1. Medical Home: Primary Care for the 21 st Century Is This the Path to Quality and Value in Health Care? Louisiana Health Care Quality Forum May 23, 2008 Richard C. Antonelli, MD, MS, FAAP Assoc Prof Pediatrics, Univ Conn SOM Chief of General Pediatrics Connecticut Children’s Medical Center AAP National Center for Medical Home Initiatives Project Advisory Committee

2. Every System is Perfectly Designed to Get the Results it Gets –Institute for Healthcare Improvement –National Initiative for Children’s Healthcare Quality

3. Definition of Medical Home Care that is: –Accessible –Family-centered –Comprehensive –Continuous –Coordinated –Compassionate –Culturally-effective

4. Definition of Medical Home And for which the primary care provider shares responsibility with the family. AAP/ AAFP/ NAPNAP/ ACP

5. Functional Definition of Medical Home Partnership between family and providers Commitment to continuous quality assessment and improvement Single point of entry to a “system” of care that facilitates access to medical and non- medical resources

6. Joint Principles of the PCMH AAP, AAFP, ACP, AOA March 2007 Whole person orientation Personal physician Physician directed medical practice Care is coordinated and/or integrated Quality and safety Enhanced access to care Payment to support the PC-MH

7. Issues Can Primary Care Survive? –Capacity of current workforce –Attracting new providers to workforce What About Quality and Value? Do We Need Medical Home? –Highest quality with least disparity to access occurs when Medical Home available

8. What About Disparity?

9. Percent of adults ages 19–64 with health problems* Figure 8. Across Income Levels, African Americans Are More Likely to Have Health Problems, Even After Adjusting for Age * Defined as having any chronic condition or disability. Note: Percentages are age-adjusted. Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

10. Lacking Health Insurance for Any Period Threatens Young Adults’ Access to Care, 2005 Percent of adults ages 19–29 reporting the following problems in the past year because of cost: Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

11. The Result of Delayed Access? More Expensive Care Rendered in Emergency Departments In case of Mental Health, services “rendered” in criminal justice system

12. Percent of adults 18–64 26 21 28 18 49* Figure ES-1. Nearly Half of Hispanics and One of Four African Americans Were Uninsured for All or Part of 2006 * Compared with whites, differences remain statistically significant after adjusting for income. Source: Commonwealth Fund 2006 Health Care Quality Survey.

13. Percent of adults 18 – 64 Figure ES-3. Uninsured Are Least Likely to Have a Medical Home and Many Do Not Have a Regular Source of Care Note: Medical home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running on time. * Compared with insured with income at or above 200% FPL, differences are statistically significant. Source: Commonwealth Fund 2006 Health Care Quality Survey.

14. Figure ES-4. Racial and Ethnic Differences in Getting Needed Medical Care Are Eliminated When Adults Have Medical Homes Percent of adults 18–64 reporting always getting care they need when they need it Note: Medical home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running on time. Source: Commonwealth Fund 2006 Health Care Quality Survey.

15. CSHCN receive coordinated, ongoing, comprehensive care within a medical home 2005-2006

16. Families of CSHCN will be partners in decision-making and are satisfied with the services they receive 2005-2006

17. Families of CSHCN will have adequate private and public insurance to pay for the services they need 2005-2006

18. % of CSHCN whose family members cut back and/or stop working because of child's health needs 2005-2006

19. What Is Important About Primary Care?

20. Primary Care Score vs. Health Care Expenditures, 1997 Starfield 06/02 US NTH CAN AUS SWE JAP BELFR GER SP DK FIN UK US NTH CAN AUS SWE JAP BELFR GER SP DK FIN UK NZ

21. While access to insurance is an important and necessary determinant for having a Medical Home, it is not sufficient to predict quality of care or outcomes.

22. Is Medical Home Enough? Transforming American Healthcare from a “Sector” to a “System” Requires Broad- based Re-design: –Financing –Quality measurement –Regulatory support –State and Federal policy support Infrastructure is Medical Home

23. Priority Areas for National Action: Transforming Health Care Quality Priorities Relating to Children and Youth –Care Coordination- across paradigms of care –Self-management/ health literacy –CSHCN –Immunizations –Depression –Medication Management Institute of Medicine

24. Functional and Clinical Outcomes Resources and Policies Community Chronic Care Model (Wagner, et al) Health System Health Care Organization (Medical Home) Delivery System Design Decision Support Clinical Information Systems Care Partnership Support Informed, Activated Patient/Family Prepared, Proactive Practice Team Family - centered Coordinated and Equitable Timely & efficient Evidence-based & safe Supportive, Integrated Community Prepared, Proactive Practice Team

25. What is Care Coordination? A process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health. AAP 2005

26. Care Coordination- ACP Ensuring communication among specialists and PCP and families Tracking if referrals happen System to prevent errors among multiple providers Tracking Test Results

27. What Is the Result of CC in a Pediatric Medical Home?

29. What Can Be Measured re: CC? Adult Medical Home –Screening rates for disease and risk factors –Screening for secondary disabilities –Presence of registry and its utilization –Development of Care Plans (these have CPT codes already) –Mechanism for linkage from practice-based CC to community-based CM –Training opportunities for CC’ers –ED and in-patient utilization for patients with chronic conditions

30. What Can Be Measured re: CC? Pediatric Medical Home –Parent/ youth partners in QI at practice level –Developmental and behavioral screening –Screening for secondary disabilities (much less prevalent than adult practice) –Presence of registry and its utilization –Development and deployment of Care Plans (these have CPT codes already) –Mechanism for linkage from practice-based CC to community- based CM –Training opportunities for CC’ers –ED and in-patient utilization for patients with chronic conditions

31. Stakeholders Families Employers (Leapfrog Group, National Quality Forum) Providers Community-Based Organizations Payers: Medicaid and Commercial (PCPCC) State and Federal Agencies Legislators

32. PCMH-PPC: NCQA, AAFP, ACP, AAP and AOA Medical Home Recognition Criteria Linked to Reimbursement

33. National Noteworthy Models of Medical Home and Care Coordination Minnesota Medicaid Transformation North Carolina PACE: case management/ CC for adults with chronic conditions

35. Useful Websites http://www.medicalhomeinfo.org: American Academy of Pediatrics hosted site that provides many useful tools and resources for families and providers www.medicalhomeinfo.org http://www.medicalhomeimprovement.org: tools for assessing and improving quality of care delivery, including the Medical Home Index, and Medical Home Family Indexwww.medicalhomeimprovement.org

36. References McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with special health care needs. Pediatrics, 102,137–140 U.S. Department of Health and Human Services. www.hhs.gov/newfreedom, accessed April 26, 2005 www.hhs.gov/newfreedom Committee on Children with Disabilities, American Academy of Pediatrics. (2005). Care coordination policy statement

37. References (cont) Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21 st century Committee on Identifying Priority Areas for Quality Improvement, Institute of Medicine. (2003). Priority areas for national action: Transforming health care quality. Adams, K. and Corrigan, J. Editors. Providing a Medical Home:The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice, Pediatrics, Supplement, May, 2004, Antonelli, R. and Antonelli, D.