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CMHI Retreat March 2003 — Parent Partner Session.............................download now.
CMHI Retreat March 2003 - Crossfire Question and Answer Session.........download now.
Winter 2004 Volume 3, Number 1
What's in this newsletter?
Current Events - read about the most recent work at CMHI
Looking in on a Medical Home Improvement Team - catch up with two teams
What's next - hear about what's next on our agenda
Where are these Medical Homes - a list of practices participating in Medical Home
Improvement with CMHI
Currents Events
Fall 2003 was a busy time at the Center for Medical Home Improvement.
Medical Homes continued their improvement efforts in partnerships
with families, practice families were re-surveyed, the Parent Partner
Guide was completed and made available, and the final Learning session
of the National Medical Home Learning Collaborative was held.
CMHI seeks to inform Medical Home Improvement Teams by helping
them to create their own data. September “post” surveys
were sent to families who had completed a survey in the spring of
2002; these families had given us permission to re-contact them.
Of the 128 surveys distributed 86 families returned completed surveys
(67%). Practices completed their third annual Medical Home Index
thereby creating quantitative evidence of their quality improvements.
Data are currently being analyzed and will be distributed to the
teams in February. This feedback will assist them in identifying
ways to further improve their practices. Watch for aggregate data
to be posted on this website.
The third and final National Medical Home Learning Collaborative
(MHLC) learning session was held in Scottsdale Arizona on November
21 and 22. The approach that this CMHI and National Initiative for
Children’s Healthcare quality (NICHQ) MCHB initiative has
undertaken is quite unique among efforts to create Medical Homes
and offers great promise to make a difference for children. Built
on the Breakthrough Series Learning Collaborative methodology developed
by the Institute for Healthcare Improvement, the MHLC brings together
teams from thirty-three practices for three face to face learning
sessions over a 15-month period. Faculty support teams in between
learning sessions in order to promote changes in care. This initiative
also involves state Title V agencies who sponsor three primary care
practice teams each (made up of lead physician, a care coordinator
and a parent partner) in their efforts. Together practices and Title
V then look for ways to spread Medical Homes in their states in
keeping with the Title V mandate to improve health and assure access
to high quality health services for present and future generations
of mothers, infants, children and adolescents.
The Parent Partner Guide Creative Forces on Medical Home Improvement
Teams: A Guide for Parent and Practice “Partners” Working
to Build Medical Homes for Children with Special Health Care Needs
was completed this fall and is available. Ann Dillon, Parent Partner
with the Exeter Pediatric Associates team in Exeter NH developed
this guide in collaboration with CMHI. Ms. Dillon is the mother
of three children, one of whom has special health care needs. She
drafted the guide using input from other Parent Partners (including
a conference call and a session at the spring retreat) and by drawing
on her six years of experience with the Exeter team. To read the
Parent Partner Guide, click here.
Looking In on A Medical
Home Improvement Team
Hagan and Rinehart Pediatricians -
Burlington, VT
Burlington, Vermont is located on the eastern shore of Lake Champlain
in northwest Vermont between the Adirondack and Green Mountains.
An extremely “livable city” it has a city population
of 38,889 (2000 census). Hagan and Rinehart Pediatricians are just
south of the city following Route 7 towards historic Shelburne.
A busy primary care practice, they serve an estimated 3500 children.
Staff include two pediatricians (Joe Hagan and Jill Rinehart), one
pediatric nurse practitioner, three registered nurses (who offer
care coordination and lactation consultation), a licensed practical
nurse and administrative /support staff. The staff each possesses
a keen interest in children with special health care needs among
other focused areas which include mental health, developmental and
behavioral pediatrics, and sleep issues. Hagan and Rinehart Pediatricians
also are affiliated with the University of Vermont College of Medicine
and with Fletcher Allen Health Care which serves a total population
of more than one million.
The Medical Home Improvement Team
Jill Rinehart, MD leads the Medical Home Team. Jill completed her
pediatric residency at the University of Vermont College of Medicine,
she is a member of the original American Academy of Pediatrics physician
advisory committee on the Medical Home, and brings the additional
special perspective as a sibling of a child with special needs (now
an adult). Parent Partners Sandy Julius and Wendy Ruggles offer
the perspective of families and of the particular needs of their
and others children. Sandy, a former Ben and Jerry’s business
professional offers the team an array of pragmatic and technological
insights. Wendy, a young mother of two brings a fresh perspective
on how health systems can be more family friendly. The dynamic trio
of Kristy Trask, RN, Kylee DeCelles, RN, and Heather Tremblay, RN,
make up the Hagan and Rinehart practice-based care coordinator resource.
Lynn Bergeron, as practice manager, helps the team stay grounded
and practical; Lynn is crucial to getting creative innovations implemented
within the reality of the day to day operations of the practice.
The team initially held their improvement meetings on Fridays at
lunch; they then made a group decision to switch to Mondays hoping
to maximize their ability to have full participation and the largest
amount of work time in common. The team represents a wonderful combination
of experience with children (both as parents and providers) and
the necessary skills for building Medical Homes. These include quality
improvement team skills, computer ability, family education capacity,
organizational experience, careful follow through and most of all
– team determination.
The Team’s Aim
Hagan and Rinehart historically have offered a strong primary care
home base for their families; the Medical Home Team set out to improve
even further. Their original aim:
To implement a full Medical Home for CSHCN within the next 12 months
with families as partners in care. Care is: coordinated, individualized,
integrated within the community, and youths are assisted with transitions
to adult life and care. (Wow!)
Team Efforts/Improvements
The team completed baseline improvement measurements using CMHI’s
Medical Home Index. 28 practice families also agreed to complete
the Medical Home Family Index and Survey. These data were combined
with that of families from seven other Medical Home sites (NH and
VT) and can be reviewed at this website (Medical
Home Family Index and Survey results). The team first focused
on putting the Medical Home fundamentals in place:
- A registry of CSHCN cared for by the practice
- A method of gaining ongoing feedback from families, and
- Full development of the role of practice-based care coordinator.
They have now identified over 80 children with special needs (children
with ADHD are not included in this number but accounted for separately)
and anticipate that there are many more to identify. A simple complexity
score of 1, 2 or 3 is then matched with each child; this helps with
care coordination assignments, allocation of staff time, and documentation
of services provided. An action
care plan was developed; Parent Partners tested its use and
helped to refine it. The care coordinators use this plan to monitor
and update care according to child needs, family input and team
determination. Unique to Hagan and Rinehart is the notion of shared
care coordination duties with three dedicated, part-time coordinators
tag teaming work efforts and supporting practice providers in their
care and coordination efforts. Hagan and Rinehart participated in
a national care coordination study whose results will be in The
Medical Home Supplement to Pediatrics: due out in May, 2004.
Now that they have a CSHCN registry - all families are being asked
to complete a Family Index and Survey (data analysis to be displayed
late winter, 2004). The practice has also completed their annual
Medical Home self-assessment (The Medical Home Index) for the third
time, each time the scores have increased for the 25 indicators;
between fall 2001 and fall 2003 Hagan and Rinehart’s MHI total
mean score increased from 4.6 to 7.24 (possible range from 1-8).
DIGMAS – the team held a (one
of hopefully many) “drop in group medical appointment”
(DIGMA). The focus of the H & R DIGMA was to gather a group
of parents whose children have similar conditions and needs and
create an opportunity for them to learn together. Medical Home and
condition specific content was offered and community resources gathered
and shared. A Vermont’s CSHNs staff person participated offering
resources and learning about the experiences of families. Highlights:
during one ninety-minute block of time eight families had the opportunity
for extended contact with their Medical Home pediatrician, care
coordinators, Title V staff, and each other. They shared their ideas
and found resources, learned about care plans and completed their
child’s first one. They created personal resource maps illustrating
their Medical Home relationships and links to needed and numerous
community resources. Of course the team would like payers to review
this innovation, see its merits and efficiencies, the potential
for enhanced child, family and practice outcomes, and help find
ways to support such activities in the future.
What is the family experience at Hagan and Rinehart
today?
The team needed to pull together their improvements and understand
what is now in place for each child and family. This led them to
develop a process flow chart of their Medical Home services. Their
flow chart shows a clear entry point into a systematized care process
for every child identified with a special need. It details the partnership
established with the family, the education offered about the Medical
Home and how the practice operates. It illustrates the links with
practice-based care coordination, the development of a care plan
with appropriate follow up/monitoring, communication with other
specialists and community-based resources, and the opportunities/checkpoints
for every family to provide feedback on pertinent practice care
issues.
Future team plans are for greater family outreach and education
around the Medical Home. A first step in this effort is the development
of a greeting/bulletin board now under construction which will portray
the mission of the practice, staff photos and roles, the role of
Parent Partner/families and the special efforts and outreach activities
now in place at Hagan and Rinehart Pediatricians. Watch for the
AAP’s CATCH/Medical Home Conference in July where Hagan and
Rinehart will present their efforts with other CMHI Medical Homes.
Dartmouth Hitchcock - Concord Pediatrics
Concord is the capital and geographical center for the state of
New Hampshire. Located on the Merrimack River, it is a commercial
and residential center “hub” with convenient access
to many rural areas which are typically “New England”.
With an immediate population of 40,687, Concord’s area health
services stay quite busy.
Dartmouth-Hitchcock Concord is a charitable,
multi-specialty community group practice that serves the health
care needs of those living in greater Concord. They have over 40
physicians and associate providers who offer a full range of health
care services. Dartmouth Hitchcock- Concord Pediatrics has two teams
of providers serving children and families. This helps them to offer
more personalized and family-centered care. They are a part of the
Dartmouth Hitchcock System and are affiliated with Concord Hospital.
DH-Concord also works closely and shares call with the Capital Family
Health Center and its NH Dartmouth Family Practice Residency Program.
DH-Concord Pediatrics is well placed as a developing Medical Home.
Nancy Van Vranken, MD, the Concord Medical Home team’s lead
physician, maintains an active practice with a devoted interest
in the care and development of CSHCN. Elizabeth Smith, MD is Dartmouth
Hitchcock – Concord’s new (this past spring) Medical
Director; she is also a pediatrician. Previously employed by a Connecticut
health plan, Dr. Smith has been involved in the Center for Health
Care Strategies “Best Clinical and Administrative Practices”
CSHCN/Medical Home workgroup. Dr. Smith brings additional energy
and vision to the Concord Medical Home endeavors with this and other
welcome relevant experience.
The Medical Home Improvement Team
Concord’s “core” Medical Home Improvement Team
is made up of Nancy Van Vranken, MD, Lynn Gaides, RN and Care Coordinator,
Helen Cote, Social Worker and Care Coordinator, and Parent Partners
Jennifer Hotz and Patty Allen. Lynn and Helen share and collaborate
around care coordination activities in partnership with the families
they serve. Jennifer is a tireless family/child advocate (and great
team scribe) in spite of giving birth to her second child recently.
Patty brings a special family and health professional perspective;
as a nurse she understands the kind of education staffs need to
help them offer a more effective Medical Home. Nancy and Lynn, who
have long teamed together to offer quality care, embrace the addition
of these Parent Partners. At a Medical Home family focus group one
parent commented that “when you get through {on the phone}
to Nancy or Lynn, you know you will be okay”. There was much
agreement in the room!
The Team’s Medical Home Aim
To improve the quality and effectiveness of care through the development
and implementation of care plans for children with special health
care needs (CSHCN).
Team Efforts/Improvements
Since the first retreat of the Medical Home Expansion Project (fall,
2001), the Concord team has been identifying CSHCN; they now have
over 150 children with special needs entered into their registry.
The clinic as a whole was “migrating” from paper to
electronic medical records at the onset of the project. At that
time Concord was able to use “CSHCN” as an indicator
on their problem list and now uses this to identify and track their
population. This enables them to identify/enumerate their population
quite readily. Like other teams, DH-Concord has had a cohort of
families respond to the MH Family Index and Survey (watch for project
wide results on this site); more recently they surveyed all CSHCN
they have identified. These data will offer up to date family feedback
which will inform future improvement efforts.
Securing staff and protecting time for care coordination activities
has been difficult for DH-Concord Pediatrics, especially in light
of today’s health care environment and nursing shortages.
This is something they are working to improve. Following an assessment
of child and family needs, Concord wants to enable effective links
to comprehensive resources for families and providers. They have
created an efficient care coordination documentation tool which
captures needs, care coordination activity, time spent, and outcomes
achieved – all electronically. It takes seconds to complete
and offers a rich data source. Reviewing these data, their utilization
statistics, and family feedback the Concord team will be positioned
to embark upon a course justifying enhanced Medical Home service
reimbursement.
Many CMHI teams (including teams who have participated in the national
Medical Home Learning Collaborative) are using the medical
care plan developed by the Concord team. Their family-centered
collaborative team uses this tool to pull critical information together
in written form, thereby creating a process for integration and
coordination of services with careful monitoring. A simple action
plan generated at every visit details out concerns, plans and responsibilities.
If a Medical Summary or Emergency plan is warranted, they then become
one of the “actions”. As such, comprehensive care planning
is developed and driven by child and family needs. The goal at Concord
is for thorough child and family assessments to generate action
plans, which will then lead to medical and emergency care plan development,
and ultimately to knowledgeable access of available resources (locally,
state, other). Staff education and buy in to enhance their Medical
Home systems are important goals of the Concord team and they have
held noon time staff workshops for both pediatrics and family practice
staff on how they are “building their Medical Home”.
Concord’s most exciting development has been seeing the dream
of an effective and supportive electronic medical record (EMR) come
to fruition. At first this EMR capacity was slow to materialize
in ways helpful to the team; in response they persevered in their
development of system tools that would enrich and improve care.
Now information system (IS) staff is able to adapt Medical Home
tools for Logician (their EMR). Using this capacity they can identify
CSHCN and keep a registry of their population, develop and update
care plans and action plans, document their care coordination, access
their directory of resources and develop and use letter templates
(durable medical equipment authorizations, letters of medical necessity,
and other templates) which help them with comprehensive quality
care.
Future
Goals for future Medical Home development include securing more
dedicated and active care coordination hours, engaging more families
- linking them to supportive activities and interventions, and reaching
out to community partners to establish essential coordination and
communications. While veteran nurse, Lynn Gaides, will be retiring
this June a new staff member has been identified to take on some
care coordination leadership. DH-Concord has strong relationships
among many of their community health partners and with their hospital;
a further aim is to strengthen relationships with area schools and
agencies serving CSHCN and families.
What's Next?
CMHI will host the fourth and final retreat for
the Medical Home Improvement –Expansion Project on Thursday
and Friday February 12-13, 2004 at the Hanover Inn in Hanover NH.
This retreat will bring together all the teams, those included in
the expansion project as well as the “veteran” teams,
Title V leaders and other collaborators. Once again the agenda will
be packed with learning opportunities.
Thursday night will
provide us with a chance to celebrate all that we have accomplished.
We will also interact with teens from the STAR program (Steps Toward
Adult Responsibility) and learn what it is like to live with a chronic
condition or disability and about their transition to adulthood.
Friday will provide
an opportunity to hear from the Expansion project teams about the
changes they have made in their pediatric practices using the Medical
Home improvement process. We will learn more about transition from
Patience White, MD of the Children’s National Medical Center
in Washington, DC. We’ll also spend time looking at sustainability
and how we can best interact with Title V to maximize gains made.
Debby Allen, PsyD, from the Health and Disability Working Group
in Boston MA, will lead this session.
This retreat will provide opportunities for the
teams to re-energize as they prepare to carry forward their efforts.
The re-energizing will be important as many of the teams are tackling
“advanced” Medical Home projects such as transition
issues, quality of life issues, and how to form significant connections
with large numbers of parents.
As the Rural Medical Home Expansion Project is
nearing its end (funding and final report close out is March 31,
2004) changes are in store for most of us here at CMHI and elsewhere.
While the future is currently uncertain, prospects for the Medical
Home in the long stretch are strengthening. Five priority areas
of new funding are currently being offered by the United States
Maternal and Child Health Bureau (a national center, subspecialty
programs, statewide Medical Home implementation, practice networks
and one autism center). The continuation of the National Center
for Medical Home Initiatives, which now operates out of the Academy
of Pediatrics national office, represents ongoing staff to offer
technical assistance and help accessing resources and materials.
You can continue to access tools and information via their website
www.medicalhomeinfo.org.
A second activity will be another USMCHB funded offering of the
National Medical Home Learning Collaborative (future dates TBA)
which CMHI has jointly developed with the National Center for Medical
Home Initiatives (NICHQ). Finally, as the Medical Home is one of
the National Performance Measures for all state Title V/Children
with Special Health Care Needs programs, Title V leaders will be
seeking out strategies and opportunities to promote Medical Homes
in their states. The most important Medical Home resource continues
to be the children, youth and parents working in partnership with
their physicians and care coordinators to implement family-centered,
comprehensive care within their communities.
Where Are These Medical Homes?
Vermont
Upper Valley Pediatrics, Bradford Vermont (original team)
Gifford Pediatrics, Randolph Vermont (original team)
Newport Pediatrics, Newport Vermont
Hagan and Rinehart Pediatricians, Burlington Vermont
Mousetrap Pediatrics, St. Albans, Vermont
Practice of Paul Berkner, DO, Middlebury, Vermont
New Hampshire
Hitchcock Clinic, Plymouth Pediatrics and Adolescent Medicine, Plymouth,
NH (original team)
Exeter Pediatric Associates, Exeter, NH (original team)
Hitchcock Clinic, Keene, NH
Hitchcock Clinic, Concord, NH
Lamprey Community Health Center, Raymond, NH
Monadnock Pediatrics, Peterborough, NH
Maine
Winthrop Family Pediatrics, Winthrop Maine (original team)
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