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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One effective method that primary care practices can use to establish a medical home is the continuous quality improvement (CQI) process. CQI is a concept where the focus is on a team approach to continuous improvement in healthcare. Team members include both practice staff and health care consumers served by the practice. This collaborative approach is the foundation of the process and is essential for successful health care improvement outcomes necessary for creating a medical home.

CQI is a management philosophy which contends that most things can be improved. This philosophy does not subscribe to the theory that “if it isn’t broke, don’t fix it.” It is a set of concepts, principles and methods developed from quality principles proposed by early quality gurus including W. Edwards Deming. These CQI principles, tools, and techniques have been found to work effectively in manufacturing industries and have recently been found to also work effectively in human service industries, including healthcare. At the core of CQI is serial experimentation applied to everyday work to meet the needs of those served and improve the services offered.

Core Concepts of CQI

• Quality is defined as meeting and/or exceeding the expectations of customers.
• Success is achieved through meeting the needs of those being served.
• Most problems are found in processes, not in people. CQI does not seek to blame, but rather to improve processes.
• Unintended variation in processes can lead to unwanted variation in outcomes, and therefore effort is focused on reducing or eliminating unwanted variation.
• It is possible to achieve continual improvement through small, incremental changes using the scientific method.
• Continuous improvement is most effective when it becomes a natural part of the way everyday work is done.

Core Steps in Continuous Improvement

• Form a team that has knowledge of the system needing improvement.
• Define a clear aim.
• Understand the needs of the people who are served by the system.
• Identify and define measures of success.
• Brainstorm potential change strategies for producing improvement.
• Plan, collect, and use information for facilitating effective decision making.
• Apply the scientific method to test and refine changes.
  

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A Model for Improvement

• Improvement is based on building knowledge (of what works and does not work) and applying it appropriately.
  
  
• The model offers a “trial and learning” approach that helps reveal the outcomes of change.
  
  
• Three basic questions:
  
  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  3. What changes can we make that may result in an improvement?
  
  
• Test a change on a small scale using PDSA:
  P = Plan; D= Do; S = Study; A= Act
  
  
  1. Plan the change strategy including who will be involved, what data will be collected, how and when the data will be collected, and when the data will be considered adequate to study.
  2. Plan a small test - one day, 5 records, etc...
  3. Do the intervention.
  4. Study the results.
  5. Act on the knowledge you gain from the data (maintain the plan, modify the plan, add to the plan). Continue with a second PDSA Cycle, and so forth. The process continually builds learning to foster improvement efforts.
     
     
• If the “change” was successful, solidify it by:
  
  1. Expanding it to the rest of the system.
  2. Establishing systems to support it.
  3. Identifying ways in which further improvements can be
     made.

Additional thoughts about improvement efforts:

• Before you try to solve a problem, define it.
• Before you try to control a process, understand it.
• Before trying to control everything, find out what is important, and work on the most important issue or on the process having the biggest impact.
• Recognize that we can learn from failures, so respect “meaningful failures”.

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Establishing a Quality Improvement Team
In Illinois, the Division of Specialized Care for Children (DSCC) is working with primary care practices throughout the state to establish medical homes. As part of this work, the practice establishes a Quality Improvement (QI) Team that includes practice staff and health care consumers. Ideally, the QI team includes a lead physician, the staff person(s) who will provide care coordination, staff from the front office involved in scheduling and billing and at least two health care consumers served by the practice (parents and/or teenage children). DSCC provides a facilitator who is knowledgeable of group processes and provides the structure for meetings to be effective.

To initiate the QI team's work, two assessment tools are utilized to obtain baseline data: the Medical Home Index and the Medical Home Family Index. These nationally validated assessment tools were developed by Dr. Carl Cooley and the staff of the Center for Medical Home Improvement (CHMI). These tools enable the practice to assess how well they provide comprehensive family-centered care and identify needed changes for providing a medical home for children with special health needs.

It is highly recommended that a practice distribute at least 30 and obtain no less than 10 completed Medical Home Family Indices for meaningful significance. If you are planning to perform statistical tests, you should consider consulting a biostatistician to determine what sample size would be appropriate to achieve statistical significance for your specific needs. You might aim for a response rate of 35%- 40%, meaning that you should distribute 25% - 50% more surveys than the sample size you are aiming for, but with some patient populations, response rates will be lower.

How do teams assess the results of these tools? The CHMI Medical Home Index (MHI) is divided into 6 domains that define the essential characteristics of a medical home:

• organizational capacity,
• chronic condition management,
• care coordination,
• community outreach,
• data management and
• quality improvement.

The MHI scores reveal the practice's strengths and weaknesses within these areas.

The Medical Home Family Index (MHFI) used by Illinois practices has been adapted so that the questions correlate to the domains of the MHI completed by the practice, thus providing opportunities for the QI teams to compare the practice results with those from families served by the practice. This comparison generally reveals the practice staff and families often agree on the same strengths and weaknesses. However, this comparison also frequently reveals deviations between the 2 groups perceptions about practice strengths and weaknesses - these areas are ideal for the QI team to begin brainstorming about planning improvement changes.

The Illinois Medical Home Project has combined the Medical Home Family Index with the Caregiver Survey to create the Illinois Medical Home Family Feedback Tool. This tool is being used to provide more comprehensive feedback and input from families on their perceptions about the care received from their primary care medical home. The Family Feedback Tool is also available in Spanish.

DSCC will score and analyze the MHI and MHFI and develop a written report for practices who are interested in establishing a quality improvement team and developing a medical home. Please use our Contact Us page to obtain more information about medical home and establishing a quality improvement team.

Once the team has reviewed the strengths and weaknesses revealed by the assessment tools, they can begin discussing the processes where improvement would be most beneficial and define specifically the small tests of change they believe will result in improvement. Using the PDSA cycle, described above, the team can define these small tests of change and begin to think and plan for subsequent larger scale changes.

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Other Resources

DSCC staff who serve as Quality Improvement team facilitators have developed a Facilitator's Guide to help practices who want to independently begin the quality improvement process.

The Illinois Chapter of the American Academy of Pediatrics (ICAAP) and the DSCC are collaborating on a new program titled “Building Community-Based Medical Homes for Children”, with support from the Michael Reese Health Trust. The initiative builds upon the success of the Illinois Medical Home Project and will provide primary care practices with free medical home quality improvement support and resources.

If your practice is interested in establishing a medical home QI process, contact ICAAP to join other practices that have already paved the way and can share their experiences and resources. Beginning July 2009, trainers will provide free support and resources to five new practices on a first come, first serve basis. The program teaches how to:

• Set up effective medical home innovation teams
• Know and identify your patient population
• Include families in the practice improvement process
• Make your practice accessible
• Make your practice family-centered and culturally effective
• Provide planned, proactive care
• Develop written care plans for special needs patients
• Become a DSCC medical home provider and receive increased reimbursement
• Participate in the National Committee for Quality Assurance’s Physicians Practice Connection evaluation program

For more information, contact:
Kathy Sanabria, MBA, PMP
ICAAP Project Director for Medical Home Initiatives
phone: 312/733-1026, ext 208

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The Illinois Chapter of the American Academy of Pediatrics (ICAAP) is pleased to announce that it has been awarded one of six new State Implementation Grants for Integrated Community Systems for Children with Special Healthcare Needs. This is a three year state implementation grant beginning June 1, 2009 through May 31, 2012 and is funded by the Department of Health and Human Services (DHHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). The ICAAP applied for the grant in collaboration with the Division of Specialized Care for Children (DSCC) and many other partners across the state.
Illinois’ new program is titled “Integrated Systems of Services for Illinois Children and Youth with Special Health Care Needs (CYSHCN) and Their Families”.

This effort builds upon the success of the Illinois Medical Home Project, which was administered by ICAAP in collaboration with the DSSC and also funded by DHHS HRSA MCHB. The principal investigator and project director for the new grant is Kathy Sanabria, MBA, PMP. The lead pediatrician and medical advisor for the program is Miriam Kalichman, MD, Associate Medical Director, University of Illinois at Chicago, Division of Specialized Care for Children, Children’s Habilitation Clinic, Chicago.

Primary goals of the program include:

For more information, contact:

Kathy Sanabria, MBA, PMP
ICAAP Project Director for Medical Home Initiatives
phone: 312/733-1026, ext 208

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In June 2009 the AAP/MCHB/National Center for Medical Home Implementation published the Building Your Medical Home Toolkit that supports primary care pediatricians' development and improvement of a Medical Home. It also prepares a pediatric office to apply for and potentially meet the National Committee for Quality Assurance (NCQA) Physician Practice Connections Patient Centered Medical Home (PPC-PCMH) Recognition program requirements. 

The Toolkit can help a practice assess and improve its medical home capacity with resources and downloadable tools organized into six building blocks that provide guidance for implementation:

• Care Partnership Support addresses family access and communication.

• Clinical Care Organization addresses standards for practice organization and use of clinical information.

• Care Delivery Management addresses the promotion of clinical care that is consistent with scientific evidence, as well as patient and family preference.

• Resources and Linkages addresses successfully linking patient and families with community resources to help meet their needs.

• Practice Performance Measurement addresses the organization and promotion of safe and high quality care.

• Payment and Finance addresses the need to match quality care and NCQA recognition with payment and value.

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