SCOPE
Stanford Care Optimization for Patients
& Education
Mentor & Resident Orientation 20132014
Directors Jori Bogetz MD, Carrie Rassbach MD, &
Julia Gabhart MD
Great Relationships, Great Medicine
• “The good physician treats the disease;
the great physician treats the patient who
has the disease.”
Sir William Osler
“The Father of Modern Medicine”
(1849-1919)
Mission Statement
• To guide residents through the longitudinal
experience of providing a Medical Home for
diagnostically or therapeutically complex
pediatric patients, and thereby improve the
quality of care for these patients.
SCOPE Provides Residents & Mentors …
• Opportunities for Investigation
• Innovation
• Insight
• A patient-and-family centered framework
• Application of Inspiration
Learner-Centered Outcomes
• Improve attitudes of pediatric residents on caring for
CSHCN by 20%.
• To assess SCOPE’s impact on the behaviors of
residents by increasing their confidence to apply what
they have learned in their future practice and care of
CSHCN by 20%.
SCOPE Provides Patients, Families
& Outside PCPs …
• Structure and coordination to help make patient
and family care meet their goals
• Tools of empowerment
• Opportunity to share their rich knowledge
• Continuity of care for a broad population
• Integrated care
Patient-and-Family-Centered Outcomes
The goal is to improve their
• Satisfaction with care obtained at LPCH
– As assessed by a survey adapted from the Consumer
Assessment of Healthcare Providers and Systems
(CAHPS)
SCOPE Educational Model
• Participants
o
The SCOPE Physician
o
Faculty Mentors
o
Patients and Their Families
o
Outside PCPs, if applicable
o
Social work, case management support
SCOPE Educational Model
The SCOPE Relationship
The SCOPE Relationship
A.
B.
If Continuity Clinic Is at 730 Welch
Home Primary
Physician
LPCH Specialists
Case Manager,
Care Coordinator,
Social Worker
Home Primary
Physician
LPCH Managing
Team
Patient & Family with
SCOPE Physician
& Mentor
School
Community
Resources
Other Care
Resources
A. If the patient’s Primary Care is outside
LPCH, their SCOPE physician will
establish a Co-Management Agreement
with the PCP.
LPCH Specialists
Case Manager,
Care Coordinator,
Social Worker
LPCH Managing
Team
Patient & Family with
SCOPE Physician
& Mentor
School
Community
Resources
Other Care
Resources
• B. If the patient’s Primary Care is
at 730 Welch, their SCOPE
physician IS their PCP.
FAQ: Does the SCOPE physician
replace existing providers?
NO.
The SCOPE physician DOES NOT REPLACE any
existing providers. The SCOPE physician works
within the existing care team to help the patient
and family achieve their goals and increase their
autonomy.
Patient Selection & Enrollment
• Patients NEW (or identify selves as inexperienced)
to LPCH living within 4-county area
•
Santa Clara, San Mateo, Santa Cruz, and San Francisco
• Identified by managing physicians/primary care
providers throughout LPCH
• Screened for appropriateness of program and
enrolled by program directors
 Upon agreement by family, primary care physician
 Matched with residents of best fit
The SCOPE Physician
• Approximately 20 Residents opt-in, providing
continuity of care over inpatient and outpatient
settings at LPCH and externally
• Can fulfill 2-week elective opportunity
• Supports work residents are already doing!
Faculty Mentors
• Approximately 20 Faculty Mentors
o General Pediatrics (inpatient and outpatient)
o Subspecialists
• 1 Resident per faculty Mentor
The SCOPE Intervention
• Patient and family are matched with a SCOPE
physician and mentor.
• The team should meet in person within 2 weeks for
an initial orientation, then at least monthly.
• Patient-centered care is promoted in all patients by
use each meeting of the SCOPE Toolkit.
Toolkit on peds.stanford.edu  rotations  electives  SCOPE/complex care
SCOPE
My SCOPE
Patient’s Picture
and Name
Physician Toolkit
My SCOPE Family’s
Picture and Names
Contents
Topic
● Emergency Letter – Copy of patient’s Emergency Letter
Section
1
●
Contact Tree – Copy of patient’s Contact Tree
2
●
Patient/Family Goal Keeper & Meeting Worksheets
3
●
My Goals & Mentor Meeting Worksheets
4
●
Care Plan – Copy of patient’s Care Plan
5
●
SCOPE Pacts – What my SCOPE family and I have agreed
upon. Co-management agreements with associated
care providers.
Key Consult Notes – Important information from specialists
6
●
My Learning – Literature relevant to my patient and Children
with Special Healthcare Needs
8
●
Letter on CPR Wishes – Copy of my SCOPE patient’s wishes 9
for end of life care
●
Other Important References – Community, hospital, and
other informational resources
●
My Research – Related to my patient or Children with Special 11
Healthcare Needs
●
Me, the SCOPE physician
7
10
SCOPE
The SCOPE Intervention: Your
Toolkit
• The SCOPE Toolkit is tailored to each group: Patients
& families, mentors, and residents.
• It is available in English, Spanish, and Vietnamese.
• Progress on completing the Toolkit is made according
to the needs of each family, always with the idea of
using it to help achieve:
– Their GOALS
– Their EMPOWERMENT.
SCOPE Timeline: Empower ME!
Meet your
SCOPE
Doctor.
SCOPE Contact Tree
You are ready for SCOPE
Graduation when you:
Make goals and build
plans to meet these
goals.
SCOPE Goal Keeper
Your SCOPE
Doctor will read
about your child.
Your SCOPE
Doctor will learn
about your child
in person.
Home visit and monthly
check ins.
•
•
•
•
Know your goals of care
Have a plan to meet your goals
Are ready to speak up about your
goals and know who to speak to
Are ready to take steps to meet
your goals
Learn to speak up
(Advocate) and take
steps (Empower) to
meet your goals.
Visits to specialists, school,
talks with other providers.
Family &
Patient
Graduation!
SCOPE: Empower ME!
Communicate
Focus on Your Goals
Identify goals and
make a plan
(Goal Keeper)
Talk with key people
involved in your child’s care
(Contact Tree,
Co-management
Agreements)
Teach
Each Other
As We Go
Learn
How to find answers and
anticipate problems
Advocate & Empower
Speak up about your goals
and work to achieve them
(Goal Keeper)
Family &
Patient
Graduation
The SCOPE Intervention
• Meeting Worksheets for are simply guides, to be
completed only as found useful.
• Key care coordination tools (to be completed
by each SCOPE Team):
– Goal Keeper: Guides each meeting, focus of
SCOPE intervention
– Contact Tree: Establishes for entire care team who
the patient should contact, when, for what, and how.
Last Updated: ________________
SCOPE should contact me by:
(Circle the best way to reach you)
My Contact Tree
•
Phone:
•
1. _________________
•
2. _________________
•
3. _________________
My child has a health issue I am concerned about.
•
I think this is an EMERGENCY.
CALL 911
Take SCOPE Toolkit with you to
Emergency Department
After reaching the Emergency
Department, contact your SCOPE
doctor,
Dr. __________
at ___________________
E-mail: ___________________
I think this is NOT an emergency.
It is an URGENT issue. I want to talk
with my primary pediatrician.
Examples:
______________________
______________________
Contact your primary pediatrician
Dr. _____________
at __________________
This is NOT urgent, but I would like to speak to
my SCOPE doctor within
24 hours.
Examples:
_______________________
_______________________
I want to speak to another member of my
Care Team.
For ___________ issues,
contact _____________
at _________________
Contact your SCOPE doctor,
Dr. _____________
at ____________________
If no answer in 24 hours, contact your
SCOPE mentor,
Dr. _____________
at _______________________
If no response from doctors above, contact your
SCOPE Directors, Dr. Bogetz, Dr. Gabhart, Dr.
Rassbach at:
(650) 497-8000, ext. 0, and ask for SCOPE
Director on Call
For __________ issues,
contact ____________
at _______________
For ___________ issues,
contact ____________
at _______________
Patients: If there is a change in your care plan, please contact your SCOPE doctor.
SCOPE doctors: If using your cellphone, provide on outgoing message with instructions for emergencies.
SCOPE
______________’s Goal Keeper
What I want to achieve for my child through SCOPE
o Last Updated: ________________________________
o Patient/Family Signature: _______________________
o SCOPE Physician Signature: ____________________
(Even 1 Goal is Great! No Need to Fill Out All the Spaces.)
Patient/Family
Goal
Steps to Meet Goal
Date I Want to
Meet Goal By:
How Will I
Know My Goal
Is Met?
Green Goals
Actively working to meet: Very Important and/or needs to be
done very soon
Yellow Goals
Not actively working to meet: Important, but can be done later
Red Goals
Maybe less important or urgent, but needs to be done eventually
The SCOPE Intervention
• Initial training session for residents, mentors
• 3 Resident Case-Based Discussions
• End-Of-Year Feedback Session
The SCOPE Intervention
Case Managers/Care Coordinators and Social
Workers as educators, expert navigators of our
system
Graduated SCOPE families
•
May serve as peer resources?
FAQ: So the SCOPE physician’s role
is social, not medical?
No.
The SCOPE physician’s role embodies
the best parts of medicine:
•Caring for the whole patient
•Understanding the disease in the context of the
patient and family
•Studying the disease and treatment in depth, as it applies to the
patient’s and family’s goals
•Advocating that others involved in the patient’s care work toward
the patient’s goals and patient/family empowerment
Expectations of every SCOPE physician
• Build a relationship with and
provide continuity for 1 Child
with Special Healthcare Needs
(CSHCN)
• Meet at least once monthly
(again, does not have to be in
person)
• Participate in
multidisciplinary care team
with co-management with
subspecialists
• Explore areas of potential
research
• Complete in Toolkit:
• Plan of Care (which is scanned into
Cerner)
• Contact Tree
• Goal Keeper
• Home Visit
• Attend at least 1 of 3 CaseBased Discussions throughout
year
•
Attend at end of the year
Feedback Session if possible
• Develop an understanding of
the home and family in the
context of a CSHCN
Save the dates!
• 12/10 12-1pm (case discussion)- LPCH- 3 East
• 1/30 12-1pm (case discussion)- LPCH Resident
lounge
• 3/11 12-1pm (case discussion)- LPCH Resident
lounge
• 5/21 5-6:30 (End of year wrap-up/feedback
session)- LPCH- 3 East
SCOPE
Stanford Care Optimization for Patients & Education
Primary Physician Co-Management Agreement
Dear Dr. _____________________:
We are very excited to have your patient, ______________________, join the SCOPE Program!
Scope is an innovative pilot (for now, limited to February 1-June 30 2012) at Lucile Packard Children’s
Hospital, meant to improve care of complex patients while teaching residents how to give them the best
possible care. Dr. __________________________, the SCOPE physician (pediatrics resident) matched with
your patient, and faculty mentor Dr. __________________________, will in no way usurp your role as
primary physician. Rather, the SCOPE Team will be consistent advocates for your patient on the Packard
campus, who aim to ease navigation through our system, improve communications among providers, and help
your patient and family work toward their goals.
In order for us to ensure SCOPE is of most benefit to you and your patient, please tell us:
1.
In what circumstances would it be OK with you for the SCOPE physician to be first-call for (nonemergent) questions regarding their care?
2.
In what circumstances should YOU be the family’s first call? What number(s) should they call?
3.
How often do you want the patient to visit your office and for what types of issues?
4.
How do you want your patient’s SCOPE physician to communicate with you?
5.
You will receive the patient’s initial Contact Tree and Goal Keeper (please example Goal Keeper)
within the next month. Would you like to receive updates as the Contact Tree/Goal Keeper change?
We look forward to sharing in your patients care. Please contact us at anytime regarding questions or concerns
about your patient or the SCOPE program.
Sincerely,
SCOPE Directors Jori Bogetz MD, Carrie Rassbach MD, and Julia Gabhart MD
jbogetz@stanford.edu; crassbac@stanford.edu, and jgabhart@stanford.edu
*
I, (primary care physcian’s printed name and signature) _________________________________, agr ee to the
above co-management terms. Date: _________________.
Or
*
This co-management agreement was completed by (SCOPE Team member’s name) ________________________,
as agreed upon by phone with primary care physician ______________________________, to w hom I then faxed the
agreement. Date: __________________.
Expectations of every SCOPE family
• Set up goals for care & work with SCOPE physician
regularly to meet these goals.
• Let resident physician know of non-emergent care
issues.
• Respond to SCOPE physician within 48 hours.
• Tell SCOPE physician of appointments or changes in
plan.
• Learn who to call for specific problems, and how to call
them.
• Goal: Empowerment!
Expectations of every SCOPE mentor
• Meet with the patient, family, and SCOPE physician within the
first 2 weeks of enrollment.
• Meet with the SCOPE physician (phone, e-mail, etc. all acceptable)
every month.
• Be available to answer SCOPE physician’s questions and those
triaged from the patient.
• Foster residents’ research interests related to SCOPE patient
or SCOPE curriculum.
• Attend case discussions as able and all-participant feedback
session.
• Attend Home Visit with resident.
Mentor Resources
• Ideas on how to optimize your mentoring relationship (also in your Toolkit)
•
Gusic ME, Zenni EA, Ludwig S, First LR. Strategies to design an effective mentoring
program. J. Pediatr. 2010 Feb;156(2):173-4.e1.
• A discussion of the balance of appropriate supervision for safe care and
allowing professional growth (also in your Toolkit):
•
Patricia Hicks, MD. View from the Association of Pediatric Program Directors: The
Role of Supervision in Creating Responsible and Competent Physicians. Academic
Pediatrics. Vol. 11, Issue 1, January-February 2011, Pages 9-10.
• For updated data on experiences families of CSHCN
•
Data Resource Center for Child & Adolescent Health. (2012). 2009-2010 National
Survey of Children with Special Healthcare Needs.
http://www.childhealthdata.org/learn/NS-CSHCN
• More first-hand on the patient/family experience
•
•
Robert A. Naseef. “Special Children, Challenged Parents: The Struggles and
Rewards of Raising a Child With a Disability” [Paperback]
Philo, Jolene. “Different Dream Parenting: A Practical Guide to Raising a Child with
Special Needs” [Paperback]
Communication Details: Timing
• Emergencies -- go to 911 or the ED.
• We ask the family contact their SCOPE physician once the
patient is safely in the ED.
• We ask that they bring their SCOPE Toolkit, if possible.
• Urgent issues -- go to the outside PCP, 730 Welch Primary
Care answering service (if the patient’s PCP is at 730 Welch), or
the appropriate subspecialty service.
• Non-urgent issues – go to the SCOPE physician.
• These correspondences will be returned as soon as possible,
but within 24 hours.
• Mentors are back-up if the resident does not return calls in 24
hours. Directors are mentors’ backup.
Communication Details: Mode
• If you e-mail with/regarding your patient/family:
• Ensure families understand these e-mails may not be truly
secure. If they do want to communicate by e-mail, they must
sign a consent form.
• When communicating to other caregivers about a patient,
always use “SECURE:” as the start of your subject line.
• CC relevant care providers.
• If you give out your cellphone number:
• Ensure your outgoing message says: “If you are calling
regarding a medical emergency, hang up and immediately dial
911.” Then record normal outgoing message.
Communication Details:
Documentation
• Document in the medical record (Cerner) any conversation that
could potentially influence your patient’s care.
• SCOPE physicians should detail that they have discussed this
conversation and recommendations with the mentor/SCOPE
director/other attending physician.
• CC relevant physicians, including attending with whom the SCOPE
physician discussed the topic.
• Summarize phone calls under General Message/Phone Message.
• Summarize e-mails and meetings under General Message.
SCOPE Pilot #3 Timeline (2013-14)
September
Patient,
Mentor,
Resident,
SW and CM
recruitment
October
Orientation
Pre-Surveys
November
SCOPE
Pilot #3
Officially
Begins
December
Resident &
Mentor
Case-Based
Discussion 1
February
Resident &
Mentor
Case-Based
Discussion 2
April
Resident &
Mentor
Case-Based
Discussion 3
May
Resident &
Mentor Endof Year
Feedback
Session
PostSurveys
SCOPE Support
Institutional Support
• Stanford University Pediatrics Residency Program
• with special thanks to Lyn Kahana and Rebecca Blankenburg
• Lucile Packard Children’s Hospital Complex Care Initiative
Designated as the educational arm of the Initiative
• with special thanks to John Mark, Christy Sandborg, Karen Wayman
Curricular Support
•
•
•
•
All parties mentioned above
David Bergman
The Lucile Packard Family Advocacy Council
1st and 2nd SCOPE Pilot Residents and Mentors!
Financial Support
• Lucile Packard Foundation for Children’s Health Young Investigator Award -Children with Special Healthcare Needs
• Department of General Pediatrics
• with special thanks to Fernando Mendoza
E-Copies of Toolkit, Patient Resources
•
Many resources are available on
the SCOPE Website (under
electives on peds.stanford.edu)
•
•
All Electronic Copies of the
SCOPE Toolkit and related
resources are shared with all
SCOPE physicians via
SCOPE Dropbox.
If you would like to have access to
the Dropbox, SCOPE Directors will
gladly invite you.
Please e-mail us.
Thank You For …
• Your time
• Your expertise
• Your dedication to teaching
• Your dedication to our patients and families
• Your example of going above and beyond
• Your feedback …
Carrie Rassbach crassbac@stanford.edu
Jori Bogetz jbogetz@stanford.edu
Julia Gabhart gabharj@pamf.org