CMHI

Building Primary Care Medical Homes for

CSHCNs & Assessing the Quality

1st Annual National EHDI MeetingFebruary 11-13 Vienna, Virginia

Jeanne W. McAllister, Co-DirectorCenter for Medical Home ImprovementHood Center for Children and FamiliesDartmouth Medical School, Lebanon, NH

Funding USMCHB

CMHI

Center for Medical Home Improvement Mission

The mission of CMHI is to establish and The mission of CMHI is to establish and support support networks of parent/professional networks of parent/professional teams to improve the quality of primary care teams to improve the quality of primary care medical homesmedical homes for children and youth with for children and youth with special health care needs and their families.special health care needs and their families.

(2001)(2001)

CMHI

CMHI

A Medical Home

Is not so much a place…Is not so much a place… But a structure and process of careBut a structure and process of care That emphasizes “home” as a:That emphasizes “home” as a:

Centralizing headquarters for careCentralizing headquarters for care Place to feel recognized, welcomed, Place to feel recognized, welcomed,

supportedsupported Connection to other community resourcesConnection to other community resources

CMHI

Primary Care Medical Homes Agree? Disagree?

All primary care practices are medical homesAll primary care practices are medical homes Family feedback is difficult to obtain & to hear Family feedback is difficult to obtain & to hear Care coordination Care coordination activitiesactivities occur in most practices occur in most practices Improvement is key to building a medical home Improvement is key to building a medical home MeasurementMeasurement discourages providers discourages providers Families report (CMHI) experiencing high levels of:Families report (CMHI) experiencing high levels of:

understanding & listeningunderstanding & listening care & respectcare & respect

CMHI

Primary Care Medical Homes Agree? Disagree?

All primary care practices are medical homesAll primary care practices are medical homes (D)(D) Family feedback is difficult to obtain & to hear Family feedback is difficult to obtain & to hear (D)(D) Care coordination Care coordination activitiesactivities occur in most practices (A) occur in most practices (A) Improvement is key to building a medical home (A)Improvement is key to building a medical home (A) MeasurementMeasurement discourages providers discourages providers (D) (D) Families report (CMHI) experiencing high levels of:Families report (CMHI) experiencing high levels of:

understanding & listeningunderstanding & listening care & respectcare & respect (A)(A)

CMHI

Improvement Strategies in Primary Care…Why are they needed?

CMHI

Pediatric primary care

Designed for the 80% of children who do Designed for the 80% of children who do notnot have special health care needs have special health care needs

Designed to provide well child preventive Designed to provide well child preventive care services and acute illness managementcare services and acute illness management

Designed to support a single service unit: Designed to support a single service unit: the provider – patient encounterthe provider – patient encounter

CMHI

Changing a pediatric practice is like trying to change the tire on a bicycle while you are riding it

CMHI

CMHI methodology emphasizes:

Partnerships with parentsPartnerships with parents Primary care-based care coordinationPrimary care-based care coordination Provider leadershipProvider leadership Continuous improvement processContinuous improvement process Linkages to community resourcesLinkages to community resources Improved office systems that:Improved office systems that:

Identify CSHCNsIdentify CSHCNs Track and monitor progressTrack and monitor progress Evaluate outcomesEvaluate outcomes

Clinical: preventive services

for CSCHN illness episodes acute encounters

Satisfaction: communication office responsiveness care plan/continuity family involvement

Functional: stress/worry school absence dx/rx information access family caregiving competence

Cost: ER, hospital visits unnecessary specialty & office visits lost parental work time care coordination activities received

Center for Medical Home Improvement - Outcomes, 2001

Clinical Value Compass Clinical Value Compass for Medical Homefor Medical Home

CMHI

Not everything that can be counted counts,

and not everything that counts can be counted.

Albert Einstein

CMHI

Levels of measurement

PopulationPopulation level measures level measures What percentage of CSHCNs receive care in a What percentage of CSHCNs receive care in a

Medical Home?Medical Home? PracticePractice level measures level measures

Where is the practice on the “medical homeness” Where is the practice on the “medical homeness” continuumcontinuum

Intra-practiceIntra-practice measures measures Which changes in care constitute improvements?Which changes in care constitute improvements? Data that can feed forward and feedbackData that can feed forward and feedback

CMHI

The Medical Home IndexThe Medical Home IndexValidation/Classification Tool Validation/Classification Tool

6 Domains (25 Themes)6 Domains (25 Themes)

Organizational Capacity (7)Organizational Capacity (7) Chronic Condition Management (6)Chronic Condition Management (6) Care Coordination (6)Care Coordination (6) Community Outreach (2)Community Outreach (2) Data Management (2)Data Management (2) Quality Improvement/Change (2)Quality Improvement/Change (2)

CMHI

Achieving “medical homeness”

MHI measures movement MHI measures movement towardtoward a Medical Home a Medical Home

Basic (good) pediatric primary care (Level 1)Basic (good) pediatric primary care (Level 1) Responsive pediatric primary care (Level 2)Responsive pediatric primary care (Level 2) Proactive pediatric primary care (Level 3)Proactive pediatric primary care (Level 3) Comprehensive pediatric primary care (Level 4)Comprehensive pediatric primary care (Level 4)

Points: (1 2 3 4 5 6 7 8)Points: (1 2 3 4 5 6 7 8)

CMHI

MHI results from 43 practices

Mean ScoreMean Score 101.72101.72

Median ScoreMedian Score 9898

Standard DeviationStandard Deviation 27.6927.69

Score rangeScore range 58 - 15758 - 157

Possible score rangePossible score range 25 - 20025 - 200

CMHI

Distribution of overall mean item scores

Distribution of MHI Mean Item Score - Site n=43

0

2

4

6

8

10

12

14

1 2 3 4 5 6 7 8

Level 1 Level 2 Level 3 Level 4Mean Overall Item Score (1-8)

Co

un

t

CMHI

(1 2 3 4 5 6 7 8)

Medical Home Index - pre-improvementMedical Home Index - pre-improvement

(*Rated by interviewer using primary care audit responses).

CMHI

Medical Home Index - post-improvementMedical Home Index - post-improvement

(1 2 3 4 5 6 7 8)

CMHI

Medical Home Index scoresMedical Home Index scores2001 & 1998 (estimate)2001 & 1998 (estimate)

2

8

2

7

4

5

0 2 4 6 8

1.5 FAMILYFEEDBACK

2.1 IDENTIFICATIONCSHCN

3.4 PLANS OF CARE

CMHI

The Medical Home Family Index -

practice level measurement

Short family survey available in English Short family survey available in English and Spanishand Spanish

Maps to the Medical Home IndexMaps to the Medical Home Index Blends parent/professional perspectives as a Blends parent/professional perspectives as a

basis for improvementbasis for improvement

CMHI

Building Medical Homes -Model

Measurement/Improvement/MeasurementMeasurement/Improvement/Measurement Learning collaborative/ networkLearning collaborative/ network

brings energy, support and family input brings energy, support and family input to primary care to primary care

contributes to their vitalitycontributes to their vitality outcome of strong medical homes for outcome of strong medical homes for

children and familieschildren and families

CMHI

CMHI

Center for Medical Home Improvement

Improvement kit keyed to Medical Home IndexImprovement kit keyed to Medical Home Index Building a Medical Home – Improvement Strategies in Building a Medical Home – Improvement Strategies in

Primary Care for Children with Special Health Care Primary Care for Children with Special Health Care NeedsNeeds

Web site: Web site: www.medicalhomeimprovement.orgwww.medicalhomeimprovement.org Download kit and measurement toolsDownload kit and measurement tools Links to other resourcesLinks to other resources NewsNews Interactive self-assessment (future)Interactive self-assessment (future)

Jeanne.W.McAllister@hitchcock.orgJeanne.W.McAllister@hitchcock.org

Home is the place whereWhen you have to go thereThey have to take you in

Robert Frost