Overview of the Medical Homes Project

1. Connecticut’s Title V ChildrenwithSpecial HealthCareNeeds Program Matrix Public Health Consultants

2. Overview of the Medical Homes Project Matrix Public Health Consultants

3. What is the Federal Maternal Child Health Bureau definition of Children with Special Health Care Needs under Title V? Children with special health care needs are defined as those children who have, or are at elevated risk for chronic physical, developmental, behavioral or emotional conditions (biologic or acquired) that require health and related services (not educational and recreational) of a type and amount not usually required by children of the same age. Matrix Public Health Consultants

4. How is Connecticut’s Title V Program accomplishing these goals? 1. Created Statewide Advisory Group which convened December 16, 2002 through June 25, 2003 and included membership from: • CSHCN Centers at Yale and CCMC • DSS • OCA • DMR • DCF • Medicaid Managed Care Advisory Council • Children’s Health Council • UConn Matrix Public Health Consultants

5. 2. Formed CSHCN Workgroup, which met on a monthly basis from January 27, 2003 through June 25, 2003 and addressed the following critical areas: • Eligibility Criteria; • Care Coordination; • Covered Services/Benefits; • Program tools for Screening, determining complexity index and encounter forms; • CSHCN Operational strengths, gaps and improvement areas • SLAITS Survey for Connecticut • Best Practices and review of other States. Matrix Public Health Consultants

6. 3. Participation in a Medical Home Learning Collaborative(MHLC), which is a partnership effort between MCHB and the National Initiative for Children’s Healthcare Quality(NICHQ). 4. Conducted an assessment of the Respite need and impact on Families of children and youth with special health care needs. 4a. Developed a tool kit to help families of CSHCN choose quality Respite Care; 4b. Development of a tool kit to help informal (Keith & Kim) Respite Care provider provide quality Respite Care. Matrix Public Health Consultants

7. 5. Utilizing the Child Development Infoline (1-800-505-7000) as a central portal entry point for CSHCN 6. Re-Directed CT-Title V-CSHCN program by: • Establishing three Medical Homes as a pilot • Standardizing the Contracts for the CSHCN Centers • Creating Integrated community systems of care for Children and Youth with Special Health Care Needs Matrix Public Health Consultants

8. Connecticut’s Medical Home Delivery System for CSHCN and Their Families Advisory Board DPH CT AAP Other State , Federal and Local Programs Infoline Regional Medical Home Support Center Regional Medical Home Support Center Regional Parent Network Regional Parent Network Specialty Centers Medical Homes Medical Homes KEY Contractual arrangement with DPH to provide services under Title V Care Coordination and parent partnership support Information sharing Parent mentoring and support services Patient referral for health care services Matrix Public Health Consultants

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10. What is a Medical Home? Alex Geertsma, M.D. Matrix Public Health Consultants

11. Medical Home Enhancement The AAP defines a Medical Home as a community-based primary care practice which is: • Accessible • Family-centered • Continuous • Comprehensive • Coordinated • Compassionate • Culturally competent Matrix Public Health Consultants

12. Medical Home Staff Composition • Physician champion within a practice • Nurse/Nurse Practitioner • Parent partner Matrix Public Health Consultants

13. Triaging phone calls to determine need for type of visit Handling prescription refills/medical equip Managing and updating IHP’s Creating individualized emergency care pans and distributing them to early intervention programs/home care/schools Serving as a liaison for teachers, school nurses, therapists Assisting with EIP referrals and transition to Head Start/preschool Conducting home visits to treat, follow up and/or coordinate services Referring to family support services Linking families to community services Patient education Effective Care Coordination: A Major Component Matrix Public Health Consultants

14. Lessons Learned & Information Sharing Sandy Carbonari, M.D. (St. Mary’s) Robin McCormack, APRN (St. Mary’s) Paule Couture, M.D. (Stamford Pediatrics) Jan Hebert, R.N. (Stamford Pediatrics) M. Alex Geertsma, MD (Children’s Health Center) Ann Gionet, Family Advocate Matrix Public Health Consultants

15. Children’s Health Center at • St. Mary’s Hospital • Waterbury, CT • Sandra Carbonari,MD • How did we, as a hospital-based pediatric • practice use our strengths to accept the • changes and challenges of this project? Matrix Public Health Consultants

16. 1. Changes and Challenges • Working as a hospital-based medical home • Working with a population with many needs Matrix Public Health Consultants

17. 2. Key Accomplishments • Committed staff with the awareness of the need for change spread their medical home from a three person team to a center-wide practice team which resulted in operational improvements including: • Phone triage script for scheduling appointments and chart prep • Cultural Sensitivity • Continuum Based Care and Family-centeredness • Care Coordinator in place • Touchpoints Model • Ongoing exchange of thoughts and ideas Matrix Public Health Consultants

18. Care Coordination • Medical Home and the Validation of Care Coordination for Children and Youth with Special Health Care Needs by The Children’s Health Center at St. Mary’s Hospital Matrix Public Health Consultants

19. How Did Our Practice Become • A Medical Home? • Paule Couture, M.D. • Stamford Pediatric Practice • How did we, as a private, pediatric, primary care practice, use our strengths to accept the changes and challenges of this project? Matrix Public Health Consultants

20. The Pediatric Center WE HAD WE NEEDED • Desire to improve what we already did • Will to “do good” • Support: intellectual & experimental • Deadlines to meet • Incentives, financial to “stretch” ourselves Matrix Public Health Consultants

21. Medical Home Practice Improvements Care Coordination at Different Levels: • Physician Partners: education & re-education • Parents: interviews through screener, care plan & pre-visit questionnaire • Specialists: referral information & follow-up • Community: outreach to schools & recreational activities • State Title V: link through MHLC, Infoline, newsletters for professionals • Insurers: working on successful reimbursement strategies within office, extend to state and HMOs Matrix Public Health Consultants

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23. SOAP Subjective Objective Assessment Plan Matrix Public Health Consultants

24. ~ The Pediatric Center ~ Our Most Powerful Change Inclusion of parents in care planning, especially through the pre-visit questionnaire Matrix Public Health Consultants

25. How do you start? Consider small steps initially such as: • Review office policies/practices in context of service delivery to CSHCN (see NICHQ checklist & Medical Home Index) • Identify CSHCN through use of a screener • Try out use of pre-visit questionnaires • Try out use of IHP’s • Have staff facilitate access to Infoline Matrix Public Health Consultants

26. Engage in Practice Dialogue to Create a Realistic Action Plan • How are we doing as a practice? • What are we doing as a practice? • How are we going to change/improve? • What can we hope to accomplish in the short term? In the long term? • Can we build in staff incentives for practice change? Matrix Public Health Consultants

27. Reality Check • This is about a philosophical shift in practice – and a long term change! • It can be time consuming and thus costly • Colleagues need to be willing to accept this change and be consistent • The commitment involves gathering data and engaging in continuous quality improvement • There are hurdles to jump Matrix Public Health Consultants

28. Discussion Sandy Carbonari, M.D. (St. Mary’s) Robin McCormack, APRN (St. Mary’s) Paule Couture, M.D. (Stamford Pediatrics) Jan Hebert, R.N. (Stamford Pediatrics) M. Alex Geertsma, MD (Children’s Health Center) Ann Gionet, Family Advocate Matrix Public Health Consultants