submit their favorites from all disciplines

MD’s who respond get a copy!!

Parent Partner and Care Coordinator add Local Resources

Every Fall, update from margin notes and new mailings

Pocket size fits Lab coat 5th edition now in use

CSHCN Directory Index State Programs for CSHCN Alternative Medicine Audiology Augm. Comm./Asst.Technology Autism Baby Nurses Carseats for CSHCN Child Abuse Child Psychiatry/Psychology Community MD’s Compounding Pharmacies Dentistry Devel. Eval and Therapy Domestic Violence Early Intervention Eating Disorders G-tube and Trach care Genetic Testing Grief Counseling/Hospice Group Homes Gynecology Handicapped Parking

Health Depts. Home Health Care/Eqpt. Lactation Services Nutrition Orthotics OT/Feeding Parent-to-Parent Podiatry PT PT Sports/Injury Rare Disorders Recreation for CSHCN Rehabilitation Specialists Respite/Residential Care School Systems Social Services Smoking Cessation Speech SSI Substance Abuse Travel for CSHCN Voc. Rehab. Misc.

Resources for Young Adult Care

Med-Peds Trained ? Family has prior

relationship? Identify by Transition

Fax-Back Transition Provider List Update List yearly Give list before Transition

A Medical Home for CYSHCN eases transitions

Trusted relationships Established access to care Providers identified (medical

and support) Current Problem List defined Established mechanisms of

communication Resources and obstacles

identified Upcoming needs anticipated

Reimbursement-How to Pay for Improvement

Market your Medical Home services

Optimize MD time with Care Coordination

Proper coding for care of CSHCN

Careful attention to charge capture

Contract renegotiations with insurers (data!)

Medicaid Community Care-case management fee pm/pm

NCQA- Physicians’ Practice Connection/Patient Centered Medical Home

Pay-for-Performance Programs

Families want a Medical Home!

Adequate time for the visit promotes appropriate coding

Remember CYSHCN visits often are 99214

Learn to use modifiers

Learn to code for time

Capture all charges Do coding reviews Code for after-hours

Appropriate Coding for Enhanced Care

% of PF Office Visits Ideal 5% 2.4% 3.1% 4.8% 4.8%

% of EX Office Visits Ideal 60% 68.0% 68.1% 70.3% 72.3%

% of DT Office Visits Ideal 30% 27.6% 27.0% 23.2% 21.5%

% of CP Office Visits Ideal 5% 1.9% 1.7% 1.6% 1.3%

Better Quality = Better Reimbursement Renegotiate Contracts with Data

Big Goals— Small Steps Adequate time for care Better planned visits Better links with

specialists Help with referrals and

resources Family satisfaction Fiscal Viability Caution-Don’t wait for

consensus

Countless Small Steps Later 4/03—10/10NICHQ Medical Home Learning Collaborative

Docs re-educated on coding for CSHCN

Title V 3 year grant

Forum with CHPA, Parents and School Admin. for CSHCN in schools

“Listening Session” with CHPA parents to identify needs

Streamlined “checkout” process

Joined NC Medicaid Managed Care Network

Computer Access for UNC, Duke

“Backlines” to Specialty Care

Identified 1500+ in registry and Office Mgmt. System

Care Coordinator from 3 hrs./wk to 2 full-time positions

5th ed. CSHCN pocket phonebook; transition referral options

93 % of Families find PVC’s helpful

Reduced ED and after-hours utilization for 4 years

Boardmaker for commun. impaired BCBS “Bridges to Excellence” P4P

program; NCQA certification; BQPP participation

So how do we get there? Identification of problem

areas Establish explicit goal to

address Break process into tiny

steps Create tools to support

weak spots Try ONE SMALL change Measurement of

improvement (or failure!) Try another test of change

and see if you’re ready to grow that change

BTE,

QI, PPC-PCMH, BTEBQPP, NCQA, PDSA??

Enhanced reimbursement for quality improvements

PLAN-consider a needed improvement

DO-try some SMALL changes to make it better (“test of change”)

STUDY-measure if your changes helped

ACT-refine the process to make it work even better

IMPORTANT…

NCQA CERTIFICATION

is NOT the same as

A Patient-Centered Medical Home

NCQA Certification Process

Pay for Performance program

Promotes processes and information systems to improve patient care

Three levels of incentive payments

Certification by NCQA for 3 years.

EVALUATES: Access and

Communication Patient Tracking and

Registry Functions Care Management Pt. Self-Management E-prescribing Test Tracking Referral Tracking Performance Reporting

and Improvement Advanced Elec.

Communication

BQPP - demands NCQA certification

Enhanced reimb. on E&M codes to max of 176% of Medicare

Measures: Clinical Quality Outcomes (NCQA cert.) Administrative Efficiency Patient Experience with Care

2 levels of reimb. increase 15% over standard 30% over standard

“When you stop getting better, you stop being good”---Wyatt Taylor

“Changing a Pediatric practice is like changing the tire on your bike while you’re riding it” --- Carl Cooley

“My family, with all its challenges, is a success story, but part of that success is because we have

had a Medical Home”… Libby

Relationships/Respect Ready access Registry and care coordination Resources Reimbursement RECRUITMENT??

WHAT DO YOU WANT TO TRY?