Creating a Medical Home

Getting Started

Parent Partnership

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Practice Improvement Methods:
Practice Assessment

Consumer Awareness

Practice Improvements

Acute Illness Management

Preventive Care Management

Chronic Condition Management

Diagnosis Modules

Transition Information

Community Resources

Medical Home Reimbursement

Quality Improvement

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Medical Home Primer for Physicians

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Medical Home Information for Families

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Additional Resources

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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
Identifying children that have special health care needs within your practice is a vital step in chronic condition management and the provision of a medical home. Approximately 12 to 15% of patients in a typical primary care setting have special health care needs. Who are the children that will be the focus of enhanced services? The process of identification yields several positive results:

• Increases knowledge of those children with chronic conditions for all office staff;
  
• Improves communication between the family and practice staff;
  
• Allows for scheduling specific to the needs of the child and family (longer appointments, time of day and any other special accommodations) ; and
  
• Provides a means to “pull” certain high risk populations or diagnoses for chronic condition management such as determining priority for flu shots.

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:

“Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”

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.

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Strategies for Developing a Practice Registry of CYSHCN

Staff Recall
Practices frequently begin with staff recall - a personal recall of patients whom they consider CYSHCN, as a starting point.

Computer Generated Lists
Practices have printed a list of all patients by their primary care physician and asked each doctor to identify those patients that meet their criteria. For practices with computerized systems and scheduling, The Center for Medical Home Improvement provides a list of ICD-9 codes which can be used in the identification process. This list is very comprehensive, and can be overwhelming when first starting this process. Rather than utilize the list in its entirety, practices can “choose” those diagnoses that they feel are more complex and most appropriate to focus medical home services. You can run computer generated reports for certain codes/diagnoses to identify additional patients.

Screening Tools
The Children with Special Health Care Needs (CSHCN) Screener is an easily administered 5-item parent survey which can be conducted in person or by telephone. An affirmative response on any question identifies a child with special needs.

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
Some children with chronic conditions may be functioning very well and require few or no special services. Two examples of tools that rate the complexity of a child's chronic condition and related service needs include:

• The Complexity Index developed by Dr. David Hirsch of Phoenix Pediatrics in Arizona and
  
  
• The HOMES Complexity Scale developed by Exeter Pediatrics in New Hampshire.

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
Clinical Risk Groups (CRGs) use enrollment and claims or other encounter level data to classify individuals into mutually exclusive categories and assign each person to a severity level if they have a chronic health condition. The commercial software for CRGs has been developed by 3M Health Information Systems.

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.

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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

1. Medical Home Visit Card - a handout for families that addresses important points to prepare for the child’s medical appointment, “Make each doctor’s appointment work for you!” (one side in English and one side in Spanish)
   
   
2. Pre-visit questionnaire - this questionnaire is given to patients and families to complete in the waiting room prior to the appointment. It lists areas of concern and or discussion. Office staff can review the survey before the child sees the physician so that they can prepare for specific needs/concerns such as the need for care coordinator assistance or educational materials. Families are asked if assistance is needed in completing the form. This sample was developed by Exeter Pediatrics, VT and is included in the Medical Home Improvement Toolkit created by the Center for Medical Home Improvement.
   
   
3. Today’s Visit Form - this tool can be used to help families document their concerns and issues about their child’s health (changes in medication, referral needs, updated therapy or specialty visits, etc) they wish to discuss at the visit.
   
   
4. Visit Summary Form - this form, developed by Pediatric Health Associates, IL, can be used to outline the treatment plan and what follow-up care is needed. Both the family and the practice staff receive a copy of the Visit Summary to help clarify "next steps" and define follow-up responsibilities. This helps to promote family-centered, comprehensive and coordinated health care.
   
   
5. Post-visit questionnaire - a companion to the pre-visit questionnaire allows families the opportunity to provide feedback on the office visit and how well the needs and concerns were addressed. This sample was developed by Exeter Pediatrics, VT and is included in the Medical Home Improvement Toolkit created by the Center for Medical Home Improvement.

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).

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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
Guidelines for the Diagnosis and Management of Asthma in Children is intended to help pediatricians, primary care physicians, and other clinicians/health care professionals diagnose and manage patients with allergic diseases. It was developed by the Pediatric Asthma Committee, a multidisciplinary and multi-organizational group of US asthma and health care experts. The guide includes the recommendations from the NHLBI "Guidelines for the Diagnosis and Management of Asthma - Update on Selected Topics."

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
Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. ADHD is also among the most prevalent chronic health conditions affecting school-aged children. The core symptoms of ADHD include inattention, hyperactivity, and impulsivity. Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder provides recommendations for the assessment and diagnosis of school-aged children with attention-deficit/hyperactivity disorder (ADHD). Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder provides evidence-based recommendations for the treatment of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). This guideline primarily addresses children with ADHD but without major coexisting conditions.

Epilepsy
The management of epilepsy in the pediatric patient requires careful evaluation, classification, and pharmacologic treatment. Behavioral and Cognitive Effects of Anticonvulsant Therapy presents an overview of pediatric studies of antiepileptic drugs and behavioral/cognitive function.

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.

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Care Coordination
Care Coordination is a collaborative process that links children and families to services and resources in a coordinated manner to maximize the potential of children and provide them optimal health care. Care coordination is a vital component of the medical home.

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:

• The National Center of Medical Home Initiatives for Children with Special Needs
  Provides tools to assist in the coordination of care at the practice, community, and state level.
  
  
• AAP Policy Statement
  Care Coordination: Integrating Health and Related Systems of Care for Children with Special Health Care Needs. PEDIATRICS Vol. 104 No. 4 October 1999, pp. 978-981.
  
  
• Center on Medical Home Improvement
  The Medical Home Improvement Kit has detailed information regarding care coordination and much more.
  
  
• Care Notebooks
  A common problem facing the parents of children with special health care needs (CSHCN) is keeping records of their children’s medical history and current treatment plans so that they can be easily accessible. As a result, the American Academy of Pediatrics has developed an Online Care Notebook that gives parents of CSHCN the opportunity to create a personal notebook that fits their family and child’s needs.

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Transition to Adulthood
The AAP Policy Statement on the Age Limit of Pediatrics indicates the purview of pediatrics includes the physical and psychosocial growth, development, and health of the individual. This commitment begins prior to birth when conception is apparent and continues throughout infancy, childhood, adolescence, and early adulthood when the growth and developmental processes are generally completed. The responsibility of pediatrics may, therefore, begin with the fetus and continue through 21 years of age. Anticipating this transition point can be accomplished by having signs in examining rooms indicating that your practice wants adolescents to make the transition to adult health care providers by the age of 21 years. There are special circumstances (e.g., a chronic illness and/or disability) in which, if mutually agreeable to the pediatrician, the patient, and when appropriate the patient’s family, the services of the pediatrician may continue to be the optimal source of healthcare past the age of 21 years.

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
Illinois, along with 6 other states, is a member of the Region 4 Genetics Collaborative. This collaborative provides a forum for these states to share available newborn screening and genetic resources, an advancement that will result in improved geographic distribution of genetics expertise throughout the region. The Region 4 Genetics Collaborative web site has comprehensive information about newborn screening and providing a medical home for children with genetic disorders.

Newborn Hearing Screening
Each year about 500 children in Illinois are born with congenital hearing loss. The technology now exists to detect hearing loss in newborns that are only a few hours old. This simple, non-invasive test can save hundreds of thousands of dollars in special education costs. Research has shown that infants who have congenital hearing loss can have normal language skills and cognitive development by the time they are ready for school if amplification devices and therapy are provided by 6 months of age. Early identification, therefore, is imperative. The Illinois Newborn Hearing Screening Program web site has more information about the programs efforts and the services provided.

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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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