1. Part I (AAP QI) - Results Ruth S. Gubernick, MPH Quality Improvement Advisor Florida Pediatric Medical Home Demonstration Project Learning Session 3 December 7, 2012

2. Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

3. Chart Review Aggregate Data Phase 2 Measures

11. Practice-based Systems Index October 2011-October 2012

13. Systems Index SYSTEMS INDEX Oct-11 N=20 Mar-12 N=20 May-12 N=16 Oct-12 N=16 1. When scheduling office visits, our practice asks about special needs and accommodations of the patient and plans accordingly50% (10) 85% (17)94% (15)100% (16) 2. We start our day with a team “huddle” 45% (9)75% (15)81% (13)94% (15) 3. Our practice has a process to identify and contact patients who are behind schedule for preventive services (reminder-recall system)45% (9)85% (17)81% (13)88% (14) 4. Our practice has a system to track and follow-up on all referrals 60% (12)85% (17)88% (14)94% (15) 5. Our practice has established a system to identify, follow, and provide chronic condition management for children with special health care needs (e.g., practice registry)30% (6)70% (14)69% (11)81% (13) 6. Our practice has processes/written protocols for co-managing care among the patient/family, pediatric medical home and specialists. 10% (2)35% (7)31% (5)44% (7) 7. Our practice is involved with planning for discharge of patients from hospital and ED and re-evaluation of patients post discharge.35% (7)55% (11)56% (9)63% (10) 8. Our practice includes one or more family members on our improvement team.70% (14)95% (19)94% (15)100% (16) 9. Our practice has completed a systematic assessment of our organization’s cultural and linguistic, attitudes, practices, structures and policies, using the Cultural Competence Health Practitioner Assessment.25% (5)50% (10)56% (9)63% (10) 10. Our practice has invited at least one community organization to a quarterly practice team “lunch and learn” during which information was shared and introductions/personal connections with staff were made.30% (6)70% (14)81% (13)88% (14)

14. What has been the impact of the FL Ped MH collab activities on your clinical and operational work this month (where 5=much easier and 1=much more difficult)? October N=20 November N=18 December N=18 January N=18 February N=18 March N=16 3.23.13.43.33.43.2 May N=13 June N=15 July N=14 August N=13 September N=13 October N=15 3.33.43.53.23.5 Phase 1 (2011-12) Phase 2 (2012)

15. Part 1 - Practice Survey Aggregate Data August 2011, March 2012, and November 2012

16. Know and Manage Your Patient Population

17. Develop a Cross-disciplinary Medical Home Improvement Team

18. Enhance Access to Care

19. Provide Family-Centered Care

20. Provide and Document Planned, Proactive, Comprehensive Care

21. Provide and Document Planned, Proactive, Comprehensive Care (continued)

22. Coordinate Care Across All Settings

23. The end of this formal collaborative is only the beginning… ---Success is only a step in the right direction

24. Continue working to sustain your successes!  Use data and continue with run charts  Continue to report and create accountability  Have leadership’s support  Meet periodically and keep in contact  Assign responsibility for key tasks  Standardize processes, make policy  Train and orient  Keep in contact with other teams

25. Questions/Comments?