The Future is Bright for Medical Home: Prevention and ... - HRSA

The Future is Bright for Medical Home: 

Prevention and Quality in the Context of Medical 

Home 

Jeanne McAllister, BSN, MS, MHA 

Paula Duncan, MD, FAAP 

Angela Tobin, AM, LSW 

Jane Bassewitz, MA

The Future is Bright for Medical Home: 

Prevention and Quality in the Context of 

Medical Home 

Jeanne W. McAllister, BSN, MS, MHA 

www.medicalhomeimprovement.org 

di lh i t

Medical Homes: Living, Breathing, Complex Organizations

Medical home transformation for high quality 

care across the lifespan since 1993 

As a result of our session today learners learners will: 

• Explain the primary care medical home, its relationship to 

Bright Futures as a key preventive component, and discuss 

national, state and practice level activities of interest to all 

MCH partners. 

• Link quality q yimprovement p methodologies g to the achievement 

of improved/transformed primary care 

• Explore key actions/roles around partnerships with health 

care teams teams, engagement of families and care coordination 

• Discuss specific personal/professional strategies for 

implementation that could be tried by learners "next week".

Agenda 

Welcome 

Medical Home and Bright Futures Overview 

• What is it? 

• How do they relate? 

• Quality Improvement strategies 

Buzz Group: Outreach to Primary Care 

Break 

Breakout Groups: 

• FFamily il EEngagement t 

• Care Coordination 

Next Steps: What can/will you do?

The Primary Care Medical Home 

At the Crossroads Integrating: 

Vertically –among health care systems/specialists/PCPs/patients & families 

HHorizontally i ll – among patients i & families/community f ili / i agencies/schools, i / h l etc … 

Continuously –with continuity of clinicians and medical home team members 

Longitudinally –over time with anticipatory guidance 

Health 

System 

Community 

Resources/Policies 

Medical 


Continuously 

Continuously… 

Longitudinally….

The Feeding and Nourishing of a Medical Home 

A Few Good Food Analogies 

Pollan & Graumbach 

NYTimes Dr. Graumbach 

Eat food Get health care 

Not too much Not too much 

Mostly plants Mostly primary care 

Nutting et al – (Lessons from first TransforMED demonstration) 

Primary care ‐ like healthy food food, works best at a local and personal level 

Kingsolver & McAllister Tomatoes … 

Animal, , Vegetable, g , Miracle, , by y Barbara Kingsolver g

Part of the local community 

“Barter” or exchange assets 

Local Tomato Grower Medical Home? 

Value health, quality products, and safety 

Sell “product” directly to customers 

Livelihood is mission as well as business 

Customers show up week after week, at a community 

gathering place 

First names common; open door/welcoming policy 

Name of the heirloom tomato she is growing? { ? }

Local Tomato Grower Medical Home? 

Part of the local community ✔ 

“Barter” or exchange assets ✔ 

Value health, quality products, and safety ✔ 

Sell “product” directly to customers ✔ 

Livelihood is mission as well as business ✔ 

Customers show up week after week, at a community 

gathering place 

First names common; open door/welcoming policy ✔ 

Name of the heirloom tomato she is growing? { “TRUST” } 

✔

Medical Home – Timeline – The Pediatric Era 

1967 AAP centralized medical record = medical home 

1992 AAP Cal Sia –Hawaii 

• Pediatric Medical Home; coordinates care with early intervention 

1994 Bright Futures Guideines First published 

1996 AAP & MCHB 

• Medical Home initiatives ‐ children with special health care needs 

• CMHI applies li CQI methods th d to t office ffi practice ti change h methodology th d l 

2000 Bright Futures Guidelines –2nd Edition 

2002 AAP selected by MCHB to implemt the next phase of Bright 

Futures Initiative 

2003 Medical Home Index –first quantitative measure of “medical 

homeness” homeness ‐ developed, validated, published‐CMHI 

published CMHI

Medical Home – Timeline – The Pediatric Era 

2003 2006 –1 st , 2 nd National Medical Home Learning Collaborative 

• MCHB funded partnership between CMHI and NICHQ 

AAP/MCHB National Center for Medical Home 

Implementation /Medical Home Toolkit –uptakes CMHI/other 

tools l 

2007 Bright Futures, 3rd Edition Released 

2007 AAP was awarded a second cooperative agreement to address 

implementation 

2008 Bright Futures Tool and Resource Kit Released 

2010 CMHI awarded ddAHRQ AHRQ grant to study d medical di l hhome 

transformation 

CMHI awarded National Health Care Transition Center

A Medical Home 

• Is a community‐based community based primary care setting which 

provides and coordinates high quality, planned, 

family‐centered health promotion and prevention, 

acute illness care, and chronic condition 

management —across the lifespan. 

– Care in a medical home is rewarding for clinical teams to provide 

and satisfying for patients and families to receive

Medical Home – Timeline –Primary Care 

Transformation 

1970’s First mention in pediatric literature 

2004 AAFP publishes The Future of Family Medicine 

• Medical home model is the foundation 

2006 ACP promotes Advanced Primary Care 

• Uses medical home language and model 

2007 Joint Statement on the Primary Care Medical Home 

• AAP, AAFP, ACP, and AOA; Medical home model as the standard of primary 

care 

2007 Erisa‐related Industries Committee launches the Patient‐Centered 

Primary Care Collaborative (PCPCC) 

• Pcpcc.net, (Waiting for pediatric incentives) 

New—Current New Current (January 2010 2010‐2011) 2011) 

• Medicare Advanced Primary Care Pilot Demonstrations… 

• Affordable Care Act 

• AHRQ Transformation Studies (1 of 14 a pediatric study!)

Accountable Care Organizations 

Key Elements 

• Pi Primary CCare iis ffoundational d i l 

• Define Roles of Subspecialists 

• Dfi Define Role R l of f HHospitals it l 

• Governance 

• Define Population 

Challenges 

• Risk Adjustment 

• Time Horizon for Outcomes

Leveraging Opportunities 

Affordable Care Act 

• Quality primary care, extended age to remain on family plan, no charge 

preventative care 

Medical Home – standards for recognition 

• Reimbursement potential for population care/registries, care plans, 

coordination coordination, population population, registries registries, care plans, plans etc. etc 

• Youth/family involvement, partnership and leadership 

• Professional Organizations (AAP, AAFP, ACP, AANP etc.) 

– Resources/toolkits / lk 

– Education, skills, proficiencies 

– Clinical training/residencies 

– MOC 

Accountable Care Organizations 

– Primary y 

Care is foundational

Families Want and Need 

• Offers a collaborative family family‐ 

centered, team approach 

• Develops p a written summary y 

of critical care information 

• Has a developed p pprocess 

to 

integrate and coordinate care 

across multiple services

Emphasis on partnerships with families 

Continuum of ways y to engage gg p patients & families, , 

as:

Every Child, Youth, & Adult 

Benefits from a Proactive, Planned, and Coordinated Medical Home 

• Jamie, an 11‐yo female, affected by Spina Bifida, arrives at 

pediatricians for a well child examination. 

examination 

• Specialists—orthopedist, urologist, and neurosurgeon 

• Jamie’s mother has two pressing concerns: 

1) JJamie i is i pubescent; b t will ill likely lik l begin b i menstruating t ti soon 

oHow to handle this event given Jamie’s catheterization program, (both 

at school and home). 

o Jamie’s Jamie s father has declared he does not want to be a part of Jamie Jamie’ss 

“home team” once menarche has occurred. 

2) Jamie endures teasing at school because her periodic urine leakage 

leaves an odor. 

oThe office nurse finds that none of the recent specialist’s notes have 

arrived & 

oThe PCP did not plan time to address these concerns today…

Jamie in a Medical Home 

Proactive, Planned, Coordinated Care 

Time Form trusting partnership with care team. 

Teamwork for 

Team is getting stronger; partner in helping 

Jamie to take a more active role/ progressively plan 

increased independence 

Care Plan Team & family develop, use, and share a 

plan of care 

Learning to partner 

in care 

Jamie, encouraged, begins to ask questions; she 

contacts her coordinator for assistance or questions 

Explicit p roles Family y understands their role 

‐ Prepare questions, maintain records, and ensure 

evaluations or tests are sent regularly 

Events Coordination & community outreach; 

‐ Gather information about events: school/urgent care/ER/ 

hospitalizations—family understands staff want and need to 

be informed 

Leadership Family’s ability to lead is variable/may at times need 

more active ti engagement t of f coordinator di t & team. 

t

Measuring the Medical Home 

• Quality Assurance Assurance—Do Do you meet standards? 

– National Committee for Quality Assurance (NCQA) 

• 10 Standards; Levels 1, 2, and 3 

• Basic requirement for many pilots 

• Quality Improvement—Where you are on the 

medical home continuum? 

– CMHI Medical Home Index (Validation Study 2003) 

– Medical Home Family Index & Survey 

• Pediatric & adult versions: long & short forms

The CMHI Medical Home Index 

6 Domains (25 Themes) 

• Organizational Capacity (7) 

• Chronic Condition Management (6) 

• Care Coordination (6) 

• Community Outreach (2) 

• Data Management (2) 

• Quality Improvement/Change (2) 

Cooley Cooley, McAllister McAllister, Sherrieb, Sherrieb & Clark; Ambulatory Pediatrics, Pediatrics July 2003

Support pp for ppediatric transformation leads to 30% improvement p overall in 3 years, y 

n=10.

Pediatric Medical Home 

Family Outcome Data of Significance 

• ↑ Family y feedback 

• ↑ Care plans/summary 

• ↑ Health status 

• ↓ Parental Worry 

• ↓ School absences 

• ↓ ER, hospitalizations, & specialty visits 

Pre & Post n=83 data sets, (p‐value of

CMHI National Outcomes Study 

Cost/Utilization 

Medical Home Index; 43 Practices, 7 Plans/5 States 

– Higher overall MHI scores or higher domain scores 

for care coordination coordination, chronic condition 

management, office organizational capacity 

• Lower hospitalization rates 

– Higher Chronic Condition Management domain 

scores 

• Fewer ER visits 

Cooley, McAllister, Sherrieb, Kuhlthau, Pediatrics, July 2009

Where does practice 

support come from 

now? 

What does it take?

CMHI Lessons Learned 

• Patient/family engagement 

– GGuidance id & vitality it lit ( (see continuum ti of f strategies t t i slide) lid ) 

• Transformation help 

Support pp redesign g and improvement p processes p 

– Guide with their personal mastery 

• Teamwork, access, population approaches, coordinated planned care, 

technology skills, etc. 

• Leadership 

Alignment of messages from all interested/investing in 

primary care 

• Payment reform 

& reinvest payment into primary care infrastructure/ 

coordination of care

CMHI’s CMHI s TAPPP (Gap) Analysis: 

A Medical Home Assessment with Transformation & 

Measurement Methods 

• Teamwork 

• Access & Communication 

• Population Approach 

• Planned, Coordinated Care 

• Patient & Family‐Centered Care

TAPPP TAPPP (Pediatric & Adult Adult Versions) 

Incorporates: 

• Medical Home Definition 

• Medical Home Index 

• Elements from: 

– Care Model for Child Health in the Medical Home 

– PCMH Standards 

– Other criteria 

• CMHI lessons learned –what it takes

CMHI ‐ TAPPP Process

Patient & Family‐Centered Medical Home 

Across the lifespan for children, youth and adults 

Reformed Coverage & Continuous Transformation 

Reformed Coverage & Continuous Transformation 

Supports

References/Resources 

• McAllister JW, Presler E, Turchi R, Antonelli RC. Achieving Effective Care Coordination in the 

Medical Home. Pediatric Annals. 2009:38(10) 

• McAllister JW, Sherrieb K, Cooley WC. Improvement in the Family‐Centered Family Centered Medical Home 

Enhances Outcomes for Children & Youth with Special Health Care Needs. Journal of 

Ambulatory Care Management. 2009:32(3);188‐196 

• Cooley WC, McAllister JW, Sherrieb K, Kulthau K. Improved Chronic Condition Outcomes 

Associated with Medical Home Implementation in Pediatric Primary Care. Pediatrics. 

2009:358‐364 

• Antonelli RW, McAllister JW, Popp J. Developing Care Coordination as a Critical Component 

of a High Performance Pediatric Health Care System. A Commonwealth Fund Report. 2009 

(www.commonwealthfund.org) 

• McAllister JW, Presler E, Cooley WC. Practice‐Based Care Coordination: A Medical Home 

Essential. Pediatrics. 2007;120;e723‐e733. 

• Cooley WC, McAllister JW. Building Medical Homes: Improvement Strategies in Primary 

Care for Children with Special Health Care Needs Needs. Pediatrics Pediatrics. 2004;113:1499 2004;113:1499‐1506 1506 

• Cooley WC, McAllister JW, Sherrieb K, Clark RE. The Medical Home Index: Development 

and Validation of a New Practice‐level Measure of Implementation of the Medical Home 

Model. Ambulatory Pediatrics. 2003:3(4);173‐180 

• AAP/MCHB BBuilding ildi YYour Mdi Medical lHHome TToolkit. lkit www.pediatricsmedhome.org 

di t i dh

Bright Futures: Health 

Promotion/Disease 

Prevention in the Medical 


At the heart of the medical home is the 

relationship between the clinician and the 

ffamily l or youthh

Bright Futures: Guidelines for Health 

Supervision of Infants, Children, and 

Adolescents, 3rd Edition 

Paula Duncan, MD, FAAP 

AMCHP Annual Meeting 

February 2011

History of the Bright Futures Guidelines 

Supported and funded by the Maternal and Child Health 

Bureau (MCHB) of the Health Resources and Services 

Administration (HRSA), Department of Health and Human 

Services 

• First published in 1994 

• Updated in 2000—2nd edition 

• In 2002, AAP selected by MCHB to implement the next 

phase of the initiative 

• 3rd edition released in October 2007 

• In 2007, the AAP was awarded a second cooperative 

agreement to address implementation.

Development p of 

The Bright Futures Guidelines, 3 rd Ed. 

The Mission 

– Develop one set of uniform guidelines for the health 

supervision/well care of infants infants, children children, adolescents 

and young adults 

– Address biopsychosocial issues impacting on child 

health 

– Strengthen medical homes 

– Use interventions which are evidence driven 

– Include recommendations on immunizations, routine 

health screening, and anticipatory guidance



• Our process 

– 4 Multidisciplinary Age‐Stage Expert Panels 

• IInfancy f 

• Early Childhood 

• Middl Middle Childh Childhoodd 

• Adolescence 

– Numerous AAP Leadership Groups Groups, including the AAP 

Committee on Practice and Ambulatory Medicine 

(co‐authors (co authors of the AAP Periodicity Schedule)



• Our process 

– Evidence Panel 

• NNominated i dand d SSelected l d 

• Worked with each age/stage panel 

– Child Children and d Youth Y thWith With Special S i lH Health lthCCare NNeeds d 

Panel 

• Nominated and Selected 

• Worked with each age/stage panel

2000 & 2002 

…is a set of principles, 

strategies and tools that 

are th theory ‐ bbased, d 

evidence ‐ driven, and 

systems y ‐ oriented, , that 

can be used to improve 

the health and well‐ 

being of all children 

through culturally 

appropriate pp p 

interventions that 

address the current and 

emerging health 

promotion needs at the 

family, clinical practice, 

community, health 

system and policy levels.

HHealth lthCCare Reform Rf 

•“With “ respect to infants, children, and adolescents, 

evidence‐informed preventive care and screenings 

provided for in the comprehensive guidelines supported 

by the Health Resources and Services Administration 

(HRSA).” (HRSA). 

•Recognizes that Bright Future Health Supervision Visits 

are the guidelines g referred to as “Recommended 

Guidelines”

Developing the Guidelines 

• Structure 

– Part I—Themes 

– Includes 10 chapters highlighting key health promotion 

themes 

– Emphasizes “significant challenges”—mental health 

and healthy weight 

– Part II—Visits 

– Provides detailed health supervision guidance and 

anticipatory guidance for 31 age‐specific visits 

– Lists 5 priorities for each visit 

– Includes sample questions and discussion topics for 

parent and child

Developing the Guidelines 

• Health ea t Supervision Supe s o Priorities o tes 

– Designed to focus visit on most important issues for 

age of child 

– AAnticipatory i i guidance id presented d in i several l ways 

– Include health risks, developmental issues, positive 

reinforcement

PPeriodicity i di it Schedule 

Shdl

Setting the 

agenda 

MMedical di l 

Screening 

Developmental 

p 

Surveillance

Vermont Child Health Improvement Project 

Let’s ’ think about Samantha and Tiffany 

• Samantha age 22 and Tiffany age 18 months have been 

living in the shelter for about four months 

• Lived with mom but left abruptly 

• Doesn’t Doesn t follow through with finding childcare for Tiffany 

•Has a boyfriend who lives with his mom


Worried about 

additional shots 

shots 

because 

boyfriend boyfriend’s s 

mother had a 

child with autism 

There is a family from 

Laos at the homeless 

shelter; h lt child hild had hdb been 

playing with their 

children


• Helps out at the shelter with reading‐ 

went to the h lib library to get the h bbooks k 

(Helps out) 

• WWants t to t hhave hher ddaughter ht grow up always l ffeeling li 

safe and smoke‐ free ( independent decision‐making 

• Finished her GED GED, works as a waitress waitress, never 

interacted with an agency before (Mastery) 

• Has a partner who has been with her and Samantha 

for 6 months – lives with his parents (Belonging)

Bright Futures Implementation 

• Bright Futures Guidelines, 3 d rd Edition 

– Implementation 

– MMeasurement of f Bih Bright FFutures. 

• BihtF Bright Futures t measures encompass rigorous i national ti l 

measures but also integrate the comprehensive 

recommendations necessary y to pprovide quality q yp preventive 

care.

CDC Domestic D ti Winnable Wi bl Battles Bttl 

• Obesity, Nutrition, Physical Activity, and Food Safety 

• Teen Pregnancy 

• Motor Vehicle Injuries 

• Tobacco 

• HIV 

• Healthcare Associated Infections

Bright Futures Quality Measures Crosswalk

Comparison p of Components p at Baseline 

and Follow‐up 

Perceent 

of Childrenn 

With Positivve 

Result Docuumented 

Percent of Children Age 0-5 Years In 15 Bright Futures Training 

Intervention Practices With 4 Bright Futures Outcomes Documented 

by Chart Review At Baseline and Follow-Up 

100 

80 

60 

40 

20 

0 

Preventive 

Services 

Prompting 

System 

Bright Futures Training Intervention Project 

Structured 

Developmental 

Assessment 

Special 

Healthcare Needs 

Identified 

Structured 

Assessment of 

Parent Strengths 

and Needs 

Baseline* Baseline 

Follow-Up**

Results from 2009 office intervention( ( 

VCHIP 2011) 

YHII Pre vs. Post Office Based Education Changes 

by Training Topic 

Percent Change in Rates of Composite 

Measures of Risks and Strengths

Quality Q yImprovement p in Practice Preventive 

Services to Improve Patient Outcomes 

Use existing mechanisms: 

– Maintenance of certification 

• AAP chapter p activities 

• AAP Education in Quality Improvement in Pediatric 

Practice (EQIPP) 

• Improvement Partnerships 

– Link with National Committee for Quality Assurance (NCQA) 

medical home scoring and reimbursement 

– Accreditation Council for Graduate Medical Education 

(ACGME) requirements for residency program 

– Presentations at partner national meetings

NNew AApproaches h 

• National AAP Preventive Services Implementation 

Project (Jan –Oct 2011) 

– Pediatricians, , family y pphysicians, y , nurse practitioners p , 

physician assistants, 

in 

– Rural, urban and suburban practices and clinics as 

well as community health centers and the Indian 

Health service 

• Partner with Health Plan and Medicaid QI activities (e.g. 

CHIPRA)

RRevision i i PProcess 

• Bright Future Guidelines, 3 d rd Edition, Revision 

– Evidence in USPSTF, CDC Community Guide and 

CCochrane h 

– Expert Opinion/Clinical Guidelines that change 

Uni Universal ersal or Selective Selecti e Screening 

– Implementation Projects Lessons Learned 

– RReview i bby EExpert PPanel lCh Chairs i and d AAP Eid Evidence 

Experts

Rf References 

Hagan JF, Shaw JS, Duncan PM, eds. 2008. 2008. Bright Futures: 

Guidelines for Health Supervision of Infants, Children and 

Adolescents, Third Edition. Elk Grove Village, IL: American 

Academy of Pediatrics 

Lannon CM, Flower K, Duncan P, Moore KS, Stuart J, Bassewitz J. 

Th The BihtF Bright Futures t TTraining i i IIntervention t ti PProject: j t iimplementing l ti 

systems to support preventive and developmental services in 

practice. Pediatrics. 2008;122 e163‐e171 

http://www.cdc.gov/about/winnablebattles.htm

Buzz Activity 

• What is your charge as you understand it in linking 

public health and primary care? 

• What prepares p p yyou 

to do this? 

• What has been working well in achieving this 

linkage? g 

• How do we replicate these successful strategies?

OOutreach t htto Pi Primary CCare – Si Simple l St Steps 

• PPartnerships t hi 

• Lunches 

• Joint offerings 

• Scholarships 

• Collaboratives 

• Share data 

• Share family feedback 

• Link coordinators

Outreach to Primary Care 

• Various Levels of Quality Improvement, based on 

experience i 

• Level 1 

• Level 2 

• Level 3 

• Use Quality Improvement Strategies 

• Build on the public health model (data‐action–data) 

• Adopt or establish guidelines, (eg Bright Futures for 

EPSDT ) 

• Consider partnership with AAP or AAFP chapters and 

medical schools


• Use Medical Home Payment Reform Incentives 

– In some states payment reform has been linked to 

recognition under the NCQA PCMH standards. 

– Other states are using unique scoring systems. 

– Some are not pursuing payment reform at this time.


• For Pediatricians, the use of new 2010 Maintenance 

of Certification (MOC) requirements is an incentive 

– Consider partnership with AAP chapter and medical school 

to develop and submit an MOC application to the 

American Board of Pediatrics 

– Topics: medical home home, preventive services services, obesity obesity, 

developmental screening, asthma, etc. 

– Need 40 points


• Choice 

• True partnership with respect 

• Willingness to try something new (co‐location) 

• Easy as possible 

• Find a champion/partner 

p /p 

• Look for flexibility in practice/clinic structure 

• Celebrate small steps


• Accelerate the Process 

– Consider AAP and AAFP chapter grants on shared 

outcomes 

– Form an Improvement Partnership (Paula)

Improvement Partnership 

…a durable, regional collaboration of public and private 

…a durable, regional collaboration of public and private 

partners that uses measurement‐based efforts and a 

systems approach to improve the quality of children’s 

health care.

Why are States Developing Improvement 

Partnerships? 

• Investments in improving the health care of children 

• Recognition and embracing the local expertise – “all 

improvement p is local” 

• Innovation and success in the State is often not 

connected nor broadly y disseminated, limiting g the 

impact on child health outcomes

VERMONT CHILD HEALTH IMPROVEMENT PROGRAM 

. 

The OKlahoma Key 

to Improving 

Developmental- 

Behavioral Services

What Do Improvement Partnerships Do? 

• Develop p and test tools, , measures and strategies g 

• Serve as a resource for improvement assistance 

• Translate knowledge g through g engagement gg of 

national and local experts 

• Disseminate findings, spreading successful 

approaches h and d iinforming f i policy li 

• Serve as convener, “honest broker”

AZ 

NM 

VT 

UT 

WV 

• Convener for the States 

• Sharing, problem solving and 

connecting states/regions 

• Repository for tools, materials, 

speakers 

RI 

WA 

NY 

OR 

CT 

MI • Tech assistance/Mentor 

‐ developing an IP 

OK 

MN 

• Advisory to federal government 

and other national initiatives 

• Scholarship ‐ publishing results 

• Shaping funding opportunities 

DC 

OH

Six Core Outcomes (Charge to All of US) 

• Children will be screened early and continuously for 

special health care need 

• Families of CSHCN will participate in decision making at 

all levels and will be satisfied with the services they 

receive 

• CSHCN will receive regular ongoing comprehensive care 

within a medical home. 

• Families of CSHCN will have adequate public and/or 

private insurance to pay for the services they need. 

• Community‐based service systems will be organized so 

families can use them easily 

• Youth with special health care needs (YSHCN) will receive 

the services necessary to make transitions to all aspects 

of adult life life.

Break 10" 

Discussion Groups: 

Family Engagement 

Care Coordination


• Title V /state level 

– Support practice /clinic level data collection and 

improvement activties 

– Provide tools. Analyze data 

– Materials and strategies for improvement 

– Parent advisory committee or members on all 

committees 

– Employ parents as team professionals 

– Support parent to parent groups


• At the medical home level 

– Share materials that involve parents in the visit 

• previsit questionnaires 

• Previsit developmental screening tools 

• Handouts 

– Consider shared documentation forms 

– Survey data from parents (PHDS) 

– Parents/youth practice advisory committee 

– Employ parents as navigators and parent advisors

Medical Home Index Family y 

Involvement –Care Coordination 

• Asked what care supports parents need and shared 

decisions 

• Given option of centralizing care coordination 

• Involved with care coordinator

Family Feedback Organizational Capacity 

• Elicited individually and shared with others 

• SSurveys, ffocus groups, iinterviews i 

• Tan ible s pports in pla e for parents to parti ipate 

• Tangible supports in place for parents to participate 

in practice needs assessment and solutions

Family Engagement – Discussion 

• How do you involve families and MCH at the state 

and local level? 

• How do you encourage medical homes to involve 

families?

Care Coordination 

• Public health and the medical home 

– Care Coordination

The Primary Care Medical Home 

At the Crossroads Integrating: 

• Vertically –among health care systems/specialists/PCPs/families 

• HHorizontally i ll – among ffamilies/community ili / i agencies/schools i / h l etc … 

• Longitudinally –over time 

• Continuously – continuity of provider and team 

Community Co u ty 

Resources/Policies 

Health 

System 

Medical 


Continuously… i l 

Longitudinally…. 

Opportunities and need for care coordination functions/care coordinators.

CMWF Framework Framework—AA Definition 

• Care coordination is a patient p and 

family‐centered, assessment driven, 

team‐based activity … 

– …designed d i dto meet the h needs d of f children, hild youth h and d adults d l 

while enhancing the care giving capabilities of families. 

– …care coordination addresses interrelated medical, social, 

developmental, behavioral, educational and financial needs 

in order to achieve optimal health and wellness outcomes 

Antonelli, McAllister, Popp, 2009

Components of CC 

• Patient & Family‐centered y 

• Community‐based 

• Proactive, Providing Planned, Comprehensive Care 

• Promotes the Development of Self‐Management 

Skills (Care Partnership Support) with Children, 

Youth, Adults and Families 

• Facilitates cross‐organizational linkages and 

relationships 

Antonelli Antonelli, McAllister, McAllister Popp, Popp 2009

Delivery of Patient & Family‐Centered Care Coordination Services

CC Functions 

• Provides separate CC visits 

• CCompletes/analyzes l / l assessments 

• Manages continuous communications 

• Develops care plans with patients/families 

• Manages/tracks tests, referrals, and outcomes 

• Coaches patients/families 

p / 

• Integrates/consolidates critical care information 

• Supports/facilitates care transitions (pedi, adult, 

nursing i hhome, hospital, h it l etc.) t ) 

• Facilitates (participates in) team meetings 

• Uses health information technology (IT)

Our Medical Home Until 

1:30 p.m. 2/15/01 

Support 

Family & 

Friends 

FAMILY 

MEDICALHOME 

PRIMARY DOCTOR 

CARE COORDINATOR* 

DAYCARE

And Then… Then Along Came The 

Amazing Miss Kate 

Congenital 

Hydrocephalus 

Multiple revisions, 

infections, 

complications 

Cerebral Palsy, 

Epilepsy l 

Downright remarkable

Our Medical Home 

Post Diagnosis 

1:35 pm 2/15/01 

SUPPORTS 

Family, 

Friends, 

Respite 

Advocacy 

HOME CARE 

SPECIALISTS 

Hospital 

FAMILY 

MEDICALHOME 

PRIMARY DOCTOR 

CARE COORDINATOR 

On-Going Care Team 

Social Worker 

OT/PT/SLP Therapists 

Daycare Staff & Aide 

EDUCATION 

EI, Preschool 

School School, Work 

AGENCIES 

CSHCN 

Clinics 

Equipment 

FUNDING

Care Coordination ‐ Discussion 

• What is your public health charge related to care 

coordination? 

• How do you y provide p care coordination 

services/resources to primary care? 

• What strategies/tools work well to integrate current 

g g 

care coordination efforts?

Right about now?

Strengths – National, Local 

• Medical Home fervor f 

– Care Coordination Integral to Medical Home 

• Pockets of Organization and Effort 

– E.g. 28 Care Coordinators in this DHMC effort! 

– 40+ PPOC in Boston 

• CMHI began in 1997 with few (4) practices 

• You bring (or how can you bring your): 

– Skills, personal and professional experience, continuous learning 

interest, , adaptable/flexible p / approach, pp , enthusiasm, , ability y to pull p ppeople p 

together and be peacekeepers, ability to make the information flow 

(communication, communication…), collaborative nature, advocacy, 

willingness to teach others, out of box thinking and more!

What Are Your Best Strategies to Partner 

With Primary Care Medical Homes – 

Individual or Group p Of? 

• BEST IDEAS? 

– Link coordinators 

– Lunch and learn 

– Resource contact people 

– Facilitate a team wrap around meeting 

• Help with care plans, insurance other…. 

• Worries? 

• What supports you? 

• Who can you partner with?

Some Tools for Delivery 

• www.medicalhomeimprovement.org 

p g 

• www.Gottransition.org 

• Framework Link (www.commonwealthfund.org) 

• www.medicalhomeinfo.org and www.pediatricmedhome.org 

– Care Coordination Assessment (adult/pedi) 

– Complexity/Acuity 

– Planned Care: 

• Care Plans/Care Plan Oversight (have) 

• PreVisit Contact 

• Community resources (starter sheet adult/pedi)

The Future is Bright for Medical Home: Prevention and ... - HRSA

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