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Creating a Medical Home
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The role of the primary care physician in providing a medical home is to utilize basic knowledge, professionally endorsed policies, best practice models and community resources while providing care that is accessible, coordinated, continuous, comprehensive, family-centered, compassionate and culturally competent. This web content provides the tools to enable physicians to do just that. Managing Chronic Health
Conditions for Primary Care Providers elaborates
how the medical home model can be applied to the management of specific
chronic health conditions in the primary care setting. The content is
designed to help primary care providers gain valuable information and
insight about the on-going care and needs for certain chronic health conditions.
This includes clinical assessment information, treatment options, practice
guidelines, patient education, and related articles and tools. Identifying Children with Special Health Needs
Developing a definition of CYSHCN to use in the identification process helps to get this process rolling. There is a wide array of health conditions that may cause physical and emotional challenges. The US Maternal and Child Health Bureau offers this definition:
The definition you choose will guide which patients are included in your special needs group. Those patients then have their charts identified either by a different colored chart, a sticker or an electronic marker, such as “CYSHCN”, or an alert box on the computer. For most practices, the process of identification is ongoing as patients are seen for appointments and complex needs are identified. It is also important to recognize that not all children with chronic health conditions require special services. Some children may have stable health conditions and be functioning very well. Strategies for Developing a Practice Registry of CYSHCN Staff Recall Computer Generated Lists Screening Tools The Questionnaire for Identifying Children with Chronic Conditions-Revised (QuICCC-R) is a 16-item validated interviewer-administered instrument for identifying children with chronic and disabling conditions. It is available in both English and Spanish and is administered either by telephone or in person to the parents or guardians of children under the age of 18. Complexity Scales
These tools can be used to identify the level of complexity and/or intensity involved in supporting and managing children with special health care needs in your practice, which can then be used for planning proactive care such as scheduling flu vaccinations, etc. The Clinical Risk Group Classification The National Center of Medical Home Initiatives for Children with Special Needs also provides additional tools to document the complexity of conditions and related services to help practices determine those children in need of prioritized care. Practical Strategies Phone script—to enable staff to better serve families. A simple script can be developed in which families are asked by the receptionist if there are any special needs to consider or special requests which will make the child’s visit go more smoothly. This information is documented on the schedule for the day and in the child’s record for future appointments. “Fast Track” to exam room - to help those children who do not do well in a waiting room setting (either with other children or with a wait). For example, an autistic child and parent are escorted directly to an exam room to wait for their appointment. Longer appointment times - to promote more effective time management. Knowing that CYSHCN typically require more time, longer appointments are automatically scheduled. Visit Preparation - to assist families in preparing for the child’s office visit provides benefits for the child and family as well as the practice staff. The primary benefit is improved communication to promote proactive primary care. Practices gather individualized information about the strengths and needs of families at office visits to better meet these needs and more effectively coordinate services. Available tools for this Preparation
Referral “scripts” - to promote family-centered coordinated care. Families are given a referral form that identifies who they will be seeing, why they are being referred and where they need to go. These forms can be used with referrals to community agencies, medical equipment and specialists. Fax back forms - to facilitate communication between the pediatrician and specialty care providers. They are given to families for appointments with the child’s specialist and the specialist then faxes back the recommendations for further care to the pediatrician. “Valet” parking - to improve access for families. A staff member meets the family as they arrive for their appointment and stays with the child while the parent parks the car or parks the car for the parent as they go into the office to sign in their child. Bulletin boards in the waiting area - to share educational information with families as well as post information about helpful community resources including support groups. Suggested topics could include information about asthma, ADHD, diet related to obesity prevention, epilepsy, transition to adult health care, autism and other commonly seen chronic health conditions. Educational handouts on these issues may also be helpful. Internet access for families - to support those families that do not have internet access. Some practices have placed a computer in the waiting area, so families are able to obtain diagnosis-specific information, family support networks, and additional state and local resource information. Web sites could be saved as favorites on topics related to autism, ADHD, epilepsy, diet related to obesity prevention, transition issues and links to the DSCC web site to learn about available services and information (financial assistance, care coordination, home care waiver program, transition assistance, and the principles of medical home). Policies and Best Practice Guidelines The following is a brief list of the more pertinent clinical policies and best practice models that can be used as a guide to make change and improve health care quality. It is not a complete list. Recognizing that practices are already busy providing care and that change is challenging, choose one at a time and slowly integrate the recommendations into your practice setting. Asthma Pediatric Asthma: Emergency Care for Emergency Care Professionals is an online slide presentation for nurses, physicians, prehospital providers developed by the Illinois Emergency Medical Services for Children (EMSC). This educational module provides an overview of the essential components of pediatric asthma management in the emergency department, including patient/family education resources. It addresses evidence-based best practice guidelines, national and local asthma statistics, barriers and misconceptions, patient/family education, and numerous statewide asthma resources. The course has been approved for 2.5 hours of nursing CEU/Category II CME credits. Managing Childhood Asthma in Primary Care: A Quality Improvement Program is an online slide presentation, and podcast for primary care physicians, and nurses developed by the Illinois Academy of Family Physicians for the Your Healthcare Plus program, sponsored by the Illinois Department of Healthcare & Family Services (HFS). This educational module provides information on the prevalence of diagnosed asthma and asthma symptoms in children and young adults; it discusses the guidelines used for diagnosis of childhood asthma and helps users evaluate appropriate use of pharmacologic agents and non-pharmacologic therapies for acute and long-term therapy. This module also includes information on how to educate patients and caregivers on how to reduce environmental asthma triggers and improve self-management with action plans. A quality improvement tool is included to help practices implement and sustain changes in their practice which will improve the care of asthma patients. Attention-Deficit/Hyperactivity Disorder Epilepsy Managing Pediatric Epilepsy Syndromes with New Antiepileptic Drugs reviews available case reports and clinical trial data related to the use of newer anti-epileptic drugs in the chronic management of epilepsy syndromes in pediatric patients. Care Coordination Care Coordination includes assessing, planning, implementing, and evaluating options and services to meet the child and family's individual needs. To learn more about care coordination and how it can be implemented within a practice, please visit the following web sites:
Transition to Adulthood The Role of the Pediatrician in Transitioning Children with Disabilities and Chronic Illnesses from School to Work or College is to provide anticipatory guidance and to promote self-advocacy and self-determination. Knowledge of the provisions of the key federal laws affecting vocational education is essential for the pediatrician's successful advocacy for patients. Pediatricians can bring much strength to this transition process, including a longitudinal relationship with the family that offers multiple opportunities for providing anticipatory guidance and constructive interventions. Research shows the transition of children and youth with special health care needs from pediatric health care systems to adult health care systems is disproportionate when compared to the transition of typical adolescents. Transition to adult health care may be difficult. Parents and health care providers need to work in a collaborative team approach with the needs and desires of the child at the center of the plan. Physicians can be proactive in assisting CYSHCN to make the transition to adult health care by age 21 years by arranging consultations with pre-arranged adult primary care physicians beginning at the age of 12 and continuing this process every two years thereafter. It gives the adolescent the opportunity to experience adult health care and be a self spokesperson and advocate for themselves. Transitions involve changes, such as adding new expectations, responsibilities and resources while letting go of others. Transition is an important part of the medical home process. Visit the UIC-DSCC Transition web site for more detailed information and valuable tools and resources for successful transitions. Newborn Genetic Screening Newborn Hearing Screening Educational Programs Both the Illinois Chapter of the American Academy of Pediatrics (ICAAP) and the Illinois Academy of Family Physicians (IAFP) provide opportunities for ongoing educational training. In addition to professional development experience, participation in these programs allows practices to promote healthy patients and families and also instructs families on your commitment to quality care. The Illinois Chapter of the American Academy of Pediatrics provides an office-based educational program on asthma. For more information about the asthma program and other available preventive-type educational programs, refer to the ICAAP website. Illinois Academy of Family Physicians provides continuing medical education
(CME) programs throughout Illinois and with the national Academy. The
website provides a listing of all IAFP meetings, including many CME opportunities,
the AAFP courses and conferences, and CME meetings around the state. For
more information about these programs, refer to the IAFP
website. The medical home care model has been adapted from the Chronic Care Model for improving chronic illness care in primary care settings. Six domains organize the model; each represents numerous change concepts and innovative action ideas for a strong health care environment supportive of a medical home for every child and youth with special health care needs (CYSCHN).
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last modified: 27 May 2008