The Operations of the Medical Home In-Depth: Developmental Screening and Care Coordination

Hilary Gillette-Walch, RN, MPHProgram Director, Cowlitz Center of Foster Care Health

Phyllis M. Cavens, MDMedical DirectorEmail: pcavens@pacifier.com

Child and Adolescent Clinic, Longview, WA www.candac.com

Cowlitz County

Cowlitz County Overview• A resource-based economy with a population

of 98,000 persons• High rate of unemployment in the state (over

8%)• Low rate of college education attainment

among adults (2000 Census) 13% of Cowlitz adults vs. 26% of Washington State adults

• High rate of women delivering without a high school education (27%) and high rates of Medicaid utilization (64%) for prenatal care and delivery (2005 birth data)

Objectives

•Discuss the implementation of developmental screening into the pediatric practice

•Review a model of care coordination, focus on children in Foster Care

•As time allows, review strategies for financially supporting this work

The Child and Adolescent ClinicLongview, WA

Child and Adolescent Clinic

•Pediatrician-owned practice and clinic•10 pediatricians, 4 PNPs, 55 support staff•20,114 patients (29% Medicaid) •41,258 yearly visits (52% Medicaid)•41% of annual income goes to the

clinicians

Medical HomePediatrician & Policy

Driven• Family Centered• Culturally Effective• Compassionate• ContinuousResource Driven • Coordinated• Comprehensive• Accessible

Developmental Screening

•AAP 2006 Policy Statement regarding developmental screening, “It is an integral function of the primary care medical home and an appropriate responsibility of all pediatric health care professionals.”▫Incorporate surveillance at every well child

preventive care visit. •Early identification is critical for access to

services and treatment.

Groundwork before Implementation• Find your physician champion• Identify one person to coordinate the process in

the medical home• Partner with and utilize your local Early

Intervention program – in Washington its “Infant Toddler Early Intervention Program (ITEIP)”.

http://www.dshs.wa.gov/iteip/

• Our model found that we needed some additional funding to support this work, approximately $3,000 annually

Clinic Budget for 2008-2009Materials $4,400.00

Staff Time (26 hours per month) $6,400.00

Subtotal $10,800.00

less insurance payments received $7,800.00

Total clinic investment/grant funds used $3,000.00

Steps to Implementation•Business contract with Early Intervention

provider- Neurodevelopmental center (Progress Center)

Clearly spells out how funds are to be used (if providing the ND center with funds to support their activities) without jeopardizing other grant money they may be receiving.

▫Indicates specific role of each agency•HIPPA clause (or make separate contract)

allows for transfer of information between the agencies – specific to the screening program

Implementation, 2• Identify a tool – with Clinician input

▫ Ages and Stages Questionnaires (ASQ), Battelle Developmental Inventory Screening (BDI-ST), Bayley Infant Neurodevelopmental Screen (BINS), etc. Complete list with details is here: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;118/1/405.pdf

• Determine the ages and visits when the tool will be used by your practice: ▫ Where will it be completed? At the office? In the

waiting room? At home? • Identify all staff that will be impacted by the

process, create a team of staff that represent these work areas

Implementation, 3• Draft a possible flow of the screening tool through

your entire clinic with team members:▫ Who copies the screening tool? Other parent ed

materials?▫ Who gives it to the parent?▫ Who scores the tool?▫ When does the clinician review the tool with the

parent? ▫ Who makes referrals on screens that are positive?▫ What information goes to the parent? ▫ Where does the screening tool get filed? ▫ Where are the results documented in the chart?▫ Who bills the insurance company for completed tools?▫ How will you track if the tool has been completed?

Flowchart Parent Completes Screening Tool

Staff Score tool, review narrative

answers

Screen is Negative Screen is

Positive

No Concerns(aide charts result

on a worksheet in chart)

Parental Concerns

RN reviews results with chart in hand. -Flags result, puts copy of tool in chart-Is child up to date on well-child exam?-Determines if the concerns have already been addressed by clinician, if yes, typically monitor future screening results. -If concern is new or no evidence that it has been addressed completely, evaluates whether a return visit is needed. -Checks with MD on some of these, if it has been some time since last visit, especially if problem severe, if rescreening might be needed, etc.

Implementation, 4 •Launching the project

▫Notify families that they are being enrolled in the screening program, give them information about the process and tool.

▫Identify your cohort of children to be screened, create a process for updating monthly with births, moves, deaths, etc.

▫Determine a process for reminder letters or calls to parents for completed tools, if desired.

▫Meet often in the first few weeks▫Train staff, then train again

Implementation, 5•Autism and ADHD evaluation:

▫Have tools and processes selected for staff to move to when a parent raises these diagnoses as a concern.

▫MCHAT gets completed by the clinician during a visit with the parent

•Appointment staff:▫Be ready to schedule appointments – for well

child exams, hearing screening, anything that might be due - or to return for further evaluation or parent conferences.

Utilize the Children With Special Health Care Needs (CSHCN) Program Public Health Nurses

•Meet your local staff•Get a copy of their referral form•Find out their procedures for following-up

on referrals and giving feedback about services provided.

•Identify the contacts for your local school district – know how they want to receive referrals for screening.

Results of Screening, June – Nov., 2008

(932 screenings completed of the 2,800 mailed out, there may be some children who were screened more than once in this period).

33.4%

72.1%

7.0%

3.7%

17.2%

0% 20% 40% 60% 80%

QuestionnairesReturned

ASQ Negative Results

ASQ Positive Results

ASQ with ParentConcerns Only

ASQ Positive andParent Concerns

Follow-up on Positive Screens and Parent Concerns (n=152)

84.2%

18.4%

73.7%

10.5%

0% 20% 40% 60% 80% 100%

Contacted

Referred forDevelopmental

Testing

Parent Education (byND Center)

Home Visits

Cowlitz Center of Foster Care Health•The Center’s goal is to create a model

medical home site specific to children in foster care which will result in improved health outcomes for participating children. ▫Participating children are defined as

children currently in out-of-home placements through the auspices of Children’s Administration and are current patients of CAC.

Cowlitz Center of Foster Care Health• Using the Medical Home Care Plan as the key

document for individual case information about each participating child. The purpose of Medical Home Care Plan:

A summary of key data regarding the child’s overall health especially in regards to their foster care placement.

Is a central location from which data entry can be completed to support performance measures

A place to communicate concerns, findings, and plans that the clinic has for the child

▫ Document results of mental health screening done by Center staff and plan for follow-up.

Medical Home Care Plan• The Program Director and Counselor review all

incoming documents and:▫ Use them to update the care plan▫ Remove duplicate files▫ Remove irrelevant files (fax cover sheets)▫ Highlight any files that might impact the ongoing

medical care of the child for the pediatrician’s review

• When it appears all available records have been reviewed, or as acute needs of the child dictate, will determine if case conferencing for individual child is needed with the pediatric clinician.

Child & Adolescent Clinic Chart

Medical Home Care Plan

MMISCHET

Medical Records

from Children’s

Administration

Mental Health

Records

To be determined, educational updates, conferencing with social worker, family.

MMIS: Medicaid management information systemCHET: Children’s Health Education Tracking

Cowlitz Center of Foster Care Health

Medical Home Care

Plan

MMIS Print out(Medicaid

management information system)A listing of services paid for in last 12 months and the service provider

Data gleaned from this: •Frequency of all health care visits•Listing of service providers•Dental visitsAlso serves a cross-check to determine that clinic’s chart is complete for all medical care, e.g., no unknown ED visits. Medicaid Print

out of all Medications

Data gleaned from this: •Listing of service providers• Again serves a cross-check to determine that clinic’s chart is complete for all medical care, e.g., no unknown ED visits.

Cowlitz Center of Foster Care Health

Medical Home Care

Plan

CHET(Child Health and

Educating Tracking) system)

Summary of the child’s status completed after removal from biologic home: •physical/medical & dental) •Developmental•Connections (visitation plans)•educational, and• emotional/behavioral Other Medical

Records held by Children's

Administration

Data gleaned from this: •Mental Health records updating the social worker on child’s progress in therapy• Results of progress center evaluations and services from other providers.

Medical Home Care Plan• Fluid document• Will need to be updated often• Will likely become an electronic database in

the future• Will probably keep changing as we gain

experience using it

7 Strategies to Develop a Cost-Effective Medical Home•Purpose: Locate resources and dollars

(outside of the fee-for-visit system) to enable comprehensive, coordinated care and access.

Strategy 1: Create a 501(c)3•Children’s Community Resources was

founded to “serve the unmet medical needs of children in our county” Form a board of pediatricians and concerned parents

•Purpose: to gather funds to provide medical care for needy children and to employ grant writers.▫Obtain tax-exempt, non-profit status▫Obtain funds from donors and grants▫Facilitate Medical Home care for needy

children by building partnerships

Strategy 2: Develop a Community Organization•Purpose: Develop a coalition of community

organizations who care for children to plan, collaborate, and deliver services▫Provide pediatrician leadership▫Invite participation of community leaders

who care for children▫Write a strategic plan for the Medial Home ▫Commit to a family and child care charter ▫Develop policy and procedures.▫Proceed as a collaborative care system

Strategy 3: Develop Cost-Effective, Coordinated Care•Purpose: Build partnerships with schools,

agencies, organizations, and clinics that care for children.▫Team Conferencing & Co-managed Care

Plans ▫Mental Health▫Early Intervention 0-3▫Early Learning 3-6▫Foster Care▫Drug Affected Children

Strategy 4: Comprehensive Care•Purpose: Support partnerships, programs,

services, and parent education that addresses the health care of our children. ▫Parent Education▫Mental Health Partnerships▫Telemedicine▫Pediatric Subspecialists (Collect Rent)▫Insurance & Care Coordinators (grant

revenue)

Strategy 5: Affirm a Clinic Commitment to Open Access• Purpose: To recruit and retain quality

pediatricians who share a commitment to the medical home system of care.▫ Medical Home program financing▫ Adequate Medicaid reimbursement ensures access▫ Training of clinic staff and other local agencies to

enroll children directly into Medicaid▫ General pediatric practice with inpatient care, 24/7

care, one out of seven call ▫ Oversight of pediatric nurse practitioners▫ Student loan forgiveness▫ Above average incomes and benefits

Strategy 6: Use a Business Approach to Cost Effective Care•Purpose: Develop a strategic plan and

budget for each program and service. ▫Recall: disease and well child management ▫Pediatric practice oriented IT partner▫Allocation of staff hours, facility use▫Allocation of pediatrician time ▫Negotiation of contracts▫Grant writing and funding▫Coding and documentation

Strategy 7: Use Marketing to Ensure Cost Effective Care

•Purpose: support a medical director, program director, and marketing consultant.▫Budget 1.25% of gross income▫Pediatrician medical director▫Pediatrician marketing consultant▫MPH program director▫Brochures, newspaper ads, e-media flash

ads, website▫Disease management, patient binders,

patient education, telemedicine

Quality Improvement Activities

•Using the Center for Medical Home Improvement tools▫Self-assessment tool – checking on our

“medical home-ness”▫Family survey

•Weekly quality assessment meetings for clinical staff

Questions?

•Phyllis Cavens, MD, Medical Director▫Email: pcavens@pacifier.com▫Phone: 360-577-1771

• Hilary Gillette-Walch, RN, MPH, Program Director, Cowlitz Center of Foster Care Health and Healthy Tomorrows Grant▫ Email: hgillette-walch@pacifier.com▫ Phone: 360-577-1771, extension 282