Pennsylvania Medical Home

InitiativeEducating Practices In Community Integrated Care

Renee Turchi, MD, MPH – Medical Director EPIC ICMolly Gatto – Associate Program Director EPIC IC

Penn State Transition ConferenceJuly 25, 2008

EPIC IC MISSION

EPIC IC’s mission is to enhance the quality of life for CSHCN through recognition and support of families as the central caregiver for their children, effective community-based coordination, enhanced communication and improved primary health care.

EPIC IC practices: Participate in monthly quality improvement teleconferences Attend bi-yearly quality improvement conferences that

provide networking opportunities Are provided education on

identification of CYSHCN (Children and Youth with Special Health Care Needs)

Parent Partner recruitment utilization of Parent Partners coding strategies time management “hot topics” like transition to adult healthcare, cultural

competency, etc.

How do practices participate?

EPIC IC Medical Home Sites

Medical Home Adopter (currently active in EPIC IC)

Medical Home Adopter (Achieved implementation)

Medical Home Adopter (First year of implementation)

Medical Home Trainee (Received Training)

In recruitment

Satellite office

Summary of EPIC IC Participation

Over 62 practices have been trained in medical home principles

Over 29 practices have received funding for care coordination activities

Practices represent 6 regions and 30 counties in Pennsylvania

Practices represent urban, suburban, and rural communities

Transition Efforts

Host two conferences focused on transition at the practice level- Healthy and Ready to Work- Dr. Patience White- Waiver programs- Wills and Trusts- Parent/patient panels

Medical Home and Transition

Practice Transition Survey

Survey administered to practices in 2005 and again in 2008 to measure growth in practice based transition efforts

Patient registry utilized to inform practices of their population over age 18

Family Medical Home Survey - tracks families with child approaching transition age- tracks areas of need and successes

Challenges

Finding adult health providers Getting support from both the parent as

well as the provider to transition the youth

Time to develop a transition care plan Linking youth to resources in the

community

Practice Models

Pediatric Alliance – Pittsburgh, PA

Center for Children with Special Health Care Needs – Philadelphia, PA

Reading Pediatrics – Reading, PA

Transition Activities for CYSHCN at Pediatric

Alliance

Elizabeth M. Wertz Evans, RN, MPM, FACMPE

Chief Executive OfficerPediatric Alliance, PC, Pittsburgh, PA

Office: 412/278-5100 x121E-mail: evanse@pediatricalliance.comWeb site: www.pediatricalliance.com

Presented by:Presented by:

Several Transition Initiatives:Information at Office VisitMeetings with CYSHCN and Families

Meetings with Adult Physicians

List Serve

Update Info at Check-inUpdate Info at Check-in

During Well Visit . . .

List Serve Info at Check-OutList Serve Info at Check-Out

Partners We identified our partners . . .

Partners:CYSHCN and Their FamiliesPediatriciansInternal Medicine PhysiciansFamily Practice PhysiciansClinical StaffAdministrative Staff

Office Managers Meetings

Celebrate Success!!Celebrate Success!!

Data Sharing:NextGen EMRPatient Provider PortalOther PhysiciansFamilies

SUMMARYSUMMARY

Any Questions or Further Discussion?

The Center for Children with Special Health Care Needs

Transition ConferenceJuly, 25, 2008

What is our mission?

To work together with families of children and youth with special health care needs to provide ongoing,

comprehensive, family-centered medical care and to improve access to services, community resources and advocacy to assure that children obtain optimal support through life stages as well as promote their independence

with dignity and respect.

The Center for Children with Special Health Care Needs

Located at St. Christopher’s Hospital for Children

Inception: 2003 Total Patients: 575 CYSHCN

and 265 Siblings Staff

3 Pediatricians Nurse Care Coordinator Clinical Nurse Social Worker Office Manager Patient Service Rep

The Center for Children with Special Health Care Needs

Transition Checklist and Evaluation Social

Plan for the future Educational

School, Work, Adult Day Program Financial

Insurance, Waivers Medical

Supplies, Nursing Services, Equipment, Medications Legal

Living Will, Legal Custody

Each player contributes: Medical, Caregiver, Patient

Philadelphia Department of Health: Community Mini-Grant

Program Funding to support:

Families’ travel and parking expenses

Supplies for families

Food for events

Stipends

Evaluation Results: Barriers to Transition

Yes NoParental protectiveness (4) Provider protectiveness (8)

Lack of adult providers familiar with CYSHCN care (4)

Insurance complications (5)

Lack of community resources (4)

Lack of communication between agencies (3)

Lack of specialists familiar with CYSHCN care (3)

Lack of vocational rehab (1)

Fear by young adult (1)

Lack of motivation by young adult (1)

Community Relationships

The Legal Clinic for the Disabled, Inc.Magee Rehabilitation Hospital

1513 Race Street,

Philadelphia, PA 19102

215-587-3461

www.legalclinicforthedisabled.org

Liberty Resources714 Market Street, Suite 100

Philadelphia, PA 19106

215-634-6630

www.libertyresources.org

Contact InformationThe Center for Children with

Special Health Care Needs3601 ‘A’ Street, Philadelphia, PA

19134

o Monica Kondrad, RN, BSN

215-427-5363o Laura Boyd, MSW

215-427-3996o Dr. Renee Turchi, MD, MPHo Dr. Francis McNesby, MDo Dr. Alisa Hoffman, MD

215-427-8363

Reading Pediatrics, Inc.

13 Doctors

1 Nurse Practitioner

~600 CYSHCN to date

4 offices

Open 365 days a year

The Transition Process

Gather information from parents of CYCHCN

Develop a relationship with potential adult practitioners

Utilize the Elks Home Service Program when appropriate

The Transition Process

Gather information from parents of CYCHCN

Develop a relationship with potential adult practitioners

Utilize the Elks Home Service Program when appropriate

TRANSITIONING of CYSHCN

Began as informal process

Identify patients of transition age

Develop a letter

Designate a ‘point’ person

Follow-up contact after letter sent

DOB Diagnosis Status

6/12/1973MICROCEPHALY / MR / SCOLIOSIS / CONG

DISLOCATED HIP Active

5/22/1975 NOONAN'S SYNDROME Inactive-Transitioned 1-16-08

7/21/1980 CEREBRAL PALSY / MR / CONG HYDROCEPHALUS Inactive transitioned 1-3-08

6/14/1981 CEREBRAL PALSY / SPASTIC QUAD / SEIZURES Transitioned 6-07

9/13/1981 LENNOX-GASTAUT SYND / SEIZURES / CP / MR Inactive transitioned 2-08

7/25/1984 CEREBRAL PALSY Inactive transitioned 2-08

5/2/1985 PDD / SEIZURES Inactive Transitioned 12-5-07

5/26/1985 MR / SEIZURES / XYY SYNDROME Inactive-Tx 9-05

6/27/1985 CYSTIC FIBROSIS Active

11/22/1985ADHD / ASTHMA / GERD / HYPOTHYROIDI / MULTIPLE PSYCH ISSUES / NARCOLEPSY Inactive transitioned 1-3-08

12/31/1985SPASTIC QUAD / STATIC ENCEPHALOPATHY /

SEIZURES Inactive-transitioned 1-16-08

3/7/1986 SPINA BIFIDA / WHEEL CHAIR BOUND Inactive-Tx 3-06

4/17/1986 DERMATOMYOSITIS / GERD Transitioned 6-07

7/17/1986 MYOTONIC DYSTROPHY / PANCREATIC DIS Inactive-Tx 9-05

8/6/1986 SEIZURES Inactive Transitioned 1-7-08

8/23/1986 CEREBRAL PALSY / ,SPASTIC QUAD Active

8/30/1986 MR/FACIAL NERVE PALSY/CARDIAC TRANS Inactive-Tx 12-05

9/16/1986 CEREBRAL PALSY Active

10/23/1986 SEIZURES / CEREBRAL PALSY / BLIND Inactive Transitioned 11-07

11/7/1986 CYSTIC FIBROSIS Active

11/17/1986 STATIC ENCEPHALOPATHY /SEIZURES Inactive transitioned 3-08

12/17/1986HEMOPHILIA A / AVASCULAR NECROSIS OF

RIGHT HIP Active

SAMPLE LETTER

Dear Parent:

It has been a privilege to be the primary care pediatrician for your child. All of the physicians and staff members at Reading Pediatrics take great pride in your child’s care. We have established a special relationship with you and your child.

At this time we are starting the ‘transition’ phase of your child’s care to an adult physician. The physicians at Reading Pediatrics feel it is in your child’s best interest to be followed by an adult physician rather that a pediatrician.

Reading Medical Group, which has offices around the county, will assist you in finding an appropriate physician. Simply call 610-988-8411 to begin the process.

We ask that you start to look at your options for this transition. Our timeline for this is within the next few months.

Please discuss this with your physician at your next visit. Our office will provide adequate information to your new physician.

If I can be of any assistance, please contact me.

Sincerely,

JoAnn B. Steinmetz

Practice Administrator

Selection of ‘POINT’ Person

Has frequent contact with the families

Understands the transition process

Personable and approachable

Good relationships with adult practitioners

Willingness to assist families during the process

Goals for the Future

Begin talking about transition @ age 14

Provide families with a ‘Transition Packet’

Continue developing relationships with other adult providers

Obtain feedback from families who have already transitioned

Work toward a more formal process

The most powerful waves begin as a single drop…..