1. Utilizing the Standards for Systems of Care to Improve Medical Home Services TEXAS PRIMARY CARE AND HEALTH HOME SUMMIT JUNE 10, 2016 RACHEL JEW, MPAFF CARL TAPIA, MD, MPH

2. Objectives After this presentation, participants will understand:  The background and purpose of the Standards for Systems of Care for CYSHCN  The Medical Home Domain Standards, specifically those related to care coordination  How the Standards can be utilized to inform policy making and guide decisions about payment for medical home services  How the Standards can be implemented within a practice or hospital system to improve the provision of care coordination and quality medical home services

3. Disclosures Rachel Jew, MPAff I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.” I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

4. Disclosures Carl Tapia, MD, MPH I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.” I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

5. http://www.amchp.org/AboutTi tleV/Resources/Documents/Sta ndards%20Charts%20FINAL.pdf

6. Standards for Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN) Designed to help communities and states build and improve systems of care for CYSHCN, the Standards are the consensus of national experts across multiple systems. Screening, Assessment and Referral Eligibility and Enrollment Access to Care Medical Home Pediatric Preventive and Primary Care; Care Coordination; Pediatric Specialty Care Community-based Services and Supports Respite Care; Palliative and Hospice Care; Home-based Services Family Professional Partnerships Transition to Adulthood Health Information Technology Quality Assurance and Improvement Insurance and Financing Disclaimer: The Standards are meant to supplement, not substitute, federal statute and regulatory requirements under Medicaid, the ACA and other relevant laws and are intended for use or adaptation by a wide range of stakeholders at the national, state and local levels.

7. Texas Action Learning Collaborative Prior to the release of the Standards, the CSHCN Services Program and its partners were thinking strategically about how to continue to improve care for CYSHCN. 1.Identify needs using data  NS-CSHCN (National Survey of Children with Special Health Care Needs)  Title V Needs Assessment  1115 Waiver DSRIP Projects 2.Develop priorities based on needs 3.Create plans for activities that address needs

8. Texas Action Learning Collaborative September 2014 – September 2015 Steering Committee  CSHCN Services Program, DSHS  Texas Children’s Health Plan  Texas Parent to Parent  Medicaid/CHIP Division, HHSC  Texas Pediatric Society

9. Texas Action Learning Collaborative Vision: To enhance the development and promote the principles of the Patient- Centered Medical Home model within the state of Texas for CYSHCN through the promotion of the Standards for Systems of Care for CYSHCN Goal: To improve systems of care related to medical home/care coordination and family professional partnerships through the formation of an Action Learning Collaborative via the Medical Home Workgroup

10. Texas Action Learning Collaborative Objectives By September 2015, the Medical Home Workgroup (MHWG) will include engaged key stakeholders representing geographic, managed care, policy, and family groups participating in the majority of calls. By September 2015, the ALC steering committee will educate 75% of key stakeholders about the Standards By September 2015, the number of families participating on the MHWG call endorsing participation in planning activities will increase by 25% By September 2015, the number of physicians on the MHWG call endorsing participation in medical home transformation activities will increase by 25% By November 2015, the MHWG strategic planning committee will have an implementation plan for the strategic plan. By November 2015, the MHWG strategic plan will incorporate medical home/care coordination and family professional partnership domains from the Standards for Systems of Care for CYSHCN.

11. Standard: Medical Home MCH Performance Measure Percentage of CYSHCN who receive coordinated, ongoing, comprehensive care within a medical home NCQA GoalPlan and manage care CMHI Medical Home Index Domain Chronic condition management Healthy People 2020 Goal Access to health services

12. General Medical Home (10 Standards) Pediatric Preventive & Primary Care (9 Standards) Care Coordination (3 Standards) Pediatric Specialty (7 Standards) MEDICAL HOME Medical Home Standards

13. 1.All CYSHCN have access to patient and family-centered care coordination 2.Care Coordinators serve as member of medical home team; assist in managing CYSHCN transitions; and provide appropriate resources to CYSHCN and families 3.A plan of care * is jointly developed, shared and implemented among PCP, specialists, family and CYSHCN, and others as needed *Addresses health problems; identifies strengths and needs of child and family; routinely evaluated and updated; delineates roles of all participating entities Medical Home: Care Coordination

14. 1.Families are active, core members of the medical home team 2.Families priorities and concerns are central to care planning and management 3.Families are connected to family and peer support organizations 4.Family strengths are respected in the delivery of care 5.Care is delivered in culturally appropriate ways 6.Families get information in family-chosen methods 7.All written materials provided to CYSHCN and their families are culturally, linguistically and literacy-level appropriate 8.Health systems that serve CYSHCN solicit feedback from the family and children. 9.Health systems that serve CYSHCN have a family advisory board of committee, inclusive of families of CYSHCN Standard: Family Professional Partnerships

15. “These Standards are great, but how do we implement them?”

16. Building a Comprehensive and Effective Medical Home: Integrating Key Functions Care coordination Manage your population Family centered care

17. Building a Comprehensive and Effective Medical Home  Physical accommodations  Develop a practice pamphlet or website and a written caregiver survey  Proactively communicate with families about services offered  Expanded hours or services to accommodate schedules  Standardized assessment of family needs and experiences

18. Office Environment: SPELL (Autism) S tructure – help predict what is going to happen (picture schedules or explanations) P ositive – supportive and caring environment (autism children on walls, changing table) E mpathy – anticipate overcoming difficulties (schedule first or last) L ow arousal – calm environment (quiet room) L inks – good communication (length of wait) 18 http://www.autism.org.uk/living-with-autism

19. Patient Family Advisory Council - PFAC Most practices want to be responsive to their patients and families but may lack the resources or merely the expertise and tools to start a PFAC. Creating a Patient and Family Advisory Council: A Toolkit for Pediatric Practices  From the National Institute for Children’s Health Quality  Available for download at: http://www.nichq.org/resources/PFAC- toolkit-landingpage.htmlhttp://www.nichq.org/resources/PFAC- toolkit-landingpage.html

20. Creating a Patient Family Advisory Council Why Create a PFAC?  Become truly patient/family centered  Get valuable feedback using family survey  Improve the delivery of high quality medical care  Meets the requirement for medical home certification by demonstrating continuous quality improvement initiatives that involves patients/families as part of this process National Institute for Children’s Health Quality

21. PFAC Toolkit for Pediatric Practices Step One: Assess practice readiness Step Two: Recruit diverse patient and family representatives as council members Step Three: Support the process of authentic engagement and involvement Step Four: Sustain and evaluate your PFAC http://medicalhome.nichq.org/resources/pfac-toolkit

22. Building a Comprehensive and Effective Medical Home Implement daily team huddles  Orients staff to the resources for the day  Facilitates efficiency with patient flow  Ensures situational awareness and team coverage Tips:  Use a written template  Lead by example  Reward attendance

23. Develop a written Comprehensive Care Plan, an ordered set of actions and activities for the patient’s unique needs  Ensures continuity and coordination of care  Is useful in centralizing and focusing care  Flattens hierarchical relationship between health-care providers and parents  Strengthens relationships Building a Comprehensive and Effective Medical Home

24. Best practices Care plan tips  Portable medical summary  Action plans

25. Use a referral and feedback form to exchange information among providers Tips:  Use an incremental approach  Start with a few patients who have special needs  If you find the form useful, expand to additional patients and gradually to your entire practice Building a Comprehensive and Effective Medical Home

26. Self-Management Tools  Help to improve adherence  Promote Self-Advocacy  Promote Self-Determination  Foster a health partnership between provider and patient Cooley WC et al. Ambulatory Pediatrics. 2003;3:173-180 http://www.medicalhomeimprovement.org/

27. Examples of Self-Management Tools  Text4Babies  State QuitLine  AAP toolkits: Mental health, autism, ADHD

28. Implement an electronic health record (EHR) system to manage your population.  Supports coordination and continuity of care  Increases efficiency  Provides interactive patient education  Gives families access to their children’s health records  Improves management of chronic conditions Building a Comprehensive and Effective Medical Home

29. Use a standardized questionnaire such as the CSHCN screener  Identify children at increased risk  Create patient registries  Plan for patient visits  Identify and recall patients Building a Comprehensive and Effective Medical Home

30. Building a Comprehensive and Effective Medical Home: Sustaining Your Medical Home Financial Human Material

31. Apply coding for Medical Home Visit Reimbursement  The AAP’s Index of Current Procedural Terminology (CPT) Codes for Medical Home highlights most of the commonly reported codes for the medical home Building a Comprehensive and Effective Medical Home

32. Engage leadership in quality improvement strategies  Provide visible and sustained leadership  Ensure that the medical home building effort has the time and resources needed to be successful  Instill medical home values into staff hiring and training processes Building a Comprehensive and Effective Medical Home

33. Policy Applications The Standards are being implemented into state plan services and, ultimately, contracts Is payment linked to the Standards? Higher rates – pmpm – pay for performance – shared savings – full risk http://www.co.fresno.ca.us/viewdocument.aspx?id=47520

34. Tools and Resources: txhealthsteps.com The Texas Health Steps Online Provider Education Program offers more than 50 free continuing education (CE) courses and tutorials covering:  Best practices  Case-based evaluation and diagnostic training  Texas Health Steps preventive and screening services  Overall Medicaid benefits

35. To learn more about developing and sustaining a medical home, enroll in the Texas Health Steps Online Provider Education module: Building an Effective Medical Home Tools and Resources: txhealthsteps.com

36. Other Texas Health Steps Online Provider Education modules: Culturally Effective Health Care Texas Health Steps Overview Texas Medicaid Services for Children Transition Services for Children and Youth with Special Health-Care Needs Tools and Resources: txhealthsteps.com

37. Thank You! Carl Tapia cdtapia@texaschildrens.org (832)822-3434 Rachel Jew rachel.jew@txpeds.org (512) 370-1509