Transcript Bringing the Medical Home… - National Center for Hearing

Bringing the Medical Home…Home:
A State Specific Model
March 3, 2005
Carol Dorros, MD
Margo Chiappinelli, AuD
First Connections Training and Resource Project
for Newborn Hearing Screening
A RI Department of Education and RI Department of Health Collaboration. Supported in Act, Health
Resource and Services Administration, Department of Health and Human Services part by project 1
H61 MC 00009 from the Maternal and Child Health program (Title V, Social Security Project funds
managed by The Hearing Rehabilitation Foundation.)
Acknowledgements and Thanks
 Ellen Kurtzer-White, Au.D.*
Project Director, First Connections
 Marianne Ahlgren, Ph.D, CCC-A
Project Coordinator, First Connections
 Mary Catherine Hess, MA
Administrator, RIHAP
 Betty Vohr, MD
Medical Director, RIHAP
 American Academy of Pediatrics
* deceased
Presentation Objectives
• Present Rhode Island’s newly developed
algorithm for medical home providers
• Present the process of its development
• Discuss gaps identified and
opportunities/solutions for strengthening
our EHDI system
Background
Literature and the RI experience indicate that
the EHDI system needs refinement to better
respond to significant issues for families:
 The emotional response to diagnosis
 Availability and access to expert services
 Increased stress and delays in services
when system is fragmented
Background
• AAP recommends a Medical Home for all
children with special health care needs. (AAP
position statement RE9902, 1999)
• A medical home is defined as an approach to
providing health care services where care is:
- accessible
- family-centered
- continuous
- comprehensive
- coordinated
- compassionate
- culturally competent
Background
Joint Commission on Infant Hearing recommends a
Medical Home for all children with hearing
loss.(AAP position statement, SO 60016, 2002)
“Pediatricians and other primary care
providers, working in partnership with
parents and other health-care professionals,
make up the infant’s “medical home.”
RI Medical Home Task Force for Children
with Hearing Loss
Goals:
• Identify strengths and barriers in the RI EHDI
system
• Refine the system into one that is better
informed, competent and linked.
• Develop a medical home model specifically for
RI’s infants with hearing loss.
Task Force Development
• Multidisciplinary team of stakeholders
• Met monthly
• Total of approximately 2 years
Initial 1 ½ years examining current system
-Identifying system strengths/barriers
-Defining roles of professionals involved
Algorithm development took 8 months
Task Force Participants
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Audiologists (community and hospital based)
Members of the Deaf Community
Early Intervention Administrators
Family Guidance Providers
Otolaryngologist
Parents
Pediatricians ( PCPs and hospital based)
Rhode Island Hearing Assessment Program Admin.
Rhode Island Dept. of Health Admin.
Working Towards a Solution…
A State Specific Algorithm
Algorithm Goals
Specifically designed for RI PCPs in order to
enhance the effectiveness of the medical
home and provide a more seamless
experience for families.
Physicians requested:
 One page document
 Defining flow of the RI EHDI system
 Defining roles/responsibilities of partners
 Local resource names and phone numbers
Algorithm Development
• Stakeholders met monthly for a period of about 8
months
• Revised the AAP/NCHAM algorithm to reflect the
specific process and resources in RI
• Systematically discussed all language, information
and process for inclusion, exclusion or modification
• Decisions all made by a consensus model
Birth
Birth
Screen
RIHAP*(401-277-3700)
Identify a Medical Home for every infant
Hospital-based Inpatient Screening
(OAE/AABR)
Results sent to PCP
At least 2 screening
attempts recommended
prior to discharge
Pass
Missed
Incomplete
Did Not Pass
RIHAP contacts family
and schedules
a rescreen
PCP Informed
Phone family to encourage them
to follow through with rescreen
3
Gap: Unclear language within algorithm
Hospital-based Inpatient Screening
(OAE/AABR)
Results sent to PCP
At least 2 screening
attempts recommended
prior to discharge
Pass
Missed
Incomplete
Did Not Pass
RIHAP contacts family
and schedules
a rescreen
Solutions:
 Clarified that screening
“results are sent to PCP”
rather than the “medical
home”
 Changed “Refer” to “Did
not Pass”
to clarify meaning to
target audience
Gap: Responsibilities/Roles unclear
Solutions:
• Added header line with partners
responsible for each stage of process
• For infants who do not pass the initial
screen, the algorithm identifies who
makes referral for re-screen
RIHAP contacts family and schedules
a re-screen.
• To support the medical home,
developed PCP action point
Phone family to encourage them to follow
through with re-screen.
Ongoing Care of All Infants
Ongoing Care of All Infants
Provides opportunity to remind PCPs about:
• Elements of comprehensive care related to
hearing, vision, speech, language and overall
development
• Monitoring for hearing loss that may occur out of
the newborn period
• Risk indicators for late-onset hearing loss that
require referral for audiologic monitoring
Before 1 Month
Birth
Before 1 Month
Screen
Re-screen
RIHAP*(401-277-3700)
RIHAP
Identify a Medical Home for every infant
Hospital-based Inpatient Screening
( OAE/AABR )
Results sent to PCP
Outpatient Screening
(OAE/AABR*)
At least 2 screening
attempts recommended
prior to discharge
Home births
Results sent to PCP
Missed
Incomplete
Did not pass
Did Not Pass
Pass
RIHAP contacts family
and schedules
a rescreen
PCP Informed
Phone family to encourage them
To follow through with rescreen
Pass
RIHAP recommends
diagnostic testing
PCP Informed
Phone family to identify an
audiologist and support need for
follow-through
Gap: Unclear roles/responsibilities
Solutions:
• For infants who do not pass the rescreen, the algorithm identifies who
is responsible for next step
RIHAP recommends diagnostic testing
• Added a PCP action point to
support the medical home
PCP phones family to identify an
Audiologist and support the need
for follow-through
Before 3 Months
Before 3 Months
Referred for Diagnostics
Every child with suspected hearing loss
Community Audiologist
Pediatric Audiologic Evaluation
RIHAP can be contacted for a list of Pediatric
Audiologists, 401-277-3700, Fax 401-276-7813
Follow-up
Every child identified with a permanent hearing loss
Hearing Loss Professionals and Organizations
Audiologist reports diagnosis to RIHAP
(401-277-3700)
 Child & family history
Audiologist refers for
early intervention and family support:
Specific Early Intervention Program ***
Family Guidance Program (401-222-4013)
 Middle ear function
PCP initiates medical evaluation
 Otoscopic inspection
 OAE*
 ABR*
 Frequency-specific tone bursts
 Air & bone conduction
 Audiologist counsels parents about results
and recommendations
PCP refers to otolaryngologist
For evaluation, to recommend treatment, and to
provide clearance for amplification
Partners in Care inform family
(Audiologist, ENT, Family Guidance Program, others)
about communication, amplification and cochlear implants
Results to PCP
Normal
Hearing
Hearing
Loss
PCP sets up an appointment
with family to review the results, intervention
benefits, and follow-up.
Results Sent to PCP
Support follow-up, with Audiology,
EI, and Family Guidance Program.
Diagnosis: Hearing Loss
Gap: Lack of family-centered communication
Family-centered communication between audiologists &
families promotes a more satisfying and successful interaction
Solution:
Pediatric Audiologic Evaluation
Audiologist counsels parents about
results and recommendations
Results to PCP
Hearing
Loss
• Address emotional distress of family
• Emphasize hope, not necessarily technical
information
• Allow the family to indicate how much
information they can take in at the time of
diagnosis
• Recognize that the family may need time to
process information.
PCP sets up an appointment
with family to review the results, intervention
benefits, and follow-up.
Diagnosis: Hearing Loss
Gap: Meaningful Communication from Audiologist to PCP
Reports from the audiologist to the PCP about diagnostic results provide an
opportunity for team building and decreased fragmentation of care
Solution:
Pediatric Audiologic Evaluation
Audiologist counsels parents about
results and recommendations
Results to PCP
Communication to PCP should:
• Describe the degree, type of HL
& implications for social and academic
development
• Use non-technical language
• Specify interventions and services needed
Hearing
Loss
PCP sets up an appointment
with family to review the results, intervention
benefits, and follow-up.
 What audiologist has done
 What PCP needs to do
Diagnosis: Hearing Loss
Gap: Unclear roles/ responsibility for PCP
Pediatric Audiologic Evaluation
Audiologist counsels parents about
results and recommendations
Results to PCP
Hearing
Loss
PCP sets up an appointment
with family to review the results, intervention
benefits, and follow-up.
Solution:
PCP Action Point
• PCP needs to be informed
of plans and issues
• Allows PCP to support
family & assist in
facilitating follow-up
Before 3 Months
Referred for Diagnostics
Every child with suspected hearing loss
Community Audiologist
Pediatric Audiologic Evaluation
RIHAP can be contacted for a list of Pediatric
Audiologists, 401-277-3700, Fax 401-276-7813
Follow-up
Every child identified with a permanent hearing loss
Hearing Loss Professionals and Organizations
Audiologist reports diagnosis to RIHAP
(401-277-3700)
 Child & family history
Audiologist refers for
early intervention and family support:
Specific Early Intervention Program ***
Family Guidance Program (401-222-4013)
 Middle ear function
PCP initiates medical evaluation
 Otoscopic inspection
 OAE*
 ABR*
 Frequency-specific tone bursts
 Air & bone conduction
 Audiologist counsels parents about results
and recommendations
PCP refers to otolaryngologist
For evaluation, to recommend treatment, and to
provide clearance for amplification
Partners in Care inform family
(Audiologist, ENT, Family Guidance Program, others)
about communication, amplification and cochlear implants
Results to PCP
Normal
Hearing
Hearing
Loss
PCP sets up an appointment
with family to review the results, intervention
benefits, and follow-up.
Results Sent to PCP
Support follow-up, with Audiology,
EI, and Family Guidance Program.
Follow-up: Permanent HL
Gap: Unclear roles and responsibilities
Audiologist reports diagnosis to RIHAP
(401-277-3700)
Solutions:
Audiologist refers for
early intervention and family support:
Specific Early Intervention Program ***
Family Guidance Program (401-222-4013)
• Identified responsible
parties (titles and phone
numbers) and expected
actions
PCP initiates medical evaluation
PCP refers to otolaryngologist
For evaluation, to recommend treatment, and to
provide clearance for amplification
Partners in Care inform family
(Audiologist, ENT, Family Guidance Program, others)
about communication, amplification and cochlear
implants
Results Sent to PCP
Support follow-up, with Audiology,
EI, and Family Guidance Program.
• Changed “advise family”
to “Partners in care inform
family”
• Developed PCP action
point
Follow-up: Permanent HL
Gap: Lack of communication among partners
Audiologist reports diagnosis to RIHAP
Audiologist refers for
early intervention and family support:
PCP initiates medical evaluation
PCP refers to otolaryngologist
Partners in Care inform family
Results Sent to PCP
Support follow-up with
Audiology, Early
Intervention,and Family
Guidance Program
Solution:
PCP Action Point
• Only if PCP informed, can
he/she support the family in
their journey
• Ongoing communication
among partners in care
maximizes the opportunity
to create the most effective
MH
Before 6 Months
Before 6 Months
Continued Follow-up
Every child identified with a permanent hearing loss
Audiologists/Early Intervention Programs/ Medical Specialists
Continued enrollment in Early Intervention and Family Guidance Program
Provide services until transition to school system at 3 years of age
Medical Evaluations
To determine etiology and identify related conditions
 Genetic
 Ophthalmologic (annually)
 Developmental pediatrics, neurology, cardiology, and nephrology (as needed)
Pediatric Audiological Services
 Hearing Aid fitting and Monitoring
 Behavioral Audiometry (starting at age 6 months)
 Ongoing monitoring
RI Algorithm
How are we using it?
• Distributed to all RI PCPs and partners in care
• To be included with all results sent to PCPs regarding:
– Initial screen “Did Not Pass”
– Infants identified at at birth with risk factors for late onset HL
• Educational programs for partners in care
• A phone survey through RIHAP will be ongoing to document
questions or comments regarding the algorithm
Conclusions
Developing a state specific algorithm is a very
worthwhile exercise
The process facilitates communication among
partners in care
Provides a succinct illustration of state specific
EHDI system flow
Defines roles of partners in the medical home
Identifies gaps in the system
Identifies opportunities for improvement
Special Thanks
First Connections Training and
Resource Project:
Project Director
Ellen Kurtzer-White, AuD
Project Coordinator
Marianne Ahlgren, PhD, CCC-A
Principal Investigator
Peter Simon, MD, MPH
Other Medical Home for Hearing
Loss in Children Task Force
Members:
Robert Burke, MD, MPH
Memorial Hospital of RI
Brian Duff, MD
University Otolaryngology
Deborah Garneau, MA
Office of Families Raising Children with
Special Needs
Ellen Gurney, MD
Providence Community Health Centers
Mary Catherine Hess, MA
RI Hearing Assessment Program
Kerri Hicks
Parent
Mary Jane Johnson, MEd
Family Guidance Program
Jennifer LeComte, MA
Family Guidance Program
Deborah Lyons, MS, CCC-A
RI Hospital Dept of Audiology
Cheryl McDermott, MS, CCC-A
RI Hearing Assessment Program
Courtney O’Neill, MS, CCC-A
RI Hearing Assessment Program
Betty Vohr, MD
RI Hearing Assessment Program