1. PCCYFS 2012 Annual Spring Conference Building a Medical Home: A Quality Improvement Initiative Presented By: Molly Gatto, MHA Renee Turchi, MD, MPH, FAAP

2. Molly Gatto, MHA Program Director, EPIC IC Renee Turchi, MD, MPH, FAAP Associate Professor of Pediatrics Medical Director, PA Medical Home Program Medical Director, Christopher’s Hospital for Children and Drexel University SPH A statewide quality improvement initiative for children and youth with special health care needs. Emily Kane Program Assistant

3. PCCYFS 2012 Annual Spring Conference 3 Objectives Describe the practical applications of chronic condition management and the AAP “medical home” concept for CYSHCN in a primary care practice. List the benefits for children, youth, families and practice staff from applying chronic condition care to a primary care practice. Recognize the methods available for connecting with community resources for patients and families. Describe the importance of data collection in quality improvement and medical home implementation.

4. PCCYFS 2012 Annual Spring Conference 4 Medical Home and Multiple Players

5. PCCYFS 2012 Annual Spring Conference 5 PA Medical Home Initiative, EPIC-IC Quality improvement initiative since 2001 EPIC framework and Chronic Care Model PA AAP Chapter

6. PCCYFS 2012 Annual Spring Conference 6 PA Medical Home Initiative Goals Support quality improvement/practice transformation Incorporate family centered care Promote care coordination Develop data collection methods Ensure financial viability Foster high quality, efficient health care delivery

7. Chronic Care Model for Child Health in a Medical Home Functional and Clinical Outcomes family-centered, timely, efficient coordinated & equitable evidence-based & safe informed, activated patient/family prepared, proactive practice team Health System Health Care Organization (Medical Home) Decision Support Clinical Information Systems Care Partnership Support Community Resources & Policies supportive, integrated community Delivery System Design

9. PCCYFS 2012 Annual Spring Conference 9 Practice Overview Over 143 practices trained in medical home principles 46 practices have received funding for care coordination 4 additional practices received funding specifically around transitioning of YSHCN; another 4 will be funded in 2012 Practices represent Six regions and 43 counties of PA Urban, suburban, and rural communities Hospital systems Federally Qualified Health Centers Rural Health Centers

10. Using Tools for Construction Photo by K. Sawyer http://www.flickr.com/photos/ksawyer/578229906/

11. PCCYFS 2012 Annual Spring Conference 11 Medical Home Implementation Identify the team in the practice Schedule regular team meetings Identify and engage Parent Partners Create a process to identify special needs patients Complete Medical Home Index Discover community resources Create special relationships with community resources Work on MH certification and reimbursement strategies (Turchi et. al, 2006)

12. PCCYFS 2012 Annual Spring Conference 12 Medical Home Team Families Parent Partners Youth Physicians Nurse Practitioners Physician Assistants Specialty Physicians Nurses Social Workers Administrators Office Staff Grant Officers Community Partners Educators

13. PCCYFS 2012 Annual Spring Conference 13 Data Collection Tools Medical Home Index Patient Registry Time Tracking Form Family Survey Cost effectiveness modeling

14. Patient Registry Pt ID DOBInsur. Sev. Score Home- care DiagnosisStatusHIPAA 14/3/1997Public2s/p MVA Active- temp Yes 22/4/2005Public3SDME Preemie, BPD, DHS involvement ActiveYes 36/8/2003Both4 DME, RN Encephalopathy, G-tube Inactive- Deceased 8/2/05 No

15. PCCYFS 2012 Annual Spring Conference 15 Patient Registry: Insurance All data current as of 3/20/12 n=20,535

16. PCCYFS 2012 Annual Spring Conference 16 EPIC-IC Family Survey Areas measured on the survey: Components of Medical Home Accessibility Parental satisfaction/trust Health care utilization Unmet medical needs Demographic information

17. PCCYFS 2012 Annual Spring Conference 17 Tools to Enhance the Team

18. PCCYFS 2012 Annual Spring Conference 18 Family Centered Care and Parent Partners Listens carefully Spends time with the child and the family Is sensitive to the values of the family Provides needed information Makes the parent feel like a partner Recognize families are the expert on their child

19. PCCYFS 2012 Annual Spring Conference 19 Successful Models for Engaging Parent Partners Focus Groups Resource Nights Individual Invitation

20. PCCYFS 2012 Annual Spring Conference 20 Tools to Enhance Communication Pre-Visit Contact Pre-Appt. referrals Fax Back Referrals Email Care plans Data reports EMRs

21. PCCYFS 2012 Annual Spring Conference 21 Care Plans Information included on the care plan: Diagnoses Surgeries Relevant pmh Medications Allergies Home Nursing PT, OT, & SLP DME Insurance info/coordinator Alternative therapies Services and providers Child’s needs and strengths

22. PCCYFS 2012 Annual Spring Conference 22 Benefits of a Care Plan Empowers the family Improves communication among care providers Provides information if family not present Family does not have to repeat history Allows salient and rapid information exchange during an emergency

23. www.pamedicalhome.org

24. PCCYFS 2012 Annual Spring Conference 24 Especially for Parents, Youth and Caregivers “Especially for Parents, Caregivers & Youth” is a web community designed with the belief that parents of children with special needs are experts who valuable insights and information to share. To join the community, visit www.pamedicalhome.org and click on the “Parents” button. Please tell your parents about the community as well! www.pamedicalhome.org

25. PCCYFS 2012 Annual Spring Conference 25 Blueprints for the Future NCQA implementation Meaningful use and PA Reach PA Chapter collaboration with partners Policy changes in care plan reimbursement, transition, complex visits, telephone calls Practice teams have improved efficiency and satisfaction

26. PCCYFS 2012 Annual Spring Conference 26 Thank you! Grant support –Maternal Child Health Bureau –PA Department of Health PA AAP Pediatric Practices in EPIC IC Children/youth and their families

27. PCCYFS 2012 Annual Spring Conference 27 Contact Information Renee Turchi, MD, MPH, FAAP Philadelphia, PA 215-427-5331 renee.turchi@drexelmed.edu Molly Gatto, MHA Media, PA 484-446-3039 mgatto@paaap.org