1. ADDRESSING PEDIATRIC SUBSPECIALTY ACCESS PROBLEMS THROUGH DELIVERY SYSTEM IMPROVEMENTS Peggy McManus Co-Director Maternal and Child Policy Research Center Washington, DC Mchpolicy.org February 7, 2006

2. PRESENTATION OVERVIEW Pediatric subspecialty workforce problem Federal Expert Work Group on Pediatric Subspecialty Capacity Importance of addressing demand Promising practices in referral, consultation, and collaborative management

3. DEFINING THE PROBLEM Pediatric subspecialists among the growing list of health professions facing current & projected shortages Insufficient numbers & maldistribution have long been a concern Whats new is changing demand for PS care

4. ADDRESSING DEMANDS Increasing prevalence & severity of certain chronic childhood conditions Increasing survival of children with complex conditions resulting from medical/surgical advances Changing patterns of care, with PCPs referring more to PS Increasing preference by families to see PS Changing managed care and hospital markets & shifts in health insurance status of children

5. EVIDENCE THAT DEMAND EXCEEDS SUPPLY Small numbers relative to population and need Excessive appointment waiting and travel times Family and PCP difficulties obtaining referrals Unmet specialty care needs by families Significant recruitment and retention problems High levels of stress and burnout among PS Declining participation in Medicaid/SCHIP & managed care

6. FEDERAL EXPERT WORK GROUP ON PS CAPACITY Federal Maternal and Child Health Bureau formed work group in 2004 Purpose: to identify scope of problems, promising practices, and develop recommendations Membership: 24 from AAP, ABP, NACHRI, Title V, AAMC, Family Voices, AACAP, etc. MCH Policy Research Center provides staff support

7. PEDIATRIC SUBSPECIALISTS 30 pediatric subspecialties: adolescent medicine, allergy/ immunology, anesthesiology, cardiology, clinical genetics, critical care medicine, dermatology, developmental-behavioral pediatrics, emergency medicine, endocrinology, gastroenterology, hematology/oncology, infectious diseases, medical toxicology, neonatal/perinatal medicine, nephrology, neurodevelopmental disabilities, neurology, ophthalmology, orthopedics, otolaryngology, pathology, psychiatry, pulmonology, radiology, rehabilitative medicine, rheumatology, sports medicine, surgical specialties, urology Except for neonatalogy, all other PS experiencing some level of workforce capacity problem Some worse than others: child & adolescent psychiatry, neurology, developmental-behavioral pediatrics, endocrinology, rheumatology, gastroenterology, orthopedics, surgical specialties

8. DELIVERY SYSTEM DESIGN IMPROVEMENTS It is vital that all providers within the Medical Home model of care understand their interdependent roles and effectively serve the child and family. (Antonelli, Stille, Freeman) Improvements identified: referral (transfer of care), consultation (one-time or time-limited), and collaborative management approaches (ongoing shared management) Care coordination/case management, telemedicine, expanded nurse roles, informatics not addressed

9. PROMISING REFERRAL APPROACHES Referral Guidelines Pre-Appointment Management of Referrals Referral Management for Special Populations Pre-Visit Contacts

10. REFERRAL GUIDELINES Madigan Army Medical Centers Referral Guidelines: offers guidance on initial diagnosis and management, ongoing management objectives, indications for specialty referral, & criteria for return to primary care Institute for Clinical Systems Improvements Care Guidelines (for providers & for families): presents algorithm for addressing symptom review, triage, diagnosis, prevention, appropriate treatment & follow-up, & criteria for specialty referral

11. PRE-APPOINTMENT MANAGEMENT OF REFERRALS University of Wisconsin Medical Foundations Rheumatology Pre-Appointment Management: Office staff collect referral information, records, labs & xrays. Specialist decides if: 1) appointment request approved (& scheduled as urgent or routine & with brief, usual or extended time), 2) further info. requested from referring MD, 3) care continued with referring doctor following conversation with patient & PCP, 4) other more appropriate consultation arranged, or 5) appointment not provided if referral inappropriate or records not provided. Each of 3 rheumatologists devote 45 minutes/week for more than 100 referred patients. Only 59% of referred patients actually required a specialty appointment.

12. REFERRAL MANAGEMENT FOR SPECIAL POPULATIONS Referral Management Initiative at NYs Childrens Health Project (also in DC, Dallas, So. Florida, & L.A.) for homeless children. PCP ranks severity of childs referral problem (immediate, urgent, routine) & case manager makes appointment. Reminders by mail, phone, and in person (with shelter staff). CM assures no insurance or transportation obstacles, assists at PS office, including translation services, & facilitates transfer of information between PC and PS. Evaluation results: increased appointment adherence, 7% to 61%, reduced time between referral & appointment, fewer barriers to care, and fewer PCP/PS communication problems

13. PRE-VISIT CONTACTS Chapel Hill Pediatrics and Adolescents: Pre-visit contacts conducted by phone by care coordinator with selected special-needs families identified based on severity score and MDs recommendation Families asked about ER, hospital, or specialist visits since last visit, including reasons, records, labs, x-rays, outcomes. Also, asked about 3 major areas or concerns that need to be addressed during preventive/chronic care visit. Results: Improved family satisfaction, sufficient appointment time, improved coding for time & complexity

14. PROMISING CONSULTATION APPROACHES Child Psychiatry Consultation & Liaison Title V Pediatric Subspecialty Consultation Family Practice Pediatric Consultation

15. Child Psychiatry Consultation & Liaison Targeted Child Psychiatry Services at UMass Medical Center (Worcester): Regional team of 2 child psychiatrists, nurse, social worker, & care coordinator working with 22 primary care practices. By paging child psychiatrist, PCP receives either 1) answers to questions, 2) referral to team coordinator to access routine behavioral care, 3) face-to-face or telephone transitional assistance by team social worker, or 4) referral to team psychiatrist for acute medication or diagnostic consultation. Half of referred children managed by telephone consult, 16% scheduled within 3 weeks for 90 min. eval. At UMass psychiatry unit and returned to PCP with treatment plan. Only a third referred to CMHCs for ongoing care.

16. Title V Pediatric Subspecialty Consultation Illinois Division of Specialized Care: 20 pediatric subspecialties are available for PCP phone consultation. Medical home providers simply call and ask about the management of a specific condition. Specialists reimbursed $300 to respond to 7 phone consults and PCPs are reimbursed if child is enrolled in the states Title V program.

17. Family Practice Pediatric Consultation Ventura County (CA) Medical Center: Network of 8 family practice clinics and residency program uses a pediatrician anchor and monthly onsite pediatric subspecialist consults from 3 So. Calif. medical schools to provide evaluation and ongoing support for family practitioners serving as medical homes for children with special needs.

18. PROMISING COLLABORATIVE MANAGEMENT APPROACHES Service Agreements Co-Management and Multidisciplinary Approaches

19. Service Agreements Used by NICHQs Epilepsy Collaborative, the VA, and others: Service agreements developed in partnership with PCPs/specialists to formalize collaborative process. Consist of 1) core clinical competencies describing conditions & services provided by PCP and PS; 2) referral agreements, including referral guidelines, work-up recommendations, & preferred communication processes; 3) access agreements, defining waiting times for emergency, routine, and ongoing referrals, questions, consults, & evaluations; 4) graduation criteria for return to PCP, & 5) QA agreements, identifying standards of care, education & training processes, and measures. Process involves 2 meetings with an objective facilitator. Benefits– PCPs have more timely access and feedback from specialist, and PS have reduced demand & more appropriate referrals

20. Co-Management and Multidisciplinary Approaches Special Needs Program (SNP) at Childrens Hospital of Wisconsin: Tertiary care/primary care medical home partnership for medically fragile children needing multiple specialties, with frequent hospitalizations & tertiary clinic visits, & multiple community services. SNP team = 4 nurses, 2 part-time MDs, 1 coordinator, 1 AA. All children have pediatric case manager. Subset have SNP physician coordinating with PCP 24/7 & providing inpatient, outpatient, and emergency consults, home visits, & arbitrating divergent PS opinions & Tx options. Evaluation: In 2004, $5 million saved with 46 children, primarily from fewer tertiary hospital admissions and shorter LOS