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Jennifer Lail, M.D., FAAP Florida Pediatric Medical Home Demonstration Project (C4K) Learning Session 2 April 27-28, 2012 Communication Between Primary Care Pediatricians and Specialists Clarifying Expectations and Knowing When to Refer

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Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

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Objectives: Discuss how Patient-Centered Medical Home model promotes communication and facilitates medical transitionsespecially for children with Special Health Care Needs Discuss practical examples of communication strategies between primary and specialty care Discuss the role of the patient/family in co-managed, collaborative care Consider improvements for your clinical setting

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Floridas CSHCN, 2009-10 606,215-- ages 2-17 CSHCN prevalence =15% (nat. avg. 15.1%) CSHCN Prevalence by Age Age 0-5 years =9.3% (9.3%) Age 6-11 years=16.9% (17.7%) Age 12-17 years= 18.8% (18.4%) CSHCN Prevalence by Sex Female =13.5% (12.7%) Male=16.3% (17.4%) Data Resource Center for Child and Adolescent Health http://www.childhealthdata.org/browse/snapshots/cshcn-profiles?rpt=9&geo=9

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CYSHCN: 1 in 5 families has one --CAMHI Screener Condition lasting >1 yr. (physical,devel.behav.,emotional) AND Needs more health care than other same-age kids Medicine prescribed by a doctor Limitation of function Special therapy Counseling - McPherson, Arango, Fox: Pediatrics 1998; 102. - The Child and Adolescent Health Measurement Initiative, 2009-10, NS-CSHCN, www.childhealthdata.org www.childhealthdata.org

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CYSHCN represent the whole health system in MH demands Family and patient see whole picture- expect seamless care. High severity; 30% in registry have >2 specialty providers Exacerbation may require ED use, admission Barriers to access (physical, financial, MD availability) Require primary-specialty access and collaboration Issues with compliance, consent Patient and Physician education is a key to outcome

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A Medical Home Model Supports Collaboration, Communication and Co-management MH knows who needs the most care Family is equal partner in the care process Specialist records are accessible (letter, fax-back, electronic) Referrals are tracked, start-to-finish Specialty followup done in MH (weight checks, labs, hospital followup) MH can synthesize thoughts from multiple specialists Family has help for referrals, services, equipment

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Where it all Blows up. When we dont COMMUNICATE Care Coordinator identifies for Pre-visit contact CC calls parent, notes concerns, and interim encounters CC gathers specialty reports, assures enough time Lab and XR slips created, EMLA cream PVC, spec. data to MD for Preview MD previews chart, requests more info or time MD/nurse visit, referrals made, resources found CC helps parent with referrals, resources Parent calls for physical appt. for CSHCN Special

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Medical Home involves Changing Systems Build Electronic Health Records Use the Medical Neighborhood Use Evidence-Based Care for populations Organize Care with Teamwork Increase Safety, decrease duplication Link between institutions and people Fund preventive & non-procedural care

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Essential Processes in a Medical Home System ( and Neighborhood) Relationships Ready Access Registry and Care Coordination Records Resources Reimbursement Recruitment

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Relationships are established Med. Center Specialists Community Specialists School Nurses Title V, State supports PT, OT, Dental, Speech/Communication Support Organizations Home Health, Durable Equipment AND MORE!

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Ready Access to Specialty Care Care Coordinators! Access to Med Center EMR Directories of Specialists Back-lines of Specialists, schedulers Access for URGENT needs (line-cutting) Phone consult for advice, stabilization Knowledge to do preliminary workup

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Registry -- Knowing Who Needs Co-management Multiple Diagnoses Technological dependence Family/Social complications Language/Literacy barriers Multiple ED visits/ admissions

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RegistryCommunicating with Specialty Care Do Pre-visit Contacts for Specialist reports File complexity scores Help with referrals-is the Specialist on-plan? Specialist gets needed clinical data and clear goals for the consult Track referrals to completion Assure we get consult report

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Yikes! Complex child, 10 minute appt.! Paper: MD completes Form with CS Form to Care Coordinator (CC) CC enters into Registry CC marks as Special in Admin EMR: Patient Message to Care Coord MD completes Autotext Form w/ CS CC enters into Registry CC marks as Special in Admin/EMR Schedule a Chronic Care Management visit with a PVC prior Build your Registry in the exam room

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Care Coordination --the Left Ventricle of the Medical Home Care Coordinators maintain registry, know dxes Separate from Advice Nurses Direct Phone Extension Brochures and Business Cards CCs know who is on plan, and wait-times Our CCs know the Specialists CCs!!

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Records: How Medicine Communicates BIG ISSUES: HIPAA Adolescent Confidentiality Docs dont know each other Non-interoperability of EMRs WE THINK WE COMMUNICATE: 69% of PCPs sent hx and reason for consult; 35% of Spec. received it 81% of Spec. sent results to PCP; 62% received it.* * OMalley and Reschovsky, Arch.Int.Med, 2011 * OMalley and Reschovsky, Arch.Int.Med, 2011

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Specialists as Resources Peds. Specialty data base Fax numbers Schedulers Wait lists Emails for urgent visits Find good collaboratorsrefer to them! Use comanagement agreements Use referral letters/faxes/emails

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CSHCN Directory of Resources 2010 ADD/ADHD Adoption Allergy/Asthma Alternative Medicine Augm. Comm/AssistiveTechnology Autism Bedwetting Bereavement/Grief Blind/Visual Impairment Breast Feeding Support/Supplies/Home Care Camps Carseats for CSHCN Cerebral Palsy Childcare Resources Chiropractors Cleft/Craniofacial Compounding Pharmacies Deaf/Hearing Impairment Dentistry (see also Oral Surg.) Dermatology Developmental Eval./Therapy Developmental Peds /Peds Rehab Eating Disorders Endocrinology/Diabetes ENT Financial Planning Gastroenterology Genetic Testing/Counseling Group Homes G-Tube and Trach Care Gynecology Handicapped Parking Permits Health Departments Home Health Care/Equipment Inclusion (see Transitions) Intervention (Early) Language Barrier/Resources Legal Massage Therapy Multiple Births Music Therapy Newborn Care Neurology Nutrition/Dieticians/Fitness Obesity Opthalmology Oral Surgery Orthopedics/Orthotics OT/Feeding Parent Education Parent-to-Parent Connections Physical Therapy/Sports Injury Podiatry Prenatal/Postnatal Counselling Psychology Radiology Rare Disorders Recreation for CSHCN Respite/Residential Care Safety and Hotlines School Systems Smoking Cessation Social Services/Abuse/Domestic Violence State of NC programs for CSHCN Speech Substance Abuse Surgery Transitions/Inclusion Travel Nurse Tutoring Urology Vocational Rehab -Index from CHPA Internal Directory of Resources, 2010, Chapel Hill, NC

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Whos in CHARGE? Primary Care, Specialists, Family? WHO: Vaccinates? Monitors safety, growth, dental care, school performance, friendships, bullying? Prevents pregnancy, watches for STIs? Prepares for transition to adult care? Self-management skills? Guardianship, Competency? Financial/Insurance coverage?

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Ideal Model of Comanagement Perfect model depends on: Stated needs and preferences of pt./family Clinical situation involved Disease process timeline Professional judgement of MDs involved Geography and Specialist availability

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The Needs and the Leads change over time Youth education around conditions, meds, risks Help with: SSI, Disab. Determ., Voc. Rehab, Insurance, Handicapped Parking, Guardianship Options of Adult Providers Medical Summary Build Youth and Parent confidence

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Red flags: when is co-management needed urgently? Kids whose care seems to belong to no one Kids with: Multiple ED visits for specialty problems Multiple preventable admissions Multiple bounce-backs Kids who only come to primary care for urgent visits and dont receive primary care at a specialist Kids who miss multiple specialty appointments

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Medical Home involves Changing Attitudes Focus on the Patient/Family Improved access/availability Empanelment- my doctor, my nurse Whole person care vs. 1 problem-10 min. QI embedded in your system More thinking, fewer tests

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Reimbursement-a new frontier IHIS TRIPLE AIM: Population Health Patient Experience Per Capita Cost FFS, face-to-face care >>> Bundled Episodes of Care Value = Health Outcomes achieved per dollars spent* Cost and Savings Attribution-who spent it--- who saved it? *What Is Value in Health Care? Michael E. Porter, Ph.D., N Engl J Med 2010; 363:2477-2481 December 23, 2010December 23, 2010

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Recruitment: Ways to Work Together The Patient-Centered Medical Home NeighborThe Interface of the PCMH with Specialty/Subspecialty Practices Preconsultation exchange: curbside Formal consultation: PCP as primary manager, Specialist as consultant (ex., PET placement) Co-management: PCP comanages with Specialist For Shared Management of the disease (ex., Type 1 DM) With Principal care for the disease (ex., Leukemia) With Principal care of the patient for a consuming illness, limited time period (ex., Prematurity) Transfer of care --American College of Physicians, 2010

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J.L., 4 year old girl with MR of ? etiology, severe sz disorder, osteopenia, GTube, recent adm. for spont. hip fx and post-op pneumonia... (Neuro, Ortho, Endocrine, Surgery are consults) Calls for appt. for fever and cough... Extra time is scheduled for J.L. Front desk knows shes in wheelchair and watches for her arrival with her 2 sibs Discharge summary is on chart for your review You ask CC to get most recent XR results and labs from on-line connection with Med Center EMR Your clinical dx: pneumonia rx: antibiotics and fup 1 day Mom reports she has bisphosphonate infusion in 2 weeks at hospital; consultants #s are in your pocket. Phone call to Pulm. CC arranges consult on infusion day to eval. and consider vibratory vest. CC tracks referrals and sends you reminder of visit Pulm. sends on-line report about consult ED visit, admission are avoided; fup care is synchonized for patient, and Pulmonary advice/care prevents further pneumonias

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A Medical Neighborhood Needs: EMR interoperability Planned careassimilate multi-source info Care coordination agreements Continuing Ed. for Primary Care Care coordinators across systems Assured, HIPAA secure, 2-way communication Financial and Legal support for collaboration, communication, non-face-to-face care Support for PCMH as provider of Whole Person Primary Care

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How Primary Care Can Help Use Evidence-Based Care Guidelines Expand office hours for better continuity, less ED use Use a registry of CSHCN Develop Care Coordination for pt. and referral support Do prelim. workup; COMMUNICATE essential info pre-consult Offer followup help (weights, labs, injections) Do ED and hospital followups

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How Specialists Can Help Alerts of ED visits, adm., status change Education, metrics for evidence-based care COMMUNICATE directives for f/up Note Lab & imaging needs Notification of referrals for secondary dxes Followup at MH for self- referrals Lunch and Learn & Hand-holding

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A Medical Home Improves Chronic Condition Care family satisfaction inpatient stays ED utilization pharmacy spending Better coordination of primary and specialty care Avoid duplication of services, tests Opportunity to address comorbid conditions

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Culture of Collaborative Care as the Norm Chapel Hill Peds patients EXPECT that we will be in communication with each other and have a sense of comfort that we arebehind the scenessomehow connected and working together in their best interest. --Dr. Sarah Armstrong, Director, Healthy Lifestyles Program, Duke University Health System I think that the Medical Home gives us comfort as specialists that the patients whole realm will be cared for in a meaningful mannera trach or a syndrome doesnt keep them from being part of a larger community. --Dr. Amelia Drake, Chief, Pediatric Otolaryngology, UNC Hospitals

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My family, with all its challenges, is a success story, but part of that success is because we have had a Medical Home Libby

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Keep up the Great Work!! Recruit your staff, families Report your small victories Inform insurers of your efforts Expect late-adopters Use MH resources from AAP Dont reinvent the wheel- steal shamelessly

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Websites: www.medicalhomeinfo.org (AAP MH site, PVC form) www.medicalhomeinfo.org www.medicalhomeimprovement.org (MH index) www.medicalhomeimprovement.org http://www.acponline.org/advocacy/where_we_stand/poli cy/pcmh_neighbors.pdf (ACP position paper) http://www.acponline.org/advocacy/where_we_stand/poli cy/pcmh_neighbors.pdf Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms www.ahrq.gov (AHRQ white paper on MH)www.ahrq.gov http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__ home/1483 (AHRQ PCMH site) http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__ home/1483