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Coordinating Care between
Home Visiting and the Primary Care Medical
HomeAn interprofessional approach
Learning Objectives• Understand the importance of care coordination
between the home visitor and the medical home
• Recognize the value of documentation to standardize the referral and care coordination process
• Effectively communicate with families by using messaging tools
• Learn elements of an organizational protocol for care coordination within the medical home
Please NoteThis training is specific to care coordination between home visitors and medical homes.
Our primary goal in this project is to encourage the use of the medical home as opposed to use of the emergency room.
Currently, ICAAP works in the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program communities to promote Care Coordination between home visitors and medical homes using materials and techniques introduced in this presentation.
Illinois MIECHV Communities
• Englewood, West Englewood, and Greater Grand Crossing
• Cicero Township
• City of Elgin
• City of Rockford
• Macon County
• Vermilion County
MIECHV Benchmarks• Improved maternal and newborn health
• Prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits
• Improvement in school readiness and achievement
• Reduction in crime or domestic violence
• Improvements in family economic self-sufficiency
• Improvements in the coordination and referrals for other community resources and supports
Importance Of Care Coordination Between The
Home Visitor And The Medical Home
What is a Medical Home?
• Comprehensive and continuous medical care is provided to patients with the goal of obtaining maximized health outcomes in a culturally and linguistically appropriate manner
• A health care setting that facilitates partnerships between individual patients, and their medical professional, and when appropriate, the patient’s family
• Care is supported by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need it
Who are Home Visitors?• They are interprofessionals who have
experience related to child development and family strengthening. They have also received extensive training in their agency’s home visiting model as well as core knowledge and skills relating to domestic violence, substance abuse, developmental disabilities, and maternal depression.
• They provide families with social support built on the development of a trusting relationship between the home visitor and parents. These relationships are designed to promote parent effectiveness and help engender strong bonds between the adults and children within families.
What is Care Coordination?
Care Coordination is a client-centered, assessment-based, interdisciplinary approach to integrating health care and social support services.
With care coordination, an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an identified care coordinator following evidence-based standards of care.
What does care coordination look like?
• Documented information sharing among interprofessionals
• Consistent messaging to the family about health related issues
• Established medical home protocol that supports care coordination
“The Role of Preschool Home-Visiting Programs in Improving Children’s
Developmental and Health Outcomes”
In this policy statement, the AAP:
• Recommends that pediatricians become aware of and participate in development of home-visiting programs in their communities
• States that there is ample reason to believe that the synergy of home visitors working with pediatric clinicians could have positive effects on child health and development
• Calls for free-flowing communication between home visitors and pediatricians.
The value of the relationship
• Connection with a home visitor gives the medical professional a view into the family’s home life and can be critical to the ability to provide care
• Home visitors can encourage the use of the Medical Home, not ER, for primary care services
• The home visitor can share valuable information to reinforce anticipatory guidance and help shape care plans and recommendations
• The home visitor can coach families for well-child visits and other medical appointments
Who benefits from Care Coordination?
• Home visitors• Contribute to more comprehensive care for families• Informed communication about family’s health needs and
risk factors to medical home• Increase opportunities for referral to additional services
• Medical homes• Can provide more comprehensive care to patients• Increase knowledge of/and access to resources not
typically known• More appropriate referrals for families
• Families/patients • Less burden for communicating information between
home visitor and medical home• Expanded opportunity for access to other important
services and supports
Care Coordination: Successful Partnerships
For both the medical home and home visitor, this requires:
• Cooperation and open communication• Documentation using care coordination
tools• Contribution of data that informs medical
care• Consistent messaging
Care Coordination:Effective Information
Sharing…• Demonstrates cooperation and open communication
• Increases accurate and timely data sharing
• Encourages consistent communication and messaging between the home visitor and the medical home
• Lessens family burden for communicating information between home visitor and medical home
• Expands family opportunity for access to other important services and supports
The MIECHV Referral and Care Coordination Process: An overview
The MIECHV Referral and Care Coordination Process
The Coordinated Intake Office:
• Contacts the family referred by the medical home • Completes the Coordinated Intake Assessment Tool
(CIAT) • Refers all positive screens within 24 hours• If all home visiting providers are at capacity, refers to
appropriate community resources and places client on waiting list
• Provides immediate referrals to community resources for all clients presenting with emergency needs
• Refers all negative screens to other community and parenting services as indicated
• Notifies the client’s medical home of referral outcome using the Coordinated Intake Office Referral Fax Back Form
The home visitor:
• Completes all case management• Completes the following screening:
o 4P’s Plus (substance abuse screening)o Relationship Assessment Tool (domestic violence
screening)o Edinburgh Assessment (maternal depression)o ASQ-3 Assessment (child cognitive development)o ASQ-SE Assessment (child socio-emotional development)
• Refers to appropriate services as indicated by screening results
• Shares pertinent information with the medical home using the Care Coordination Form (CCF)
Using the Care Coordination Form, the medical home and the home visitor share:• screening results• information about referrals made to resources • concerns related to the client/patient/family’s well-being • pertinent medical information regarding the
client/patient
The medical home completes the Medical Home Referral Form to MIECHV Coordinated Intake Office
Getting started: Completing the medical home referral form
Why use the Medical Home Referral Form
• Contains contact information that allows CI office to connect with the family
• Initiates the process for referring a patient/family to a MIECHV Coordinated Intake Office, with patient/family consent.
• Creates an intentional opportunity for the medical home to: • have a conversation with the patient/family
about significant observations, concerns, etc.• Indicate the reason you are making a referral
to determine eligibility for home visiting services
Section 1: Family Contact Information
It is important to provide accurate information about the patient/family as completely as you are able
Section 1. Family Contact Information Patient Name: __________________________________________ AKA_______________________ Patient is (check one) ☐child ☐mother Parent/Guardian Name (if patient is under 18): ___________________________________________AKA________________________________ Street Address: __________________________________________________________________________________________ City: ___________________________________ State: __________ Zip: ______________ County: _____________________ Patient Date of Birth: _____/_____/_____ Patient Gender: M F Race: _________________________________________ Type of Insurance Coverage: Medicaid Private Insurance Medical card # _____________________________________ Name of Previous Healthcare Provider: __________________________________________________ Primary Language: ___________________________ Home Phone: _____/_____-_______ Other Phone: _____/_____-_______ Alternate or Emergency Contact Person: _____________________________________________ Phone: _____/_____-_______
Section 2: Reason(s) for Referral
Inform the CI office of referrals made to other resources (e.g. Early Intervention)
Indicate reason(s) for referral to CI office
Section 2. Reason(s) for ReferralReason(s) for referral to Coordinated Intake Office (Please check all that apply): At-Risk (Please describe risk factors):
_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Identified area[s] of concern: ___Motor/Physical ___Cognitive ___Social/Emotional ___Speech ___Language/Communication ___Behavior ___Vision/Hearing ___Adaptive/Self-help Skills ___Maternal Mental Health ___Substance Use ___Relationship Assessment ___Other, specify______________ Comments: _______________________________________________________________________________________________________ _________________________________________________________________________________________________________________
Referral made to ________________________________________________________________________________(e.g. Early
Intervention)
Family is aware of reason for referral
Section 3: PCP Contact Information
Share your organization contact information with the CI office
Section 3. Primary Care Provider Contact Information Name of Patient’s Primary Care Provider: __________________________________________________________________________________ Street Address: _______________________________________________________________________________ City: ____________________________________________ State: __________ Zip Code: _____________ Office Phone: _____/_____-_______ Office Fax: _____/_____-_______ E-mail: _____________________________________________________ Contact Person at Primary Care Provider Office: ________________________________________________________
This enables the family to know that there is a care coordination team in place for them and relieves the family of the burden of information sharing among service providers.
Section 4: Office Referral Location
Section 4. Office Referral Location Referral Date: _____/_____/_____ Please indicate the CI office referral location and fax to: ATTN Coordinated Intake Worker: Cicero: Family Services & Mental Health P: 708/834-8180 F: 708/222-8824 Elgin: Kane County Health Department P: 630/208-5150 F: 630/897-4845 Englewood/
West Englewood/ Greater Grand Crossing: Children’s Home and Aid Society P: 773/476-6998 x224 F: 773/776-8986
Macon: Macon County Health Department P: 217/423 6988 x1140 F: 217/423-6804 Rockford: Winnebago County Health Department P: 815/720-4346 F: 815/720-4302 Vermilion: Aunt Martha’s Youth Service Center P: 217/483-2229 F: 217/442-0375
Indicate the date the referral is madeIndicate the CI office referral location
Section 5: Authorization to Release Information
Clause a. Referral to Coordinated Intake Office provides the opportunity for the patient or parent/guardian (if patient is under 18) to consent to referral whereby the medical home can share reason(s) for referral as indicated under Section 2. Reason(s) for Referral with the CI Office
Section 5. Authorization to Release Informationa. Referral to Coordinated Intake Office. The purpose of this disclosure is to refer __________________________________ (print name of patient) to a Coordinated Intake Office to determine eligibility for home visiting services. I, _____________________________________(print name of patient or name of parent/guardian if patient is under 18), give my permission for the primary care provider, __________________________________ (print name of provider), to share pertinent information about, __________________________________ (print name of patient), regarding reason(s) for referral as indicated under Section 2. Reason(s) for Referral of this form with the Coordinated Intake Office. I understand that I may withdraw this consent by written request to the primary care provider listed in Section 3. Primary Care Provider Contact Information of this form, except to the extent it has already been acted upon. b. Release Home Visiting Services Eligibility Determination to Primary Healthcare Provider. The purpose of this disclosure is to release information from the Coordinated Intake office to the primary care provider about _________________________(print name of patient), including name, date of birth, and information about eligibility for home visiting services, including other referrals made by the Coordinated Intake Office. This consent allows the Coordinated Intake Office to share information with the assigned primary care provider (doctor) and treating doctors within the group, for care coordination. Care coordination allows the primary care provider (doctor) to be notified of patient eligibility for home visiting services and/or other referrals received. I give my permission for the Coordinated Intake Office to share outcomes related to this referral with the primary health care provider (doctor) listed above. Initial______ (of patient or of parent/guardian if patient is under 18). I understand that I may withdraw this consent by written request to the Coordinated Intake Office, except to the extent it already has been acted upon. I certify that this Authorization to Release Information has been given freely and voluntarily. Information collected hereunder may not be re-disclosed unless the person who consented to this disclosure specifically consents to such re-disclosure and or the re-disclosure is allowed by law. I understand I have a right to inspect and copy the information to be disclosed. Patient or Parent/Legal Guardian Signature (if patient is under 18)*_____________________________________ Date:_______/_______/_______ *Consent is effective for a period of 12 months from the date of patient signature or parent/legal guardian (if patient is under 18) signature on this release.
Clause b. Release Home Visiting Services Eligibility Determination to Primary Care Provider provides the opportunity for the patient or parent/guardian (if patient is under 18) to consent to the release of information (including name, DOB, home visiting services eligibility determination, and other referrals made) from the CI Office to the PCP
Consent is effective for a period of 12 months from the date of release
Important to know• This consent form has been vetted for HIPAA and
FERPA requirements
• Information sharing (as indicated under Section 2) consent is effective for a period of 12 months from the date of release
• If clause a. is not signed by the patient or parent/ guardian the medical home CANNOT share ANY information with the Coordinated Intake Office
• If clause b. is not signed by the patient or parent/guardian the Coordinated Intake Office CANNOT share information with the medical home
Sharing information with the medical home using
the Care Coordination Form
Why use the Care Coordination Form (CCF)
• share important information including health concerns and referrals
• encourages the use of consistent anticipatory guidance and messaging
• incorporates family consent• enables all providers to offer
additional support to the family• relieves the family of the burden of
information sharing among providers
Section 2: Reason(s) for Contact
Formally introduce yourself to the medical home as a professional service provider who is an important
member of the care coordination team for the family
Based on both your professional training and the fact that you are seeing the family routinely,
provides an opportunity to inform the medical home about validated concerns you may have
Share important family updates and/or status changes with the medical home
Initiate a conversation with the family about significant observations or concerns, and why
sharing this with the medical home is beneficial
Inform the medical home of referrals made to other resources (e.g. Early Intervention)
Request patient medical information from the medical home (e.g. immunization schedule)
Section 2. Reason(s) for Contact Reason(s) for contact (Please check all that apply): ☐ Family/Patient has been assigned a home visitor (see Section 3. Referral Source Contact Information) ☐ Suspected medical condition or previous medical diagnosis (e.g., spina bifida, Down syndrome):
______________________________________________________________________________________________________
☐ Concern based on objective screening using:
☐ 4P’s Plus ☐ Relationship Assessment Tool ☐ Edinburgh Assessment ☐ ASQ-3 Assessment ☐ ASQ-SE Assessment ☐ Other, specify__________________________________________________
Other Area(s) of concern (please check all that apply): __Motor/Physical __Cognitive __Social/Emotional __Speech __Language/Communication __Behavior __Vision __Hearing __Adaptive/Self-help skills __Maternal Mental Health __Relationship assessment __Substance Use Comments _______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
☐ Referral made to ____________________________________(name of referral source) on ________________________(date referral made) ☐ Request for patient medical information (please specify the type of information)_______________________________________________ __________________________________________________________________________________________________________________ Family is aware of reason(s) for contacting the Primary Care Provider
Section 5: Authorization to Release Information
Section 5: Authorization to Release Information a. Information Sharing with Primary Care Provider. The purpose of this disclosure is to share information concerning ___________________________ (print name of patient) with the patient’s primary care provider. I, __________________________________(print name of patient or name of parent/guardian if the patient is under 18), give my permission for the referral source contact, ____________________________________ (print name of referral source contact), to share pertinent information about _________________________________________ (print name of patient), regarding specified reason(s) for contact under Section 2. Reason(s) for Contact of this form, with the primary care provider_________________(print name of primary care provider). I understand that I may withdraw this consent by written request to the referral source contact, except to the extent it has already been acted upon. b. Information Sharing with Referral Source. The purpose of this disclosure is to release information from the primary care provider about____________________(print name of patient) including name, date of birth, relevant referrals made, and relevant medical information as requested by the referral source under Section 2. Reason(s) for Contact, to the referral source contact. I understand that I may withdraw this consent by written request to my primary health care provider, except to the extent it has already been acted upon. This consent allows the Referral Source to share pertinent information with the assigned primary care provider (doctor) and treating doctors within the group, for care coordination. Care coordination allows the Referral Source to receive relevant medical information (as specified under Section 2. Reason(s) for Contact of this form) concerning the named patient from the assigned primary care provider (doctor) and treating doctors within the group I certify that this Authorization to Release Information has been given freely and voluntarily. Information collected hereunder may not be re-disclosed unless the person who consented to this disclosure specifically consents to such re-disclosure and or the re-disclosure is allowed by law. I understand I have a right to inspect and copy the information to be disclosed. Patient or Parent/Legal Guardian Signature (if patient is under 18)*_________________________________Date:_______/_______/_______ *Consent is effective for a period of 12 months from the date of patient or parent/legal guardian signature on this release.
Clause a. provides the opportunity for the patient or parent/ guardian (if patient is under 18) to consent to information sharing whereby you can share indicated reason(s) for contact under Section 2. Reason(s) for
Contact with the medical home
Clause b. provides the opportunity for the patient or parent/guardian (if patient is under 18) to consent to
information sharing as specified under Section 2. Reason(s) for Contact whereby the medical home can
share information with you
Consent is effective for a period of 12 months from the date of release
Important to know• This consent form has been vetted for HIPAA and
FERPA requirements
• Information sharing (as indicated under Section 2) consent is effective for a period of 12 months from the date of release
• If clause a. is not signed by the patient or parent/guardian the home visitor CANNOT share ANY information with the medical home
• If clause b. is not signed by the patient or parent/guardian the medical home CANNOT share information with the home visitor
Communicating with families
Messaging
• Needs to be consistent specifically related to:oWhy you screenoWhen Screening results are of concernoWhen there is a need for further
assessment and referral
• Supports the mutual goal of medical homes and home visitors to provide comprehensive health care.
Messaging is both about what you say and how you say it.
Why you Screen
• Explain that screening is an opportunity to learn what is expected next in a child’s development
• Make clear that screening is a form of preventative care and the earlier it is done, the better the opportunity for addressing concerns
• Describe to the family what to expect during screening
• Let the family know that you will conduct screenings routinely to assure the child’s continued healthy development.
When screening results are of concern
• Find helpful and encouraging words if the screening results are of concern
• Work with the parents to find helpful ways to communicate screening results with others
• Before addressing areas of potential concern, affirm to the family that screening results are not a reflection of their parenting skills
When there is a need for further assessment or
referral• Let the family know that you are making a
recommendation for further assessment or referral to support them in promoting their child’s optimal development
• Encourage the family to read or play with their child (using specific skill tools) with intentionality while they await further assessment or referral eligibility
• Let families know what will happen next, and who will be contacting them
Finding the Words• Do not use diagnostic language such as
“developmental delay.”
• Consider using phrases such as: “children develop differently, and some need extra attention and support during their earliest years”
• Emphasize that screening results indicate whether or not there is a potential concern
Consider:
• Your own non-verbal behaviors such as:• body language and gestures• eye contact • facial expressions
• The culture of the family in their reactions and responses to information:• primary language spoken in home • cultural understanding of developmental
concerns • family history of developmental concerns
Tactics for Communication
• Normalize the conversation
• Acknowledge parent’s concerns and respond to their questions
• Point out the child’s positive areas of development or areas of temperament
• Discuss the family’s supports and resiliency
• ‘Demystify’ the referral process. Let families know what will happen next, and who will be contacting them
Elements Of A Care Coordination
Protocol
An organizational care coordination protocol
includes:• Knowledge of community resources
• A standardized referral process to community resources
• Managing the Care Coordination Form (CCF)
• Messaging tools
• Medical home team responsibility
Medical Home Team Responsibility
• Promote and implement the care coordination protocols in the practice
Responsible for managing the care coordination protocol of the medical home
Prepare chart prior to office visit, insert appropriate screening tool(s)
Offer families the screening tool form(s), explain purpose
Offer assistance with completing form
Score the screening tools form(s)
Involve in screening, scoring, and discussing child developmental/behavioral concerns with caregivers
Offer assistance with referrals to community resources
Responsible for reviewing all completed forms
If necessary, administer follow-up screening
Discuss results and concerns with families
Make appropriate referrals to community resources
Plan for a follow-up appointment
Order, reproduce, reorder supplies
Formulate a plan on where to store materials and how to distribute and collect materials
Care Coordination Resources
For forms shared in this presentation, as well as additional resource information for families and home visitors, visit:http://illinoisaap.org/projects/early-childhood-development-initiatives/home-visiting
Project Contact Information
Cherie Estrada, Practice Management ConsultantIllinois Chapter, American Academy of [email protected]
Elise Groenewegen, Project CoordinatorIllinois Chapter, American Academy of Pediatrics312/733-1026 ext. [email protected]
