University of Hawai’i Integrated Pediatric Residency Program Continuity Care Program Medical Home Module Case 3

A 4 day old infant of a constantly moving homeless family presents to your clinic for the first time. The history and physical exam is otherwise normal. The father is not involved. The mother is unemployed, and currently living with a friend she met at her drug rehabilitation program. There is a 3 year old sibling who lives in foster care. On review of systems, you learn that the baby is sleeping in a sleeping bag with the mother.

What are the problems in this case? Homeless family Homeless family Staying at mother’s friend’s house Staying at mother’s friend’s house Father not involved Father not involved Sibling placed in foster care Sibling placed in foster care Mother unemployed Mother unemployed Mother in drug rehabilitation Mother in drug rehabilitation Baby in sleeping bag Baby in sleeping bag

How would you communicate your concerns to this family? Before answering….

Think of a personal situation where you needed to completely depend upon others for help… 1. How did this situation make you feel? 2. What did you appreciate the most about the person who helped you? 3. Keep these qualities in mind when trying to provide compassionate care for patients like this…

What personal qualities do patients and parents recognize as compassionate? “goes out of the way to make sure we’re ok” “treats us like family” “never turns us away” “answers all our questions, even the silly ones” “makes us feel like we’re in this together”

What medical home principles need to be addressed? Compassionate care Compassionate care Family centered care Family centered care Accessible care Accessible care Continuous Continuous Comprehensive Comprehensive Coordinated Coordinated

How would you provide family centered care in this situation? 1. Ask the mother what her concerns are for this child’s care 2. Ask the mother if anyone else is helping her provide care for this child 3. Include all responsible caretakers in the discussion of this child’s care and management plans.

How would you provide comprehensive care in this case? 1. Obtain and review neonatal records. 2. Social history: identify high risk behaviors and risk factors that need to be followed closely. 3. Family history: r/o maternal mental health problems, current substance abuse, etc. 4. Provide routine anticipatory guidance. 5. Educate mom on sleep safety practices. 6. Address financial and social needs to improve access to care.

How would you provide accessible care for this family? 1. Discuss potential barriers to care: financial, cultural, transportation, etc. 2. Identify yourself as this child’s new PCP. 3. Inform mother how to access you easily. 4. Offer plan for after hours care to ensure healthcare needs are being met.

How would you provide continuous care for this patient? 1. Give your business card to this mother to help her identify you to others as her child’s PCP. 2. Inform mother how frequently she will need to bring baby in for routine health maintenance. 3. Teach mom to ask other healthcare providers to notify you when child is seen in ER or hospitalized.

What outside agencies or individuals would you call? 1. Social Work 2. Public Health Nurse 3. Healthy Start 4. H-KISS

Social Work Will provide you a psychosocial assessment consisting of: 1. The mother’s coping ability to care for herself, the child, and prognosis for sobriety. 2. The mother’s support system: is the partner involved, can he/she provide emotional and financial support; if no partner, are family members available to provide emotional and financial support. 3. Referral to community agencies for emotional and financial support if no support system. 4. Counseling and case management services: liaison with the substance abuse treatment facility, housing agency, and Child Protective Services (if warranted).

Public Health Nursing Public Health Nursing (PHN) provides: 1. Care Coordination Services to infants and toddlers for Early Intervention Services. 2. Care Coordination services to special needs population* with medical/health conditions to facilitate access to services and support caregivers. *those at risk for developmental delays, abuse/neglect, substance use, domestic violence, and parental challenges that negatively impact young children

Healthy Start Program (HSP) Hawaii's HSP is a nationally known home visiting program providing early intervention family support services to young children from birth to age 5 who are at risk for maltreatment. Under the supervision of health or social services professionals, paraprofessional home visitors work with families to prevent child abuse and neglect, improve family functioning, improve child development, promote access to primary health services, maximize child health status, and promote readiness for school.

Hawaii Keiki Information Services (HKISS) A comprehensive early intervention program targeting: Any child that has/or is suspected of having a chronic condition that is expected to last more than a year, and is in need of surgical, medical, or therapeutic and care coordination services beyond the level of care provided by a primary care physician. HKISS will provide care coordination, case review services, medical nutrition services, social work, and specialty care services.

How would you coordinate care for this patient ? 1. Obtain a social worker to help find housing, obtain a crib, liason with child protective services, if indicated. 2. Obtain a public health nurse to help evaluate the home environment and coordinate services. 3. Communicate your concerns to social worker and PHN; follow up on reports. 4. Enroll patient for Early Intervention program. 5. Review plans with family.

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

Which of the following statements regarding community services is incorrect? a. A 15 month old with developmental language delay should be referred to Hawaii Keiki Information Services b. A 2 day old with infant of a mother with a history of cocaine use should be referred to the Healthy Start Program c. A 4 year old with difficulty concentrating in preschool should be referred to Hawaii Keiki Information Services d. A 5 year old with unexplained bruises to the face should be referred to Social Work services e. A 2 year old with poorly controlled seizure disorder due to medication non-compliance should be referred to a public health nurse Answer: c

A 15 year old girl comes to see you in clinic for nausea and weight gain. You diagnose that she is pregnant. She does not desire to return home, and is currently staying at a friend’s house. Which is the most appropriate next step in management? a. obtain a public health nurse to initiate coordination of services b. obtain a public health nurse to assess social situation c. enroll patient in Hawaii Keiki Information Services to initiate coordination of care d. enroll patient in Hawaii Keiki Information Services to initiate early intervention services e. obtain social worker to assess psychosocial situation Answer: e