1. Educating Practices in Community Integrated Care for Children with Special Health Care Needs Pennsylvania Chapter, AAP A Medical Home Initiative of the MCHB

2. EPIC-Integrated Care Community Integrated Care for Children with SHCN  Federal MCHB  Medical Home Initiative  EPIC-IC Education/QI Program  Demonstration Projects  Advocacy  Pennsylvania DOH Program  Support EPIC-IC  Care Coordination Demonstration Projects  Child Care Education about children with SHCN

3. EPIC-Integrated Care Other EPIC Programs u Immunization Education u Stop Child Abuse Now (SCAN) u Smoking Cessation

4. EPIC-Integrated Care Case Presentation

5. EPIC-Integrated Care Why should you care about children with SHCN? u Increasing numbers of children with SHCN--time, cost u Opportunity for improvement  Health care system built around acute care, not chronic care  Families want more involvement in care process  More care provided in the home and community  Primary care practice staff want to provide the best care possible

6. EPIC-Integrated Care Take Home Message Primary care practices can u Develop patient/family centered care u Identify and monitor children with SHCN u Improve coordination of care and communication u Improve documentation to enhance coding and reimbursement. u Improve how the primary care practice team provides chronic care through systems change u Facilitate patient access to services in practice and community

7. EPIC-Integrated Care Community Integrated Care for Children with SHCN u Who are “Children with SHCN”? u What is a “Medical Home”? u Where should we focus? u How does this relate to our practice? u How can we improve our practice?

8. EPIC-Integrated Care Who are children with special health care needs? “ Children with Special Health Care Needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” (Maternal and Child Health Bureau ’95)

9. EPIC-Integrated Care Children with Special Health Care Needs 600 360 140 4 2

10. EPIC-Integrated Care Epidemiological Statistics of Children with Special Health Care Needs (1994) 18% of Children or 12.6 million (0-18 years of age)* u Avg. Annual School Absences 7.4 2.8 3.6 u % with Health Insurance 88.8 86.4 86.8 u % with Usual Source of Care 94.4 93.2 93.4 u % not Satisfied with Care 17.9 13.6 14.7 u % with Unmet health Needs 12.9 6.4 7.6 u Avg. Annual Physician Contacts 6.4 2.6 3.3 u Avg. Annual Hosp.Days/1000 691 122 225 *Newacheck et al. Pediatrics, Vol 102, No. 1, July. 1998, pp 117-121 CwSHCN Typical Avg.

11. EPIC-Integrated Care Annual Cost of Medical Care for Children with SHCN

12. EPIC-Integrated Care A Medical Home u Is an approach and process to providing care u Is not a building u Is a partnership with the child, family and practice care staff u Emphasizes the primary care practice as the “home” where the family and child  Feel recognized and supported  Find a centralized base for medical care  Find connection to other medical and non-medical community resources

13. EPIC-Integrated Care Components of Care in a Medical Home l Family-Centered l Accessible l Comprehensive l Continuous l Coordinated l Compassionate l Community-Based l Culturally-Competent l Provided in an Environment of Trust and Mutual Responsibility

14. EPIC-Integrated Care Identifying Challenges to Medical Home Care u TIME, TIME, TIME u (and reimbursement) u Organized systems of care u Adequate parent-professional partnerships u Knowledge u Communication u Coordination u Medical staff turnover u Awareness of community resources and programs

15. EPIC-Integrated Care Physicians’ and Parents’ Ranking of Services Ranking Service Physicians Parents Respite care 1 9 Day care 2 21 Parent support groups 3 3 Help with behavior problems 4 10 Financial information or help 5 2 After-school child care 6 20 Assistance with physical household changes 7 15 Vocational counseling 8 6 Psychological services 9 5 Homemaker services 10 22 Recreational opportunities 13 4 Information about community resources 14 1 Dental treatment 16 8 Summer camp 19 7

16. EPIC-Integrated Care Benefits to the Practice u Increased professional satisfaction u Improved coordination of care u Efficient use of limited resources u Streamlined office procedures u Compensation for the additional care provided

17. EPIC-Integrated Care Benefits to Patient/Family u Increased quality of care u Increased patient and family satisfaction u Improved communication with physician and staff

18. EPIC-Integrated Care Benefits to the Community u Improved coordination of care u Increased integration of CSHCN into schools and extracurricular activities

19. EPIC-Integrated Care Community Services for Children with SHCN and Their Families Role of Primary Care Practice in Community Services Child Welfare Social Services Early Childhood Services Education Mental Health Community Based Therapies Public Health Family Support Spiritual Support

20. EPIC-Integrated Care Changing a primary care practice is like trying to change the tire on a bicycle while you are riding it

21. EPIC-Integrated Care Getting Started u Identify the team within the practice u Evaluate practice u Identify the CSHCN in the practice u Select a parent advisor u Share concepts and goals with practice staff

22. EPIC-Integrated Care Identifying the Team u A practice team includes  Primary care clinician  Nurse manager/care coordinator  Office manager  Parent advisor

23. EPIC-Integrated Care Evaluating the Practice u Medical Home Index u Medical Home Family Index

24. EPIC-Integrated Care Identifying CSHCN u Utilize severity scoring tools available u Define chronic conditions within the practice u Use ICD-9 codes and Flu shot list to identify u Review utilization reports to determine those children seeing > 1 specialist on a regular basis u Determine how to identify the chart i.e., using color coded charts, stickers, and binders

25. EPIC-Integrated Care Select a Parent Partner u Identify potential parent advisors who will provide effective input u Communicate role and responsibilities of parent advisor u Be open to constructive feedback regarding practice policies and procedures

26. EPIC-Integrated Care Share Concepts/Goals With Practice Staff u Present the broad, general topics of the medical home and role of parent advisors to all members of your practice u Meet with your practice team to choose and plan your first improvement project u Implement practice wide u Review with your practice team  What worked  What did not u Celebrate your success

27. EPIC-Integrated Care Key Factors for Success u Unifying leadership u Common goal u Thorough planning u Staff buy-in u Communication plan u Small steps first u Learn from your mistakes

28. EPIC-Integrated Care Practical Applications u Scheduling  Use a telephone script for all schedulers to easily identify those children requiring extra time u Parent Advisors  Develop Tips sheet for parents  Act as a resource for other families of CSHCN  Provide community resource information for the practice

29. EPIC-Integrated Care Practical Applications u Coordination of Care  Complete care plans or summaries for each child with SHCN. One copy for chart, one for family.  Fax back forms being used to facilitate communication with subspecialists  Develop flow sheets for specific diseases that providers and staff will use for care

30. EPIC-Integrated Care Practical Applications u Reimbursement  Conduct coding sessions for staff to understand correct coding for CSHCN  Update encounter forms to include CPT and ICD9 codes that reflect the population seen  Develop progress note templates to ensure accurate documentation

31. EPIC-Integrated Care Compensation u Coding u Documentation u Data Collection u Managed Care Negotiation

32. EPIC-Integrated Care Coding for Children with Complex Medical Needs  No specific code exists for additional time and effort required  Use appropriate E & M code following documentation guidelines  Remember if it’s not documented it didn’t happen

33. EPIC-Integrated Care Coding for Children with Complex Medical Needs  Preventative medicine service codes (99381-99397) [with the use of E/M codes (99201-99215) and the –25 modifier]  Counseling and/or risk factor reduction codes (99401-99412)  Team conferences (99361-99362)  Telephone calls (99371-99373)

34. EPIC-Integrated Care Coding for Children with Complex Medical Needs  Care plan oversight services (99375-99376)  Prolonged physician service (99354-99359)  Office or other outpatient service codes (99201-99215)  Consultations (99241-99245)  Modifier –21/09921

35. EPIC-Integrated Care Summary u This is introductory material; a starting point to create an ongoing process to:  Develop a patient/family-- physician/practice relationship of care  Improve how the primary care practice team provides chronic care  Integrate comprehensive care of the child with the community

36. EPIC-Integrated Care Other EPIC IC Trainings Available u Family Centered Care u Care Coordination u Practice Management/Care Design u Transition

37. EPIC-Integrated Care Where Do We Go From Here? u Develop the infrastructure, develop the process u Start with a few small steps u Recognize that change needs to be gradual u Implement medical home strategies one at a time u After strategies have been implemented for a few months, evaluate progress

38. EPIC-Integrated Care Contact Information u EPIC IC Program:  (800) 414-7391  Email at paaap@voicenet.compaaap@voicenet.com Helpful Websites

39. EPIC-Integrated Care Home is the place where When you go there They have to take you in R. Frost