1. Fostering Partnerships and Teamwork in the Pediatric Medical Home: A “HOW TO” Webinar Series brought to you by the National Center for Medical Home Implementation Enhancing Care Partnership Support March 27, 2014 1 – 2 pm Central

2. Fostering Partnerships and Teamwork in the Pediatric Medical Home: A “HOW TO” Webinar Series brought to you by the National Center for Medical Home Implementation Moderator: William Schwab, MD University of Wisconsin Department of Family Medicine, WI

3. Fostering Partnerships and Teamwork in the Pediatric Medical Home: A “HOW TO” Webinar Series brought to you by the National Center for Medical Home Implementation Faculty: R.J. Gillespie, MD, MHPE The Children’s Clinic Portland, OR

4. Fostering Partnerships and Teamwork in the Pediatric Medical Home: A “HOW TO” Webinar Series brought to you by the National Center for Medical Home Implementation Faculty: Cortnee Whitlock The Children’s Clinic Portland, OR

5. Fostering Partnerships and Teamwork in the Pediatric Medical Home: A “HOW TO” Webinar Series brought to you by the National Center for Medical Home Implementation Faculty: Jill Rinehart, MD, FAAP Hagan, Rinehart, & Connolly Pediatrics, Burlington, VT

6. Fostering Partnerships and Teamwork in the Pediatric Medical Home: A “HOW TO” Webinar Series brought to you by the National Center for Medical Home Implementation Faculty: Kristy Trask, BSN, RN Hagan, Rinehart, & Connolly Pediatrics, Burlington, VT

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

8. Webinar Objectives Define the term “care partnership support” and explain its effectiveness as part of an approach to providing family- and patient-centered care. Describe strategies for implementing successful care partnership support within a pediatric practice. Provide examples of how care partnership support can be exemplified in pediatric practices.

9. Pediatric Medical Home Team-based approach Families are essential team members Care partnership support is a strategy which helps to ensure families are essential team members within the medical home

10. Defining Care Partnership Support A meaningful collaboration between families and the pediatric care team to ensure effective and quality care for the patient. Addresses:  Family and patient access to quality care  Effective communication

11. Benefits of Enhanced Care Partnership Support Health care plan is specific to each family’s individual circumstances Empowers families and caregivers Increased patient follow through, understanding, and compliance

12. Benefits of Enhanced Care Partnership Support Increases access to  support services  specialty care  educational resources Improved health outcomes Meets the challenges faced by vulnerable populations

13. Implementation of Care Partnership Support Create and articulate a policy of care partnership support Market/communicate your policy Encourage patient and family involvement in the health care plan

14. Best Practice R.J. Gillespie, MD, MHPE Cortnee Whitlock The Children’s Clinic Portland, OR

15. The Children’s Clinic, OR Parent Provider Partnership Partnership is a collaborative relationship between two or more parties based on trust, equality, and mutual understanding for the achievement of a specified goal. World Health Organization, 2009

16. The Children’s Clinic, OR In the beginning, parents often feel very lost Establishing a trusting relationship with the medical specialists and team members decreases a large percentage of parental stress regarding care Access to support and continuing education All in it together The Value of Partnership

17. The Children’s Clinic, OR Parent Partner Impact: Vital team member Coordinated team care that is centralized around the child Provider, parent, and child team development Role in improving and making a difference in the health care system

18. The Children’s Clinic, OR Maxims of Patient-Centered Care: “The needs of the patient come first Nothing about me without me Every patient is the only patient.” From: D. Berwick. What ‘Patient-Centered’ Should Mean: Confessions of an Extremist. Health Affairs, 28, no.4 (2009): w555-565.

19. The Children’s Clinic, OR From: D. Berwick. What ‘Patient-Centered’ Should Mean: Confessions of an Extremist. Health Affairs, 28, no.4 (2009): w555-565. Patient-Provider Encounter ProviderPatient Micro-system ClinicHospital Macro-system Health PlanDelivery System Environmental Context Policy

20. The Children’s Clinic, OR Steps for Adding Parents To Your Team: 1. Embracing the idea of a parent partner 2. Discussing characteristics, traits, and qualities 3. Successfully selecting a parent partner 4. Inviting and compensating a parent partner 5. Replacing a parent partner (when necessary)

21. The Children’s Clinic, OR What We Hoped To Get: Genuine interest in improving care for families Our state’s medical home standards include patient and family involvement We thought we had a good idea of what parents wanted/ needed, but felt it would be important to ask  Goes beyond “clearing ideas” with a parent partner and involves meaningfully listening to their perspective and experience We have specific questions about access, shared care plans, and other medical home principles

22. The Children’s Clinic, OR Embracing the Idea: Discuss the concept in depth  Include all stakeholders on current team  Be sure to include key thought leaders and decision makers at your practice  It is best not to debate the concept AFTER bringing a parent into the mix Start this journey committed to the concept  There may be barriers experienced and refinements needed- committing to work through this experience is key to achieving success and realizing the value

23. The Children’s Clinic, OR Discussing Traits and Qualities: Determine what collection of characteristics meets your needs Key traits include:  Has the time to commit (access to childcare, etc.)  Confident, able to speak up in group settings  Fits in with group dynamic -- humor!  Experience with local resources and multiple specialists

24. The Children’s Clinic, OR Discussing Traits and Qualities (Continued): Parents of children and youth with special health care needs have an extremely valuable perspective when it comes to medical homes for children Multiple parent partners with different experiences provide for an even richer parent perspective

25. The Children’s Clinic, OR What We Got: A parent who is dedicated to the improvement of her own medical home, in the interest of her children A perspective that cannot be achieved any other way Important insights:  What aspects of the care we provide are going well  Where we needed to improve (some of which we didn’t know)

26. The Children’s Clinic What’s Next? Having a parent on a quality improvement (QI) team is one of many ways that parent perspectives can be heard We have also conducted parent surveys (CAHPS CG PCMH) which gave vital information about our practice  Designed QI project based on the findings  Re-fielding the survey in summer/fall 2014 Now in the planning phases for a parent advisory group  Broader parent perspective  Less time commitment for parents (quarterly instead of 1-2 meetings a month)

27. Best Practice Jill Rinehart, MD, FAAP Kristy Trask, BSN, RN Hagan, Rinehart, and Connolly Pediatrics, PLLC Burlington, VT

28. Hagan, Rinehart, and Connolly Pediatrics, VT Effective Care Coordination Care Planning Care Plans Care Conferences

29. Hagan, Rinehart, and Connolly Pediatrics, VT 5 Key Elements of Highly Effective Care Coordination The Concept: 1.Needs assessment for care coordination 2.Care planning and communication 3.Facilitating care transitions 4.Connecting with community resources 5.Transitions The Person: Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009

30. Hagan, Rinehart, and Connolly Pediatrics, VT A Framework for Highly Performing Pediatric Care Coordination Care Coordination Competencies 1)Develops partnerships 2)Proficient communicator 3)Uses assessments for intervention 4)Facile in care planning skills 5)Integrates all resource knowledge 6)Possesses goal/outcomes orientation 7)Approach is adaptable & flexible 8)Desires continuous learning 9)Applies solid team building skills 10) Adept with information technology Care Coordination Functions 1)Provide separate visits & interactions 2)Manage continuous communications 3)Uses assessments for intervention 4)Develop Care Plans (with families) 5)Integrate critical care information 6)Coach patient/family skills learning 7)Support/facilitate all care transitions 8)Facilitate care conferences 9)Use health information technology for care coordination Antonelli, McAllister, Popp. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund, May 2009.

31. Hagan, Rinehart, and Connolly Pediatrics, VT Partnership Care Planning Model

32. Hagan, Rinehart, and Connolly Pediatrics, VT ECOMAP Medical Home Primary Care Provider Care Coordinator Family Financial Supports Medical Specialists Community and State Services Informal Supports Childcare School

33. VG CG 5 yo 7 yo 4 yo Hagan, Rinehart and Connolly Pediatricians Shelburne Community School Special Educator Speech Language Pathologist School Physical Therapist Occupational Therapist Swimming at YMCA Rue Kendrick- classroom teacher PCA Debbie- Para-professional S.&J., MGM friends (service dogs in training) Petsmart Therapy Dogs of Vermont Dr. Hastings- Peds-Ophthalmology Dr. Benjamin- physiatrist Dr. D'Amico- Gastroenterologist Dr. Filiano- Neurologist at Dartmouth Dr. Bauer- Peds Neurosurgeon at Dartmouth Dr. Tranmer- Neurosurgeon CSHN Registered Dietitian Apria Medical Store Keen Medical Biomedic Appliances CSHN Social Worker Howard Center Deborah Keel- Flexible Family Funding Delana- BRIDGE Shelburne Community School Shelburne Nursery School Community Alliance Church in Hinesburg Children's Ministry Outings- Sugar House, Echo, Lowes, town activities, swimming etc. Section 8 Housing Wheels for Johnny-Fundraiser for handicap accessible vehicle SSI SSA PSE Child Only Reach Up Grant 3 Squares Vermont Champlain College- Healthcare Technology Garrison, Victoria. Interview by Marley Donaldson. Personal interview. 26 Mar. 2013. Medical Family State/Education/ Community Hagan, Rinehart, and Connolly Pediatrics, VT

34. Tools: Care Conferences Introductions Set Agenda Set Roles Review Youth & Family Strengths Discussion Minutes Update Care Plan with “Goals” Create Next Steps Set Next Conference Date Share Care Plan

35. Hagan, Rinehart, and Connolly Pediatrics, VT Care Study 1: Matt 13 year old boy with autism, non-verbal, self injury, polydipsia Parents struggling with bolting, overall safety Middle school unable to educate or keep safe Medical issues of skin infections, enuresis, sleep dysfunction Family has gone above and beyond capacity of most families to deal with this at home

36. Hagan, Rinehart, and Connolly Pediatrics, VT Care Planning 1: Patient/Family/Team GoalsCICP Negotiated ActionsProcess and Outcome Measures Less Self InjuryPsychiatry Assessment, co- management from psychiatry, medical home and subspecialists In-home behaviorists Keeping family together Less need for police, mental health crisis support Improve school attendance Improve education supports Same behavior plan across settings Explore alternative school placement Clear communication between home/school/providers Alternative program found Repetitive behaviorsImproved psych pharm Improved wrap around services Improved behavior plans Innovation: across silos of mental health, developmental disabilities, children with special health care needs, and school

37. Hagan, Rinehart, and Connolly Pediatrics, VT Care Study 2: Mary 4 year old with tuberous sclerosis  self-injurious behaviors  tantrums  sleep dysfunction  heading toward inpatient psychiatry hospitalization Despite having a VT developmental services waiver, respite care and a team of multidisciplinary medical experts at Massachusetts General Hospital

38. Hagan, Rinehart, and Connolly Pediatrics, VT Care Study 2: Mary (Cont) Intractable seizures seemed the least of her concerns in comparison to behaviors Strengths:  strong parent involvement and expertise  loving respite family  Mary engaging  verbal with cognitive strength (can anticipate seizures)

39. Hagan, Rinehart, and Connolly Pediatrics, VT Care Planning 2: Patient/Family/Team GoalsCICP Negotiated ActionsProcess and Outcome Measures Less need for “crisis” intervention Co-management from psychiatry, medical home and subspecialists In-home behaviorists Less need for police, mental health crisis support Improve SleepSame behavior plan across settings Less communication errors about medications Improved work attendance Increase Home Safety-of Mary and family Improved psych pharm CSHN SW: Waiver allowed for enhanced access to in-home behaviorists Innovation: region contracted with vendor outside of network Less Crisis Need Mary to attend school Improve social relationships Communication opened between school, behavioral plans, family, medical home Making academic gains Attendance improved Cannot pick her out from peers

40. Hagan, Rinehart, and Connolly Pediatrics, VT Principles for Successful Use of Shared Plan of Care Active engagement in care Clear, frequent, and timely communication Patient and family assessment based on full understanding of needs Strong family/professional relationship characterized by mutual trust and respect. Family-centered care teams can access the information they need to make shared, informed decisions. McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: 2014 (in press), Lucille Packard Foundation for Children's Healthcare

41. Hagan, Rinehart, and Connolly Pediatrics, VT Principles for Successful Use of Shared Plan of Care (Cont.) Shared goals and negotiated actions; mutual understanding on behalf of all partners Monitoring, feedback, adjustment Anticipate, prepare and plan for all transitions Common, shared document; used consistently by all providers Care is well coordinated across all involved organizations/systems McAllister, J., et al., Achieving a Shared Plan of Care for Children and Youth with Special Health Care Needs: 2014 (in press), Lucille Packard Foundation for Children's Healthcare

42. Hagan, Rinehart, and Connolly Pediatrics, VT Why is a Family- Centered Medical Home Important to family? Opportunity for the family to build a trusting and collaborative relationship with the pediatrician and office staff Care coordination provides smooth facilitation among all members of the child’s care team including family, specialists, pharmacy staff, community and school services Comprehensive source of complete patient medical history Victoria Garrison, “Innovations in Medical Home,” VFN annual conference, April 2013

43. Conclusions Care partnership support helps to ensure family, caregiver, and patient involvement within the pediatric medical home. Implementation of care partnership support results in improved health of the child and improves future care goals.

44. Resources National Center for Medical Home Implementation (NCMHI): Care Partnership Support Care Partnership Support NCMHI: Positioning the Family and Patient at the Center, Resources and ToolsPositioning the Family and Patient at the Center, Resources and Tools Family Voices: Family Centered CareFamily Centered Care National Initiative for Children’s Healthcare Quality: Powerful PartnershipsPowerful Partnerships Region 4 Genetics Collaborative: Partnering With Your Doctor, the Medical Home ApproachPartnering With Your Doctor, the Medical Home Approach

45. NCMHI Educational Video Series Don’t forget to view the National Center for Medical Home Implementation (NCMHI) Video Series. Topics Include:  Team Huddles Team Huddles  Care Partnership Support Care Partnership Support  Family Advisory Groups Family Advisory Groups

46. Save the Date Fostering Partnerships and Teamwork in the Pediatric Medical Home: A “HOW TO” Webinar Series Starting and Supporting Family Advisory Groups April 24, 2014 11 am – Noon (Central) REGISTER NOW!

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49. Save the Date Fostering Partnerships and Teamwork in the Pediatric Medical Home: A “HOW TO” Webinar Series Starting and Supporting Family Advisory Groups April 24, 2014 11 am – Noon (Central) REGISTER NOW!