Optimizing Health Outcomes for Delaware’s Children: Pediatric Patient-Centered Medical Home Presentation to the Delaware Health Care Commission Patricia Redmond, Senior Advisor Policy, Evaluation and Research Nemours

Overview  The Many Faces of Nemours  The Challenge for Nemours—and the Country  Pediatric medical home definition and plans  Population health and primary care: what can be gained from this marriage?  Questions/Stay Tuned 2

The Many Faces of Nemours  Integrated health system with a continuum of care including: – Clinical treatment – Health promotion and prevention services, including community-based – Research – Education – Policy and advocacy  Alfred I. du Pont Hospital for Children and outpatient facilities in the Delaware Valley.  Operating foundation dedicated to children's health & health care.  Specialty care services in Northern/Central Florida; building new state-of-the-art Children’s Hospital near Orlando. 3

Challenge for Nemours—and the Country  For the first time in our history, the United States is raising a generation of children who may, because of the toll of chronic disease, live sicker, shorter lives than their parents.  We need to respond to this reality with a comprehensive model that integrates and coordinates across health, education and human services  Where is this model? Examples of change throughout the country, but Nemours is responding in part with a medical home model that unites primary care and population health services 4

The Challenge: Continued 5  Many elements of pediatric health care were designed decades ago to treat infectious disease; they are not fully capable of addressing current threats such as: –Obesity –Chronic diseases –Mental illness  Our existing children’s system is: –Highly fragmented –Highly complex for families, providers and administrators –Financed by multiple public and private categorical funding streams that perpetuate silos in the system

The “Blind Side of Health Care”  blind side n. the part of one’s field of vision where one is unable to see approaching risk and is particularly vulnerable; the opposite side of where one is looking  The current health care system has a blind side—one which our system change efforts will attempt to address. 6

The “Blind Side of Health Care”  Four months ago, the Robert Wood Johnson Foundation released survey results that reveal physicians believe unmet social needs are directly leading to worse health for Americans — and that patients’ social needs are as important to address as their medical conditions.  These social issues are the health care system’s “blind side.” 7

The “Blind Side of Health Care”  Strong evidence linking social needs to health and life expectancy. Health care itself plays surprisingly small role (10 percent of contributing factors) in life expectancy.  Social circumstances, environmental exposure and behavior are estimated to account for 60 percent of the risk of premature death. 8

9 McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993; 270(18): McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to population health promotion. Health Affairs 2002; 21(2):78-93 Slide content borrowed from Dr. Bailey 10/26/10 LDI presentation 40% Behavior (tobacco, alcohol, obesity, auto safety, etc.) 20% Environment and social circumstances 30% Genetics 10% Health care delivery In 2007, $7,123 per person spent on health care in U.S. Below average life expectancy compared to 30 other developed countries Children: 26% of population, 13% of health care dollars 15% of children have chronic diseases accounting for 70%+ of pediatric health costs Main Determinants of Health High Cost Why Change the Delivery Model?

10  We are examining our own system as part of this work. Asking: –How do our patients access us? –How can we do better for our patients? –Where does the “blind side” of health care come into play in our work? Why Change the Delivery Model at Nemours?

11  Recent record review of the 20 most frequent users of our Emergency Department (ED) revealed the likely extent of social issues involved with avoidable ED visits and hospitalizations.  The overwhelming majority of parents in the high user sample were between the age of 15 and 21; half self- identified as single parents; and more than half were first time parents. How Do Our Patients Access Us?

12  Most of the patients presented with symptoms of common infant and childhood illnesses during at least one, if not several, visits. Parental-reported asthma represented nearly half of the visits.  For the large part, we are looking at (in this small sample) avoidable ED visits. But avoidable HOW?

13  Just released from the Institute of Medicine (IOM): –“The integration of primary care and public health could enhance the capacity of both sectors to carry out their respective missions…” –Each has knowledge, resources and skills to enable the other to carry out its role. –Examples of integration, but it is not the norm. One Solution: Primary Care and Public Health

14  Caveat: Only part of the answer. This is a multi-tiered, big, hairy problem.  Nemours is launching a pilot in three primary care practice sites in which we will achieve Level 3 NCQA recognition as a medical home and begin work to address non-medical needs, “the blind side of health care.” Nemours Medical Home “Plus”

15  Starting from Academy of Pediatrics definition: –Primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective to all children and youth, including children and youth with special health care needs. Nemours Medical Home “Plus”

16  Launching pilot to achieve Level 3 medical home recognition by the National Committee for Quality Assurance (NCQA) in three of Nemours nine primary care practices: Jessup St; Seaford; Dover.  NCQA provides a set of standards that describe, in very clear and specific terms, how practices may organize care around patients, work in teams, and coordinate and track care across time.  Level 3 is the highest level of recognition. Nemours Medical Home “Plus”

17  Level 3 NCQA recognition PLUS  The creation of a medical home in which non-medical needs and the fostering of healthier communities are integrated into the mission of pediatric primary care  Our guiding principle is “The Triple Aim.” The “Plus”

18  The Triple Aim, developed by the Institute for Healthcare Improvement and adopted by the Department of Health and Human Services, focuses on three aims to improve health and health care in the United States: –(1) enhance the patient experience (quality) of care; –(2) improve the health of the population; and –(3) reduce the cost of care. Triple Aim

19  Medical home alone cannot achieve the Triple Aim.  We need a systemic approach to address the blind side. Medical home Plus is a beginning.  Very intentionally a pilot: ambitious goal, test on a smaller scale first. Why Medical Home “Plus”

20  Pilot sites: Nemours Pediatrics practices—Jessup Street; Dover; and Seaford.  Three communities; very different needs. We are targeting six zip codes—two surrounding each site. “Hyper local.”  NHPS will partner with community leaders to identify, prioritize and address non-medical needs in schools, child care, housing & other systems of targeted zip codes. Medical Home “Plus”

21 Connecting Clinical Care and Population Health What it Looks Like Our CommunityOur Health System Resources, Policies and System Change Health Care Organization Informed, Activated Patient, Family and Community Partners Productive Interactions & Spreading Change Organized, Prepared, Proactive Health Team with patient/family Improved Health Among Patients Improved Health for Delaware’s Children Health Policy Health Promotion Practice Change Self-Management Support Delivery System Design Decision Support Clinical Information Systems

22  Individual level: Decrease in ED visits for asthma diagnosis.  Systems level: Increase in number of school nurses linked to Nemours Pediatrics and managing children with asthma appropriately; increase in number of homes with reduction in asthma triggers.  Population level: Increase in number of children with asthma engaged in appropriate healthy behavior, such as physical activity. Ultimately, reduce, prevent or manage morbidity related to asthma. A Possible Outcome to Measure

23  Individual: Increase in number of identified patients/families receiving non-clinical services that improve health (e.g., parenting support).  Systems: One or more concrete policy or practice changes in child-serving systems as a direct result of the model (e.g., state grant-in-aid funds used to imbed parenting classes in communities).  Population: Increase in the number of children demonstrating healthy behaviors and outcomes. Another Possible Outcome to Measure

24 Optimal health for all children, with both medical and non-medical needs appropriately addressed. Overall Outcome

25 “ To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks a real advance in science.” Albert Einstein

26 Questions?