The Pediatric Medical Home:
Building a Strong Foundation
R.J. Gillespie, MD, MHPE, FAAP
Medical Director
Oregon Pediatric Improvement Partnership
Roadmap
• BEING a medical home
– What does it look like?
• BECOMING a medical
home
– How does my practice
get there?
Medical Home Fervor
What’s actually happening…
Factors Influencing Health Status
Medical Care: 10%
Behavior /
Lifestyle: 50%
Genetics: 20%
Environment: 20%
BEING A MEDICAL HOME
A Medical Home
• Is a community-based
primary care setting which
provides and coordinates
high quality, planned,
family-centered health
promotion and prevention,
acute illness care, and
chronic condition
management — across the
lifespan.
Medical Home – AAP definition
Accessible
Family-Centered
Continuous
Comprehensive
Coordinated
Compassionate
Culturally Effective
Primary Medical Home Model
Preventive Care
• Well visits
• Screening for
risk factors
• Health
promotion &
Anticipatory
Guidance
• Immunizations
Acute Illnesses
• Telephone
triage and
advice
• Office visits
• Coordination
with ER /
Urgent Care
• Coordination
with hospitals
Chronic Condition
Management
• Identification &
Monitoring
• Care plans /
care
coordination
• Comanagement
with specialists
General Activities of the
Medical Home
• Anticipatory guidance – prevention and developmental
promotion
• Identification of risk factors – physical, mental, social
• Understanding family strengths and protective factors
• Helping families set goals and priorities for selfmanagement
• Management / referral to medical and community
resources
• Ensuring follow-up – was the patient able to follow
recommendations, complete referrals?
• Planning for future encounters ahead of time (instead of
reacting to problems as they are presented)
Delivery of Patient & Family-Centered Care Coordination Services
Lessons of the National MHLC
• If you do nothing else…
– Identify your population of CSHCN
– Develop the capacity for practice-based care
coordination and the use of care plans
– Gain family participation/feedback
From Carl Cooley’s presentation to the T-CHIC Annual Meeting, June 2012
Why worry about identifying CYSHCN?
• In order to improve care for CYSHCN…you have to know who they are
• Identifying CYSHCN is different than identifying adults with special
health care needs
– chronic conditions vary considerably in severity, degree of
impairment and service needs
– a complete condition list would be unwieldy and include many
children who do not require special services
– a functional status approach would not capture children who
function well but need special services to maintain function
– the inherent difficulties in measuring functioning of very young
children and infants
How Identification is Done
• Three general techniques:
– Provider “gestalt”
– Running diagnostic codes
– Using a consequences-based screener like the
CAHMI screener
• Most practices do a combination, depending
on goals and purposes for identification
Shared Care Plans…Background
“Every patient can benefit from a care plan (or
medical summary) that includes all pertinent
current and historic, medical, and social aspects
of a child and family's needs. It also includes key
interventions, each partner in care, and contact
information. A provider and family may decide
together to also create an action plan, which lists
imminent next health care steps while detailing
who is responsible for each referral, test,
evaluation or other follow up.”
From www.medicalhomeinfo.org
Shared Care Plans for CYSHCN
• Developed collaboratively with child and family,
incorporates child and family goals
• Effective way to support self-advocacy and selfdetermination
• Types of care plans
•
•
•
•
Medical summary/transition summary
Emergency care plan
Working care plan or action plan
Individual Health Care Plan for educational setting
Key Elements in Shared Care Plans
•
•
•
•
•
•
Name, DOB
Parents/Guardians
Primary Diagnosis
Secondary diagnosis(es)
Original Date of Plan, Updated last
Main concerns/goals
– Current plans/actions
– Person(s) responsible
– Date to be completed
• Signatures
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.
Environmental Context
Policy
Macro-system
Health Plan
Delivery System
Micro-system
Clinic
Hospital
Patient-Provider Encounter
Provider
Patient
Engaging families and/or youth
• In working with practices, this is difficult but
meaningful in many ways
• Some ideas for how to engage families:
– Recruiting families for QI teams or standing clinic committees
– Focus Groups
• Recruit a group of parents to discuss specific topics
• Example: focus group to review service needs for CYSHCN
– Parent Advisory Group
• Can also be subject-specific, or have the agenda driven by the parents
– Survey patients and families about their experience of care
• Formal surveys
• Shorter surveys of topics of interest
BECOMING A MEDICAL HOME
Adaptive Reserve
• What’s predictive of medical home
transformation is the characteristics of the
practice themselves…specifically adaptive
reserve
• The ability of a practice to be resilient, to
bend, and thrive survive under force.
Facilitates adaptation during times of
dramatic change.
Initial Steps
•
•
•
•
•
Understand your practice’s culture
Create a team
Set priorities
Decide on accountabilities
Measure your progress
As the Project Starts
• Understanding Clinic’s Change Culture
• Knowing who the clinic needs to be engaged
• Getting the backing of clinic leadership
Key thought: Understanding how your practice
typically addresses change and decisionmaking will facilitate project spread.
As the Project is Underway
• Developing QI skills as a practice (aim statements,
PDSA cycles)
• Engaging patients and families in QI efforts
Key thought: QI skills and knowledge can’t live
in the brain of a single individual (or small
group of individuals) if change is to be
sustained.
As the Project Finishes
• Creating a multi-disciplinary team for ongoing
QI work
• Developing a clinic-wide strategic plan for QI
• Creating systems for tracking and sharing
performance measures
Key thought: Ongoing sustainability requires a
permanent infrastructure for QI.
Food for thought
• Given that medical home transformation is a
flexible, long-term process…
How can you build your project team and do your
project-level work in a way that sustains the work
beyond the timeframe of the learning
collaborative?
Key Questions: Understanding Your Clinic’s
Change Culture
• How are changes made in your practice?
• Who holds decision-making authority in your
practice?
• How can you engage other providers to
participate in changes being made?
• What are the structural supports needed to
maintain continued growth as a medical
home?
Simple Steps to Implement Now
• Working on team identity and function
– Are you meeting regularly? Do you create an agenda? Are
you dividing accountabilities?
• Finding ways to share project information, goals, aim
statements with others
– What are the avenues for sharing information with other
providers and staff? Are there standing meetings that you
need to get yourself on the agenda for?
• Publicizing project data with other staff members,
providers and patients
– How is performance data shared with others in the
practice?
Structural Supports
• Implementing large scale change calls for
dedicated support structures
– Many highly functioning medical homes have
created QI Teams and are working on a Strategic
Plan for Quality
• Success increases if multiple tactics for change
are used
Final Thoughts…
• Start small. One small
change can make a big
difference.
• Use existing medical
home tools to prioritize
your efforts.
• Know which patients are
in most need of your
help.
• Involve your patients in
improving their own care
as well as your practice.