The Enhanced Medical Home - Children's Health Fund

The Enhanced Medical Home:Improving child outcomes throughcomprehensive health care deliveryArturo Brito, MD, MPHChief Medical Officer & Executive Vice PresidentRoy Grant, MADirector of Applied ResearchChildren’s Health FundNational Initiative for Children’s Healthcare Quality (NICHQ)Grapevine, TXMarch 11 th 2009

Objectives To define an Enhanced Medical Home anddifferentiate it from the traditional pediatricmedical home To discuss areas where evidence existsfor components of the medical home To describe a statewide model To review current health policy that affectsthe medical home model

CHF Mission Statement The Children’s Health Fund (CHF) iscommitted to providing health care to thenation’s most medically underservedchildren and their families through thedevelopment and support of innovativeprimary care medical programs, responseto public health crises, and the promotionof guaranteed access to appropriatehealth care for all children.

The Pediatric Medical Home Originally defined (1960s) by the AmericanAcademy of Pediatrics (AAP) to address theneeds of Children with Special Health CareNeeds (CSHCN) AAP Task Force on the Future of PediatricEducation expanded its recommendation toinclude all children (Pediatrics(2000; 105:163-212)

Definition “…not a building, house, or hospital but anapproach to providing care in a high-quality, cost-effective manner.”(AAP. The medical home. Available at:www.medicalhome.org; ; 2004)

The Pediatric Medical Home

Evidence for… “International and within-nation studies indicate that arelationship with a medical home is associated withbetter health, on both the individual and populationlevels, with lower overall costs of care and withreductions in disparities in health between sociallydisadvantaged subpopulations and more sociallyadvantaged populations. Although important infacilitating use overall, insurance does not guarantee amedical home.”(Starfield B, Shi L. The medical home, access to care, and insurance: areview of evidence. Pediatrics 2004; 113 (5):1493-1498.)

Future studies… “The evidence provides moderate support for thehypothesis that medical homes provideimproved health-related outcomes for childrenwith special health care needs. Additionalstudies with comparison groups encompassingall or most of the attributes of the medical homeneed to be undertaken.”(Homer CL, Klatka K, et al. A review of the evidence for the medical home forchildren with special health care needs. Pediatrics 2008; 122: e922-e937.)

ELECTRONICHEALTHRECORDSELECTRONICHEALTHRECORDSEnhanced Medical Home ModelPATIENT/FAMILYCENTEREDTEAM-ORIENTEDCAREELECTRONICHEALTHRECORDSELECTRONICHEALTHRECORDSEHREHRTELEMEDICINEEHREHR

Electronic Health Records Essential pediatric needs* Immunization management Growth tracking Medication dosing Data norms Privacy in special populations* Spooner SA & the Council on Clinical Information Technology. SpecialRequirements of electronic health record systems in pediatrics. Pediatrics.2007; 119: 631 – 637

With appropriate pediatric content,Electronic Health Records…..Facilitate use of evidence-based & -linked protocolsInclude templates for: Pediatric-focused screening (e.g., developmental, psychosocial and maternaldepression) Special Population needs National standards (e.g., NHLBI asthma guidelines)Facilitate integration of mental, medical & oral health services (shared EHRmodel)Link directly to, for e.g., municipal immunization and newborn screeningregistriesGenerate reports for applied research Descriptive, CQI and outcome/efficacy studies

Medically underserved:A special needs population Risk factors* Economic Geographic Psychosocial*Brito A, Grant R, Overholt S, Aysola J, Pino I, Spalding SH, Prinz T &Redlener I. The Enhanced Medical Home: The pediatric standard of carefor medically uderserved children. Advances in Pediatrics 2008; 55: 9-28.

Geographic barriers Low-density rural county residence High-poverty inner-city residence Residence in a Health Professional ShortageArea (HPSA) Lack of safety net providers, including CHCs,MMUs and SBHCs Living in an area affected by a disaster Key point: Limited or no access to publictransportation can be a powerful barrier to care

Psychosocial barriers Vulnerable population Domestic Violence Maternal depression Key Point: Screening for familypsychosocial problems should be part ofthe Enhanced Medical Home.

Psychosocial barriers Limited English-language proficiency Low literacy Low health literacy Key Point: The Enhanced Medical Homecan be a catalyst for school preparedness.

Innovative primary care Mobile medical unitsdelivery models Proven efficacy in reaching underserved and isolatedpopulations [1] School-based and school-linked clinics Success reducing asthma hospitalizations [2] Mental health treatment outcomes comparable tocommunity-based clinics [3] [1] P Madrid, H Sinclair, A Bankston S Overholt, A Brito, R Domnitz, RGrant. Prehospital and Disaster Medicine. . 2008;23:314-321. [2] MP Webber, KE Carpiniello, T Oruwariye, Y Lo, WB Burton, DK Appel.Archives of Pediatrics & Adolescent Medicine. 2003;157:125-9 [3] P Armbruster & J Lichtman. Community Mental Health Journal.1999;35:493-503.

Health Information Technology:Telemedicine Bridges geographic barriers Transportation Health professional shortages Especially effective in rural communities Synchronous (real time) [1] Asynchronous (store-and forward) [2] [1] Young T & Ireson C. Effectiveness of school-based telehealth care inurban and rural elementary schools. Pediatrics. 2003; 112: 1088 – 1094 [2] Callahan C, Malone F, Estroff D & Person DA. Effectiveness of aninternet-based store-and-forward telemedicine system for pediatricsubspecialty consultation. Archives of Pediatrics & Adolescent Medicine.2005; 159: 389-393

Internal medicine model:The patient-centered medical home Focuses on the needs of the patient Health information technology Coordination of primary, specialty and inpatientcare Preventive services Health promotion and maintenance Disease management and prevention Behavioral health services Patient education American College of Physicians. Online at:http://www.acponline.org/advocacy/where_we_stand/medical_home/pcmh07.pdf

Regulatory barriers to medicalhome implementation Reimbursement rules vary from state tostate for Health care in mobile medical units Mental health services in health care settings Mental health services by social workers andother differently credentialed professionals Telemedicine Further complicated if the telemedicine connectioninvolves two different states

Financial barriers to medical homeimplementation Length of time for visit Negatively impacts third party revenue Collateral contacts: not reimbursed Telephone contacts with patient: notreimbursed Start-up costs for electronic health records

Motivation for policy makers Improved patient outcomes, better health Improved chronic disease management Poorly managed chronic diseases drive uphealth care costs Asthma, diabetes, cardiovascular disease Reduce health disparities Reduce preventable hospitalization andemergency department (ED) use Result: significant cost reduction

Model state initiative: North Carolina Carolina Access Established in 1991 with CMS 915(b) waiver Went statewide in 1998 Creates system of coordinated health care forMedicaid recipients Community Care Of North Carolina As of 2007, 14 regional community healthnetworks More than 3,000 physicians Local health departments, hospitals, socialservice agencies and community providers Designed to improve care for ~760,000Medicaid enrollees

Financing Enhanced fee-for-service model Designated medical homes receiving$2.50 per member/per month (pm/pm) Local networks receive $3 pm/pm tosupport local case management andchronic disease managementactivities and staff

Program elementsNurse advice phone line (“HealthDirect”)Refrigerator magnet with local pediatricoffice and HealthDirect phone numbersExtended clinic hours (6:00-10:00 PM)Case managersPhysician champions Local inter-agency steering committees Interpret changes in utilization data forpediatric practices

Program outcomes Decreased pediatric ED visits by 17% infirst year of operation (fiscal year 1999) During the first four years of programoperation, Medicaid utilization datashowed a $27.5 million savings statewidefor children with asthma Reduced ED and hospital use CF Willson. NC Medical Journal. 2005;66:229-233

Conclusion Developing and testing diverse medicalhome models is consistent with currenttrends in national health care reform Preliminary data strongly suggest that theenhanced medical home model willimprove outcomes, reduce costs and leadto a more efficient and responsive healthcare system

Additional on-line resources American Academy of Pediatricshttp://www.medicalhomeinfo.org/ American College of PhysiciansPolicy Briefhttp://www.acponline.org/advocacy/where_we_stand/policy/adv_med.pdfFrequently Asked Questionshttp://www.acofp.org/advocacy/downloads/FAQ--Patient-Centered%20Medical%20Home--10-28-08.pdf Society of General Internal MedicineBibliographyhttp://www.sgim.org/userfiles/file/AMHandouts/AM07/handouts/WE05.pdf

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