Transcript Slide 1 - UNC School of Medicine

The Medical Home on Steroids:
Caring for Children with Medical Complexity
Dennis Z. Kuo, MD, MHS
Assistant Professor of Pediatrics, UAMS
Denny Society 2011 Triennial Meeting
September 23, 2011
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Disclosures
• Dennis Z. Kuo, MD, MHS has no financial
relationships or commercial interests to
disclose
• No off-label use of medications or therapeutic
devices will be discussed
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Alex (name is changed)
• Alex is a 3 month old child you have seen since birth.
In the nursery, you noticed dysmorphic facies, low
tone, undescended testes, and a heart murmur. He
developed heart failure shortly after and required
surgery to repair a large VSD.
• Today, you suspect craniosynostosis on exam. He is
developmentally delayed and small for age.
• What specialists does he need?
• Therapists?
• What is the role of the PCP?
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Objectives
• Define medical complexity
• Define the ideal model of care
• Discuss the role of the medical home (with or
without steroids) for the child with medical
complexity
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History of the Medical Home
• 1967: AAP – central source of records
• 1978-9: efforts in NC and HI to meet health needs through
community-based primary care
• 1992: first AAP policy statement (update 2002)
• 1994: Medical Home Training Program – MCHB
• 1999: National Center
• 2006: PCMH Joint Statement
• 2009: ACA – multiple provisions (Health Homes, CMMI, etc)
• Medical Home is rooted in community-based primary care,
particularly for children with special health care needs
Sia (2004)
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Medical Complexity
• Medically fragile, medically complex, etc
• Usually described by:
– Multiple subspecialists
– Technology dependence for basic health needs
– Frequent visits to tertiary care centers
• High prevalence of neurodevelopmental
disabilities and genetic disorders
Srivastava 2005; Cohen 2011, Pediatrics
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Why consider these children separately?
Complex/Chronic, %
# school days missed last year, median [IQR]
# doctor visits last year , median [IQR]
# of ER visits, median [IQR]
Received early intervention services, %
Received special education services, %
10 [5, 16-20]
11-15 [6, >21]
1 [0, 3]
82.2%
76.9%
Kuo et al (2011) Arch Pediatr Adol Med, in press
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Bending the cost curve
• Medicaid projected growth rate: 8.8%
• A small number of children are responsible for a
majority of health care costs
– Medicaid: 10% of children = 72% of costs
– 0.4-1% of children = 12-15% of total costs, 20-25% of
hospitalized patients, and 45-50% of hospital days
– Most are children with medical complexity
• Willie Sutton
Shortell (2009), JAMA; Kenney (2009), Health Affairs; Neff (2004);
Berry (2011) unpublished, by permission
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Chronic Care Model: Addressing needs
of children with medical complexity
Antonelli R (2005). Adapted from Bodenheimer (2002)
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The Medical Home Clinic
• Comprehensive care assisting PCPs
– Team-based care: physician, nurse, social work, nutrition, psychology,
speech
– Medical needs: nutrition, dysphagia, respiratory
– Care coordination and oversight with specialty colleagues at ACH
• Infants and children with at least 2 complex medical
conditions that require care by at least two subspecialty
clinics
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Select Characteristics of 344 Children
Medical Condition*
N
Gastrostomy
155
Preterm with BPD
110
Seizure Disorders
72
Cerebral Palsy
60
Genetic Syndromes
57
Congenital Heart Defects
50
Age in Months at First Medical Home Program Visit (mean, SD)
18(21)
Male (%)
60
*Medical condition categories not necessarily mutually exclusive.
Slide 11
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Overall Costs: Adjusted vs Predicted and 95%
Confidence Intervals
Pre-Post Analysis
•Pre Medical Home average costs per child
per month = $4,678
•Post Medical Home average costs per child
per month = $3,427
•Pre – Post = -1,251, p < 0.001
Mean Cost Per Child Per Month
7000
6000
5000
4000
Adjusted
Costs
3000
2000
Predicted
Costs
1000
0
N=
111
Pre
12
N=
118
Pre
11
N= N= N= N= N= N= N= N= N= N= N= N= N= N= N= N= N= N= N= N= N= N=
122 129 136 146 160 175 187 204 222 235 235 235 235 235 235 235 235 235 219 199 183 168
Pre Pre Pre Pre Pre Pre Pre Pre Pre Pre Post Post Post Post Post Post Post Post Post Post Post Post
10 9
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
9 10 11 12
Casey et al (2011) Arch Pediat Adol Med
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Downsides
• Financially difficult to sustain
– Gordon: deficit of $400K in 2005
• Services located at tertiary care centers
• Capacity
– MHCL enrollment: 450
– ~3700 children with medical complexity in
Arkansas
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Co-management:
The medical home on steroids
• Multiple health care professionals partner with
families to provide a consistent direction of care
– Integrates all components of care
– Reinforces the active role of the PCP/Medical Home
• Can we bring comprehensive care services to
the community setting?
Stille (2009)
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Physician practices
N=203
Always/Usually, %
Offer written care plan
15.4%
Schedules extra time
45.3%
Satisfied with available time to care for CYSHCN
32.6%
Refer to community resources
57.7%
Keeps registry of CYSHCN patients
5.4%
Kuo et al. Clin Pediatr (2011)
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Implementing co-management
• Is the Medical Home communicating with
other service providers?
• Are the roles of all providers clear?
• Are there clear protocols of care?
• Is there patient and family engagement?
• Are there strong community linkages?
Taylor (2011), AHRQ
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Roles
• Medical Home: ALWAYS good primary care
–
–
–
–
–
First point of contact
Anticipatory guidance
Immunizations
Care hub / care coordination
Verify/Initiate Early Intervention
• Act as “eyes and ears” for specialty teams
– Remind families that you can be first point of
contact
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Additional roles
• With good communication with specialty
colleagues, may consider:
– Labs
– Medication initiation / adjustment
– Referrals to community services
• Consider designating office staff (such as nurse)
to be single point of contact
– Additional roles for office staff
Kuo (2007) Pediatrics
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Clear protocols of care
• Common medical issues
– Swallowing/feeding/growth; maximize pulmonary
function; promote development/function
• Engage specialty providers
– Networking most important
– “good neighbor” referrals
• Define your communication lines
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Patient and family engagement
• “The ultimate measure of effectiveness of
health care is how patients and families
experience it” (Antonelli, 2009)
• Educate families on roles
• Family-centered care assessment tools
• Families as partners on committees, QI teams,
learning collaboratives
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Community linkages
• Know your resources
– Get involved with statewide initiatives, AAP, etc
– Develop relationships with local family-to-family
health information center, other groups
• Other folks to engage: care managers, social
work, tertiary care centers
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Ongoing projects
• Learning collaboratives
– Supported by HRSA D70 System of Care grant
• Co-management protocols for complex
neonates
– Evaluate health care outcomes
• Quality improvement
– Implement practice changes
– Carrot: get MOC Part 4 approval…hopefully
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Conclusion
• Children with medical complexity: high resource utilizers,
multiple specialty needs, technology dependence
• Comprehensive care and care coordination can reduce
hospitalizations and overall costs
• The Medical Home on steroids
–
–
–
–
Defined roles with colleagues
Care protocols
Patient and family engagement
Community linkages
• Research continues
• Health care reform???
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Thank you!
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