University of Hawai’i Integrated Pediatric Residency Program Continuity Care Program Medical Home Module Case 1

14 year old boy with asthma presents to your clinic complaining of a chronic cough. His PMH is significant for recurrent ER visits for asthma exacerbations with multiple hospitalizations. He has been non-compliant with his preventive asthma medications. His parents are immigrants from the Marshall Islands, and have been giving him “herbal tea” instead of Flovent. No parents are at work, and not currently present.

What are the problems in this case? Chronic cough Chronic cough Recurrent ER visits for asthma Recurrent ER visits for asthma Multiple past hospitalizations Multiple past hospitalizations Parents and patient non-compliant with meds Parents and patient non-compliant with meds Parents giving “herbal tea” Parents giving “herbal tea” No parent present during this visit No parent present during this visit

What is the Medical Home? A partnership approach with families to provide primary health care that is accessible, family- centered, coordinated, comprehensive, continuous, compassionate, and culturally effective.

What is Family Centered Care? Family can identify PCP as personal physician Family can identify PCP as personal physician Mutual responsibility and trust exists in relationship Mutual responsibility and trust exists in relationship Family is recognized as the principal caregiver and center of strength and support for child Family is recognized as the principal caregiver and center of strength and support for child Information & options are routinely shared with family Information & options are routinely shared with family Families, youth and physicians share responsibility in decision making Families, youth and physicians share responsibility in decision making Family is recognized as the expert in their child’s care, and youth are recognized as the experts in their own care. Family is recognized as the expert in their child’s care, and youth are recognized as the experts in their own care.

How would you provide Family Centered Care for this case? 1. Identify yourself as this patient’s PCP. 2. Ask open ended questions to identify both patient and parent concerns about cough. 3. Call parent(s) to elicit parent concerns. 4. Ask the patient and parent why they thinks he is coughing or if he thinks his asthma is inadequately controlled. 5. Educate both patient and parent. 6. Include patient and family in decision making process for management and treatment.

What is Compassionate Care? Concern for the well being of the child or youth and family is expressed and demonstrated in verbal and nonverbal interactions. Concern for the well being of the child or youth and family is expressed and demonstrated in verbal and nonverbal interactions. Efforts are made to understand and empathize with the feelings and perspectives of the family as well as the child or youth. Efforts are made to understand and empathize with the feelings and perspectives of the family as well as the child or youth.

How would you demonstrate compassion in this case? 1. Be aware of non-verbal communication: sit down while questioning patient, use good eye contact, allow patient time to think. 2. Ask what has made it difficult for this patient to comply with medication regimen. 3. Ask patient if there is anything about his cough or his asthma that worries him. 4. Screen for underlying issues or social problems. 5. Express empathy when appropriate.

What is Accessible Care? All insurance, including Medicaid, is accepted. All insurance, including Medicaid, is accepted. Changes in insurance are accomodated. Changes in insurance are accomodated. Practice is accessible by public transportation, where available. Practice is accessible by public transportation, where available. Families or youth are able to speak directly to the physician when needed (24 hours/d, 7 days/wk, 52 wks/yr) Families or youth are able to speak directly to the physician when needed (24 hours/d, 7 days/wk, 52 wks/yr) The practice is physically accessible and meets ADA requirements. The practice is physically accessible and meets ADA requirements.

How would you demonstrate your accessibility in this case? 1. Ask how far patient lives from your clinic. 2. Assess method and ease of transportation. 3. Ask patient if insurance or medical coverage is a barrier to seeking routine care or obtaining meds. 4. Educate patient how to access emergency care. 5. Educate patient how to call for after hours care.

Culturally Effective Care Cultural background, beliefs, rituals, and customs, are recognized, valued, respected and incorporated into the care plan Cultural background, beliefs, rituals, and customs, are recognized, valued, respected and incorporated into the care plan PCP ensures the child and family understand the results of medical encounter and care plan PCP ensures the child and family understand the results of medical encounter and care plan Provision of (para) professional translators or interpreters are utilized if needed Provision of (para) professional translators or interpreters are utilized if needed Written materials are provided in the family’s primary language if possible Written materials are provided in the family’s primary language if possible

How would you address cultural differences in this case? 1. Learn about patient’s cultural beliefs: Determine content and purpose for “herbal tea.” 2. Explain medical rationale for plan of care to family in understandable language, use interpreter if necessary. 3. Recognize difference in cultural approach to care and make recommendations for plan of care in a respectful manner.

What is Continuity of Care? Same primary pediatric health care professional sees patient from infancy through the adolescence and young adulthood Same primary pediatric health care professional sees patient from infancy through the adolescence and young adulthood Physician assists with transitions whenever possible Physician assists with transitions whenever possible Physician participates in all aspects of care, including hospitalizations, ER visits, or care that is provided at another facility or by another provider. Physician participates in all aspects of care, including hospitalizations, ER visits, or care that is provided at another facility or by another provider.

How would you ensure continuity of care in this case? 1. Discuss long term goals with patient and plan for scheduled monitoring of asthma. 2. Tell patient he should be requesting to see you for all clinic visits. 3. Give patient your business card to keep so that he can identify you as his PCP and ask that you be contacted in future hospital or ER visits. 4. Call or fax clinic notes to referring health care providers. 5. Follow up consultant reports with patient.

What is Comprehensive Care?  Physician manages and facilitates essentially all aspects of care: -ambulatory and inpatient care for ongoing and acute illnesses and maintenance of comprehensive central record that contains all pertinent information  Physician provides preventive care which includes: -immunizations, growth and development assessments, appropriate screenings, health care supervision, and patient and parent counseling about health, safety, nutrition, parenting and psychosocial issues.

How would you ensure comprehensive care for this patient? 1. Review patient’s chart to ensure all aspects of care are addressed and updated. 2. Schedule routine health maintenance visits. 3. Address financial and social needs to help improve access to care and follow-up. 4. Enlist appropriate community resources and referrals to optimize health needs.

What is Coordinated Care? Plan of care is discussed or shared with other providers, agencies and organizations involved with the care of the patient. Plan of care is discussed or shared with other providers, agencies and organizations involved with the care of the patient. Consultation reports and other medical information is shared with patient. Consultation reports and other medical information is shared with patient. All pertinent medical information, including hospitalizations and specialty care is maintained at the practice. All pertinent medical information, including hospitalizations and specialty care is maintained at the practice.

How would you ensure coordinated care in this case? 1. Involve nursing or respiratory care staff to help educate patient on use of preventive asthma meds: -communicate concerns to staff -review nursing/RT findings or reports 2. Call parents to review findings and discuss plans of care. plans of care. 3. If referring to specialist, call or fax chart notes or patient summary to consultant.

Medical Home Elements: 1. Family centered 2. Accessibility 3. Coordinated 4. Continuous 5. Compassion 6. Comprehensive 7. Culturally Effective

Which of the following definitions of Medical Home is most accurate? a. a place where all medical information about a patient can be coordinated and easily obtained b. a compassionate physician who provides coordinated home visits to treat patients who are unable to come to medical centers c. a mobile van which serves as an accessible home for underserved patients in need of medical care d. a family-centered approach to provide compassionate medical care that is comprehensive, accessible, and culturally effective e. a systems based approach to providing cost-effective medical care for homeless patients Answer: d

Which of the following statements regarding the medical home is LEAST accurate? a. family centered care involves developing a trusting partnership with parents b. comprehensive care includes maintaining central record containing all pertinent patient information c. accessible care includes assurance that ambulatory and inpatient care will be available 24 hours a day, 5 days a week, 48 weeks a year d. continuity of care includes visiting patients when they are hospitalized e. culturally effective care involves recognition and incorporation of family customs into the care plan Answer: c