Medical Home in Pediatrics:
The HOW TO Webinar Series
brought to you by the National Center for Medical Home Implementation
How To Use Data to
Improve Care Delivery
Christina Bethell, Ph.D., M.P.H., M.B.A.
Child and Adolescent Health Measurement Initiative
RJ Gillespie, MD, MHPE, FAAP
Oregon Pediatric Improvement Partnership
April 25, 2013
Disclosures
We have no relevant financial relationships with the
manufacturers(s) of any commercial products(s) 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 my presentation.
Webinar Objectives
By the end of this webinar, the participant will be able to:
 Review the updated state profiles and additional resources on
the Medical Home Data Portal
 Illustrate the practical use of state-level data sets to improve
care equity, access and quality for children and families
 Explain how to effectively work with state-level data to
advance the medical home model
History of Medical Home Measure
 American Academy of Pediatrics (AAP) published the first
policy statement on medical home in 1992 followed by
updates in 2002 and 2008.
 U.S. Department of Health and Human Services’ included
medical home as a Healthy People 2010 and 2020 goal and
objective.
 Federal Maternal and Child Health Bureau identified medical
home as one of the 18 national performance standards
established for state Title V programs
Many PCMH recognition tools exist today;
Content domains overlap
This figure was adapted from the Urban Institute (March 2012), full report
available at http://www.urban.org/uploadedpdf/412338-patient-centeredmedical-home-rec-tools.pdf.
The NCQA PCMH 2011 Overall Standards Encompass the
Following Content Domains*:
AAP Domains of Medical
NCQA PCMH Standards
Home
 Enhance Access and
 Accessible
Continuity
 Family-Centered
 Identify and Manage Patient
Populations
 Continuous
 Plan and Manage Care
 Comprehensive
 Provide Self-Care Support
 Coordinated
and Community Resources
 Compassionate
 Track and Coordinate Care
 Culturally Effective
 Measure and Improve
Items that are highlighted indicate similar domains for
Performance
NCQA PCMH Standards and APP Domains of Medical Home.
Overview of Medical Home Measure
The Child and Adolescent Health Measurement Initiative (CAHMI) led the development and
testing of the Medical Home Measure for the Maternal and Child Health Bureau

Beginning in 2001, CAHMI coordinated a national measurement effort to design and test
options for measuring Medical Home for 2003 National Survey of Children’s Health—building
on prior work to measure MH in the 2001 NS-CSHCN.

This 2003 NSCH measure was “provider focused” and revised to be more “systems focused” for
the 2005/06 NS-CSHCN

Current measure has been used in 2005/06 & 2009/10 NS-CSHCN and 2007 & 2011/12 NSCH

Measure is endorsed by the National Quality Forum (NQF)

Measure explicitly build on CAHMI work to design and test the initial CAHPS CCC, which
addressed many MH components (see Pediatrics 2004 article)

“Best Possible” MH measure has also been constructed for the Medical Expenditures Panel
Survey

All measures lack a comprehensive focus on patient engagement and continuity (for a reason!)
and lack more robust care coordination measures

All measures face issues related to a provider, team and systems notion of MH
Overview of Medical Home Measure
In order to meet medical home criteria, parent must report:
Child has a Personal Doctor or Nurse (PDN)
 Child has a Usual Source of Care (USC)
 Child usually or always experiences positive communication
with providers (FCC) Child does not have problems getting
needed referrals
 When parents perceive it is needed, child receives help with
care coordination When needed, parents are very or always
satisfied with doctor-to-doctor and doctor-to-school
communication

Why Use a Patient-Reported Measure?
 The goal of a medical home is

“not a building, house, or hospital, but rather an approach to providing
continuous and comprehensive primary pediatric care from infancy
through young adulthood, with availability 24 hours a day, 7 days a
week, from a pediatrician or physician whom families trust.”
 Infrastructure of a practice can facilitate this care delivery, but ultimately
the focus should be on the patient experience.
 Having medical home friendly policies and procedures in place is very
important. However, only patients and families can report on the
continuous and comprehensive health care they received from a
provider that they trust—the “medical homeness” of that care.
The Story We Want to Tell!
Patient Experience of Care Provided Versus Patient “Satisfaction”
MOV/Art of Medicine and PHDS
Rank Group
2
1
0
Overall Satisfaction
Survey Item
Anticipatory Guidance
& Needs
Parental
AGPE
Met
Education
Mean Score Rank Groups: 0=Lowest 2; 1=Middle 6; 2=Highest 2
Source: 2004 CAHMI PHDS Data, Kaiser Permanente Northwest (N=2,116); 2004 Art of Medicine/MOV
MOVLevel:
and PHDS
Data:
Comparison
Analysis
Office
MOV Q03
by Selected
PHDS Item
State and National-Level Policy Making
 The NSCH and NS-CSHCN provide standardized data at the national and state-
level
 Compare performance across geographic locations
 Compare performance across key socio-demographic subgroups, including
insurance type, race/ethnicity, household income, household education,
complexity of needs
 Trending of medical home measure across survey years to examine impact
of state-level medical home implementation
 The NSCH and NS-CSHCN include measures of health insurance status, health
care utilization, impact on child and impact on the family
 Provide comprehensive understanding of the impact and key factors
associated with meeting medical home criteria
State Application Illustration
The American Academy of Pediatrics' (AAP) description of a "medical home"
lists seven defining components: accessible, continuous, comprehensive, familycentered, coordinated, compassionate and culturally effective.
Prevalence
of Medical
Home in
Prevalence of Medical
Home Overall
and
California,
by Complexity
of Health Care
Subcomponents,
Nationwide
vs California
100
80
60
40
20
0
43.0 38.3
6052.7
56.0
Needs
76.6
66.1
64.654.2%
61.2
Nation
California
40
29.2%
CSHCN who
Care
Family-Centered No Problems
receive care
Coordination
Care
Accessing
within a medical
Referrals
home
20
70% of CA
CSHCN
California State Ranking on
Medical Home Overall and
Subcomponents
Overall Medical Home
44th
Care Coordination
46th
Family-Centered Care
Problems Accessing
Needed Referrals
44th
0
Less Complex Health More Complex Health
Needs
Needs
DATA SOURCE: 2009/10 National Survey of Children with Special Health Care Needs
50th
Data Application Example: Interplay
between Medical Home, Parent Work
Force Participation and Transition
Services
Association between
“transition services”
and parent
employment
Exploring the Medical Home Data Portal
www.medicalhomedata.org
Exploring the Medical Home Data Portal
Exploring the Medical Home Data Portal
Exploring the Medical Home Data Portal
Exploring the Medical Home Data Portal
Exploring the Medical Home Data Portal
TOP 5
STATES
BOTTOM
5 STATES
Exploring the Medical Home Data Portal
TOP 5
STATES
BOTTOM
5 STATES
Exploring the Medical Home Data Portal
 Additional Content Available to Learn About Medical Home
Measurement and Implementation

Search for More Medical Home Data

Learn about the Medical Home

Medical Home Measurement in States

Medical Home Measurement in Practices

Medical Home: New Opportunities for Implementation
Through Health Care Reform

Medical Home: Data in Action!

Medical Home Measurement for Families
Exploring the Medical Home Data Portal
Understand Your
Population
User generated tables, bar and pie charts, and customizable
reports supply prevalence estimates and population counts to
help define your population of CSCHN and their health needs
Assess System
Performance
Immediate access to over 100 state-specific indicators of child
health and well-being and system performance for children
overall and children with special health care needs (CSHCN).
Examine
Improvement
Opportunities
“Point and click” menu allows users to explore disparities and
gaps in access and services for different population subgroups
of children and CSHCN.
Exploring the Medical Home Data Portal
Select Priorities
User generated tables, bar and pie charts, and customizable
reports supply prevalence estimates and population counts to
help guide selection of priority needs.
Set Targets
“All States” ranking maps and tables provide benchmark data
to assist in identifying state-negotiated performance measure
targets.
Identify Promising
Improvement
Models
Information on national, within and across States variation
using standardized indicators helps identify where quality is
better and can help in cross-state learning for purposes of
identifying promising models for improvement as well as
identify key collaborators for improvement.
Monitor Progress
Centralized resource for standardized, population-based
survey questions to use in collecting child health and health
care quality data locally.
Data In Action!
 National and state-level organizations utilize the medical
home measure as tools to educate, build partnerships, and
provide evaluation of health care service delivery for
subpopulations of children.
Data In Action!
 Practices are extremely busy with limited resources

Need policies and incentives to begin implementation
 Need to create a demand and incentive for practices to
implement the medical home model



Framing medical home as a protection of a child’s health trajectory
Affordable Care Act Section 2703 provide additional compensation to health
care providers if child meets chronic condition requirements
Education of families about the potential impact of medical home on child
and family  Create demand for enhanced service delivery
 Conversation begins at a higher level, including System
Administrators

The medical home profiles are intended to be easily accessible tools to start
the conversation about the importance of medical home and current
performance within your state.
RJ Gillespie, MD, MHPE, FAAP
Medical Director,
Oregon Pediatric Improvement Partnership
Practice Perspective
 Disconnect between what measures are useful at a practice
level and what measures are collected by the state, health
plans, and public reporting entities
 Applying standardized measures to a practice may not get
you to the core issues within a practice that need change
 Complex system change within a practice (such as medical
home transformation) usually doesn’t budge standardized
measures like CHIPRA core set
 Complex system change means complex measurement to
assess that change
What is Sensemaking?
 “Sensemaking is the process through which the fluid, multilayered
world is given order, within which people can orient themselves,
find purpose, and take effective action. Organizations don’t
discover sense, they create it.” --Don Berwick, MD
 When it comes to quality measures, sensemaking is the process of
creating a story about data to give that data meaning within a
clinical context.
 Once you can give the data meaning within a practice, an action
plan becomes a simple next step.
Example: Patient survey data

One of our early quality initiatives was to implement a
patient survey that assessed the clinical content of well child
visits.

Network of providers utilized the online Promoting Healthy
Development Survey developed by the CAHMI.

Previous data we were getting only spoke to frequency of
service, but didn’t help us understand the content of visits.
•
HEDIS Measures: did well child care occur on schedule?

The PHDS, which looks at the content of well child visits,
provided us ideas for areas of improvement.
Opportunity for Improvement:
Assessing for Parental Depression
80%
Proportion of Children With Parents Experiencing Symptoms of Depression
% ASKED About Depression: Child's parent IS EXPERIENCING symptoms of DEPRESSION
60%
% ASKED About Depression: Child's Parent NOT experiencing symptoms of depression
38%
40%
33%
29%
28%
24%
24%
20%
16%
12%
11%
13%
12%
13%
0%
All Children
Child 3-9 Months Old
Child 10-18 Months Old Child 19-48 Months Old
Source: 2008-2009 CAHMI Online PHDS Data
Relationship between children with depressed parents
and other child/family factors
100%
Child's Parent experiencing symptoms of depression
Child's Parent NOT experiecing a symptoms of depression
80%
60%
46%
37%
40%
24%
20%
19%
0%
Problems Paying for Key Child Health and Medical
Supplies
Do Not Regularly Read to Child (4 or less days)
Source: 2008-2009 CAHMI Online PHDS Data
An Opportunity for Improvement:
Peripartum Depression
 Common narrative in primary care
pediatrics: “I don’t need a screening tool
to identify mothers who are depressed –
I can see it in their faces.”
 12% of parents of children under a year
of age were experiencing depression.

Only 24% of these parents were asked
about the presence of symptoms.
 The new narrative, based on
sensemaking: “Maternal depression has
negative consequences for our patients.
We need to do universal screening for
postpartum depression.”
Source: Promoting Health Development Survey, CAHMI, 2008-9.
Maternal Depression Screening:
Our first few PDSA Cycles
Interval
2 week visit
Number of
visits
Percentage
Screened
Prevalence
of positive
screens
Percentage
referred out
625
79.0%
8.7%
65%
2 month visit 588
78.9%
5.4%
48%
Interval
Number of
visits
Percentage
Screened
Prevalence
of positive
screens
Percentage
referred out
2 month visit 705
78.6%
5.1%
71%
6 month visit 711
68.5%
4.7%
>100%
Source: Independent chart review, The Children’s Clinic, Portland, OR. 2011-12.
More Sensemaking
 Our detection rate at two weeks is higher than at other ages
– why?
 Are we picking up normal baby blues instead of actual
postpartum depression?
 Our referral rate at six months is 100% - why?
 The literature indicates that 6 months is a spike in the
incidence of postpartum anxiety.
 Our overall detection rates are still lower than expected
prevalence – why?
 Is there a problem with the screening tool itself?
 Next cycle is to add the question: Do you look happier on
the outside than you feel on the inside?
Sensemaking of Bigger Datasets
 In order to understand what needs to change within a
practice, often need to look at data sources outside of
what can be collected within a practice.
 When looking at larger datasets for a region, state or
the nation…



Does this information reflect what I think it going on in my
practice?
Does this information need to be acted upon?
Does this information imply a course of action?
Care Coordination
 Does this information reflect what I think it going on in
my practice?

Very few practices that I’ve worked with have care coordinators
or any formal care coordination program.
 Does this information need to be acted upon?
 CYSHCN without effective care coordination have problems
accessing specialists, over-utilize emergency rooms and have
frequent readmissions to the hospital.
 Does this information imply a course of action?
 Practice-based care coordination (or improved access to
community-based care coordination) may be an answer to this
problem.
Medical Home – AAP definition
Accessible
Family-Centered
Continuous
Comprehensive
Coordinated
Compassionate
Culturally Effective
So how does one measure all this?
How do you know that practice transformation
efforts are working?
Oregon’s Medical Home Learning Collaboratives
 While medical home principles are generally agreed upon,
how to get there is highly debated
 Wide variation in clinic capacity for change, experience with
quality improvement, and needs for technical assistance
 Currently unclear which medical home concepts lead to the
greatest gains in patient outcomes
 Eight practices currently participating in a 2 ½ year learning
collaborative dedicated to implementing and measuring
medical home
 Second learning collaborative of five more practices are
working on faster implementation of core principles
Practice-based Steps for Care Coordination
 Standardized methods for identifying CYSHCN
Before care coordination can be delivered, you have to
know who needs the help
 Use of complexity scales
 Further refines who needs help, and what type of help is
necessary
 Implementation of shared care plans
 Goals for self-management and patient education

Definition of practice-based care coordination
Within the medical home is a direct, family/youth-centered,
team oriented, outcomes focused process designed to:
 Facilitate the provision of comprehensive health promotion
and chronic condition care;
 Ensure a locus of ongoing, proactive, planned care activities;
 Build and use effective communication strategies among
family, the medical home, schools, specialists, and
community professionals and community connections; and
 Help improve, measure, monitor and sustain quality
outcomes (clinical, functional, satisfaction and cost)
Source: J McAllister and C Cooley
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.
 So how do you measure Adaptive Reserve?
What are the most critical components
associated with practices’ ability
to change?
Factors that Contribute to Ability to Change
 EMR “Maturity”
Ability to mine data and manipulate EMR to create decision
support structures
 Size
 Relates to staff support, ability to implement broad practice
change
 Previous QI experience
 Participation in learning collaboratives
 Enduring structures within a practice dedicated to quality
improvement, interpretation of measures

Measuring Medical Home
 Medical home attestation
Description of core medical home operational structures
 Medical Home Index
 Delivery of core medical home services to CYSHCN,
including care coordination services
 Family involvement in clinical QI processes
 Patient Surveys – CAHPS-CG PCMH
 Access to medical home services
 Developmental promotion
 Self-management support

Questions?
Please submit your questions in the
Question Box window!
We’re Here to Help You!
Have a question about medical home?
Contact us!
Medical_home@aap.org
800/433-9016 ext 7605