Transcript Medical Home

Building a Medical Home:
A Quality Improvement
Initiative
Presented By:
Molly Gatto, MHA
Renee Turchi, MD, MPH, FAAP
PCCYFS 2012 Annual Spring Conference
A statewide quality improvement initiative for
children and youth with special health care needs.
Renee Turchi, MD, MPH, FAAP
Associate Professor of Pediatrics
Medical Director, PA Medical Home Program
Medical Director, Christopher’s Hospital for Children and
Drexel University SPH
Molly Gatto, MHA
Program Director, EPIC IC
Emily Kane
Program Assistant
Objectives
• Describe the practical applications of chronic
condition management and the AAP “medical
home” concept for CYSHCN in a primary care
practice.
• List the benefits for children, youth, families
and practice staff from applying chronic
condition care to a primary care practice.
• Recognize the methods available for
connecting with community resources for
patients and families.
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• Describe the importance of data collection in
quality improvement and medical home
implementation.
Medical Home and Multiple Players
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PA Medical Home Initiative, EPIC-IC
• Quality improvement initiative
since 2001
• EPIC framework and Chronic Care
Model
• PA AAP Chapter
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PA Medical Home Initiative Goals
• Support quality improvement/practice
transformation
• Incorporate family centered care
• Promote care coordination
• Develop data collection methods
• Ensure financial viability
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• Foster high quality, efficient health care
delivery
Chronic Care Model for Child Health in
a Medical Home
Community
Resources
& Policies
Health System
Health Care Organization (Medical Home)
Care
Partnership
Support
Delivery
System
Design
Clinical
Information
Systems
Decision
Support
supportive,
integrated
community
informed,
activated
patient/family
prepared,
proactive
practice team
family-centered,
timely,
efficient
evidence-based
& safe
coordinated
& equitable
Functional and Clinical Outcomes
EPIC IC Medical Home Sites
Participated in Medical Home implementation
Has received Medical Home Outreach/Education
There are 97 sites that have participated in implementation (green dots) and 28 sites (yellow
dots) that have received education marked on this map dated 1/19/12. Some pushpins may
overlap when sites are in close geographical proximity.
Practice Overview
• Over 143 practices trained in medical home
principles
• 46 practices have received funding for care
coordination
• 4 additional practices received funding
specifically around transitioning of YSHCN;
another 4 will be funded in 2012
• Practices represent
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Six regions and 43 counties of PA
Urban, suburban, and rural communities
Hospital systems
Federally Qualified Health Centers
Rural Health Centers
Using Tools for Construction
Photo by K. Sawyer
http://www.flickr.com/photos/ksawyer/578229906/
Medical Home Implementation
• Identify the team in the practice
• Schedule regular team meetings
• Identify and engage Parent Partners
• Create a process to identify special needs
patients
• Complete Medical Home Index
• Discover community resources
• Create special relationships with
community resources
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• Work on MH certification and
reimbursement strategies
(Turchi et. al, 2006)
Medical Home Team
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Families
Parent Partners
Youth
Physicians
Nurse Practitioners
Physician Assistants
Specialty Physicians
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Nurses
Social Workers
Administrators
Office Staff
Grant Officers
Community
Partners
• Educators
Data Collection Tools
• Medical Home Index
• Patient Registry
• Time Tracking Form
• Family Survey
• Cost effectiveness modeling
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Patient Registry
Pt
ID
DOB
Insur.
Sev.
Score
1
4/3/1997
Public
2
2
3
2/4/2005
6/8/2003
Public
Both
Homecare
Diagnosis
Status
HIPAA
s/p MVA
Activetemp
Yes
Active
Yes
InactiveDeceased
8/2/05
No
3S
DME
Preemie, BPD,
DHS
involvement
4
DME,
RN
Encephalopathy,
G-tube
All data current as of 3/20/12
Patient Registry: Insurance
Uninsured
1%
Unknown
5%
Public/Private
13%
Public
47%
Private
34%
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n=20,535
EPIC-IC Family Survey
Areas measured on the survey:
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Components of Medical Home
Accessibility
Parental satisfaction/trust
Health care utilization
Unmet medical needs
Demographic information
Tools to Enhance the Team
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Family Centered Care
and Parent Partners
• Listens carefully
• Spends time with the child and
the family
• Is sensitive to the values of the family
• Provides needed information
• Makes the parent feel like a partner
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• Recognize families are the expert on their
child
Successful Models
for Engaging Parent Partners
• Focus Groups
• Resource Nights
• Individual
Invitation
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Tools to Enhance Communication
• Pre-Visit Contact
• Pre-Appt. referrals
• Fax Back Referrals
• Email
• Care plans
• Data reports
• EMRs
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Care Plans
Information included on the care plan:
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Diagnoses
Surgeries
Relevant pmh
Medications
Allergies
Home Nursing
• PT, OT, & SLP
• DME
• Insurance
info/coordinator
• Alternative therapies
• Services and providers
• Child’s needs and
strengths
Benefits of a Care Plan
• Empowers the family
• Improves communication among care
providers
• Provides information if family
not present
• Family does not have to repeat history
• Allows salient and rapid information
exchange during an emergency
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www.pamedicalhome.org
Especially for Parents, Youth
and Caregivers
“Especially for Parents,
Caregivers & Youth” is a
web community designed
with the belief that
parents of children with
special needs are experts
who valuable insights
and information to share.
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To join the community, visit
www.pamedicalhome.org and click on the
“Parents” button. Please tell your parents
about the community as well!
Blueprints for the Future
• NCQA implementation
• Meaningful use and PA Reach
• PA Chapter collaboration with partners
• Policy changes in care plan
reimbursement, transition, complex visits,
telephone calls
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• Practice teams have improved efficiency
and satisfaction
Thank you!
• Grant support
– Maternal Child Health Bureau
– PA Department of Health
• PA AAP
• Pediatric Practices in EPIC IC
• Children/youth and their families
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Contact Information
Renee Turchi, MD, MPH, FAAP
Philadelphia, PA
215-427-5331
[email protected]
Molly Gatto, MHA
Media, PA
484-446-3039
[email protected]
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