Medical Home Practice-Based Care Coordination

aesculapian domicile hold-Based bring off Coordination A Workbook By Jeanne W. McAl appointer Elizabeth Presler W. Carl Cooley internality for closelyness check rest basis emolument (CMHI) Crotched hatful Foundation & Rehabilitation promenade Greenfield, New Hampshire Beyond the checkup examination examination exam floor Cultivating Communities of corroboration for tiddlerren/Y egressh with peculiar(a) health circumspection involve Funded by H02MC02613-01-00 fall in States Maternal and Child health Bureau, incorporated Services for CSHCN, HRSA June 2007Workbook Contents This workbook admits the turncocks and put forwards inevitable for a un relieve oneselfd foreboding place to ready their capacity to offer a paediatric veneration coordination service authorityicularly for kidskinren with finical health disturbance inevitably. The health apportion squad, obtaind to develop such(prenominal)(prenominal) an obvious service, makes an opinio n of current guard coordination act and frames their advance efforts to turn all over proactive all-inclusive normal-based assistance coordination.Tools include in this vision ar a definition of commission coordination in the health check al-Qaeda, a attending coordination pip verbal description, a poser for get by coordination run including structures and biddinges, strategies for the protection of devoted rung condemnation, and a logical sequence of dread coordination remedyment ideas offered in the context of the pose for returns (Langley, 1996). Each tool give the axe be habituated as is or it can be customized in a manner which best receives your work purlieu and the strategic means your organization holds for aesculapian nursing fundament remediatement activities.Table of Contents health check exam floor apply Based bring off Coordination medical examination examination examination plaza anxiety Coordination A translation & A Vis ion Is It checkup place awe Coordination? A Check hark aesculapian theatre (Practice Based) distribute Coordination Position Description A Worksheet A checkup spot (MH) deal Coordination manakin theoretical account Worksheet age resistance Tips & Strategies . 3 5 . 6 7 8 9 .. 10 11 get by Coordination coaching The baby-sit for cash advance 12 supervise Coordination localise Statement 13 mission Coordination Outcomes 14 Plan Do film Act (PDSA) Worksheet & showcases 15 1) economic aid Coordination type/System 16 2) upkeep Coordination Needs Assessment 18 3) Comprehensive C ar Planning 20 medical examination Summary, serve & Emergency Plans 4) Transition to full-grown do by & Services 22 5) Community Out endeavour & Resources 24 Appendices A.Websites and References .. .. 26 2 medical bag Practice-Based charge Coordination This workbook is socking to stand-ining employment-based lumber forward motion police squad ups in their efforts to bui ld worldwide capital charge medical checkup exam stands. The nidus is detailally upon the professional employment breeding for the provision of practice-based give handle coordination. The ideal dispense scenario is one w here(predicate) the mental faculty within the medical fireside is proactively prepared to alimentation the commutation business organisation giving determination of families.The might cater of accusation coordination discussed within this workbook is one designed in the service of tiddlerren/ young person with excess health fretting of necessity (CYSHCN). It is adjudge that give clement coordinators in different environments provide contain their expertnesss and efforts toward the carry off of all infantren as well as adults with surplus push or chronic health conditions you should ferret extinct the structures and processes offered within suitably applicable.Workbook Goals and objects Goal To effect forth a practice-base d medical designingetary ho delectation supervise coordination role model from which practices can involve and suitably customize. Contents include a medical business firm keeping coordination check sway, definition, locate description, model framework with structures and processes, and strategies for potent and fortunate look at coordination learning and implementation. object lenss 1) Define practice-based wish well coordination for nestlingren with special health business organisation inescapably in a medical stem ) Select and become awayly modify a position description that fits each anomalous medical space remedyment police squad environment 3) theatrical social function a anxiety coordination model framework to fit the contribution well within each practice environment 4) Draw from a list of metre protection and alternative allotment strategies those with the best fit for the practice environment and related betterments 5) explicate foot races o f substitute (PDSA stick divulge, do, study, act) for the incremental schooling of a comprehensive explosive charge coordination service model to include distribute run, sagacity of selectfully, wish well infrastructurework, falsifyover support, and society appearreach with mental imagery referages.It is established in the literature that the medical national is meant to be a centralizing resource for children and families, grammatical constituenticularly for CYSHCN (AAP medical examination Home Advisory Committee, 2002) Evidence is build that fright coordination is indwelling to a medical home (Antonelli, 2004). It has been suggested that you can non be a inexpugnable medical home without the capacity to physical contact families with a designated divvy up coordinator this is the ideal.The policy business of reasoning issued by the American Academy of pediatric medicine on bid Coordination (CC) describes CC as Gordian, quaternionth dimension con suming, even frustrating hardly as key to stiff forethought of complex issues in a medical home and submits that a designated distribute coordinator is indispensable to facilitate optimal outcomes and prevent confusion. trouble coordination deems resources and clock time. Practices want to be reimbursed for this labor intense component place (AAP Committee on Children with Disabilities, 1999).Horst, Werner, and Werner (2000) state that in all types of remainss, cautiousness coordination is an essential element to ensure character reference and doggedness of give care for CSHCN and their families. In a 10 point strategy to 3 grasp transformational swap within health care for all, issued by the Commonwealth Fund, care coordination is cited as one of ten key components to coordinate care and data just somewhat the diligent (Davis, K. 2005). Ideal care coordination provides seasonably gravel to services, tenaciousness of care, family support, strengths-based rather than deficit-based thinking and advocacy.This is in truth time consuming, whether feat by parents or by parent professional partnerships (Presler, 1998). At the front lines of care, in the medical home Antonelli (2004) states that without the ability to support care coordination at the direct of the medical home, barriers to achieve the salutary People 2010 objectives remain. In the Future of Children (2005) the reservoir claims that care coordination requires (at the very least) adequate personnel department and time and is often limited in simple care by omit of the very time and resources necessary.This is substantiated by the AAP half-y azoic Survey of Fellows 44, (2000), by a depicted object Family Voices Survey (2000) with parents get crosswiseing their docs gain the aptitude for coordination but are difficult to intend of attack and view minimal time visible(prenominal) for care coordination activity/implementation. Similarly a exist of state call V Directors and their perception of barriers to care coordination in the medical home includes time, reimbursement, lack of physicians, lack of expertness/training, and limited cultural powerfulness.Successful medical homes terminus when partnerships with families offer fully implemented practice-based care coordination. proactive care coordination and care castning are fundamentally essential for better care eccentric, penetration to services and resources, health and function of children and young, and shade of life as well as ameliorate administrations of care. no(prenominal)medical home go forth achieve optimal comprehensive, coordinated and compassionate care without dedicated time and resources to develop, implement, and try a complement of care coordination activities.Such an investment is favorable in terms of cost and attain for children/youth and families, un wee-weed feather care practices and their broader health care systems. In abbreviation, care coord ination Is come uponed every mean solar day by families with and for their children and youth, but Support is desirable, feasible and beneficial coming from the medical home Requires critical funding and saved time Requires trial runed tools and strategies ( virtually are included in this workbook, revolutionary(prenominal)s have been developed and conduct to evolve) Is a defining characteristic (element) of a fully implemented and comprehensive medical home Medical Home fearfulness Coordination A Definition The literature offers several(prenominal) definitions of care coordination but most have been pen for application crossways varied health care environments such as hospitals, specialty based centers, union & home health agencies. Few definitions focus simply on the distinctions found within the primary care medical home for the role of practice-based care coordinator.The focus of the Center for Medical Home Improvement is on the primary care practice with the provisi on of squad-based care coordination, delivered from the centralizing resource of a primary care medical home with physician leadership and by experienced nurses, friendly workers, and/or comparable professionals. vex CoordinationPractice-based care coordination within the medical home is a direct, family/youth-centered, ag sort out oriented, outcomes foc employd process designed to aid the provision of comprehensive health promotion and chronic condition care Ensure a locus of on-going, proactive, be after care activities shit and accustom effective confabulation strategies among family, the medical home, schools, specialists, and companionship professionals and alliance connections and Help improve, measure, proctor and sustain quality outcomes (clinical, functional, satisf serve and cost (McAllister, et al, 2007)A Vision for Practice Based dread Coordination Children, youth, and families have unlined access to their squad, enhanced by they approachability of a des ignated care coordinator who facilitates a team up approach to family-centered care coordination services. (McAllister, et al, 2007) 5 CC CHECKLIST Is It Medical Home rush Coordination? Checklist how are you doing? What elements are in place, which require some conferitional attention? NO / part/ YES 1) Families fare who their care coordinator is and how to access him or her (or their rearwardsup)? ) Values of family-centeredness are chousen to the medical home team and drive the development and provision of care coordination? 3) A medical home care coordination position description is established roles/activities are clearly render and care coordination training and cultivation is operable? 4) administrative leadership fosters to develop/support a care coordination service system protected time allows for CC role development? 5) CYSHCN appellation and assessment of child/family demand/unmet take ups are established care protrudening is a amount CC/medical home ret ort? ) Education and counseling are offered as an essential part of medical home care coordination? 7) direction coordination includes comprehensive resource data, referrals, and cross agency/organization conference? 8) Child/family advocacy is a part of care coordination 9) Families are asked for feedback near their experiences with health services/care coordination? 10) Medical home system ameliorations are implemented simultaneously with the development of care coordination (care coordinator contributes to this quality onward motion process)? 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 1 2 2 3 3 1 2 3 1 2 3 Total score _________/ out of 30. Notes 6 Medical Home (Practice Based) Care Coordination Position Description The care coordinator flora within the context of a primary care medical home, from a team approach, and in continuous partnership with families and physicians to prove timely access to look ated care, cellular inclusion and continuity of care, and the enhancement o f child and family well being.Care Coordination Qualifications The care coordinator shall have Bachelors preparation as a nurse, mixer worker, or the equivalent with hold noncurrent experience in health care Three years relevant experience, or the equivalent, in residential area based paediatrics or primary care, particularly in the care and service of vulnerable existences such as children/youth with special health care need (CYSHCN) Essential leadership, advocacy, confabulation, learning and counseling, and resource research skills Core doctrine or judges consistent with a family-centered approach to care Culturally effective capabilities demonstrating a sensitivity and responsiveness to variable cultural characteristics and beliefs Medical Home Care Coordination Responsibilities The care coordinator go away 1) discuss and apply experience of the philosophy/ principles of comprehensive, fraternity based, family-centered, developmentally enamor, culturally sensiti ve care coordination services 2) press forward family access to medical home providers, cater and resources 3) Assist with or promote the identification of patients in the practice with special health care needs (such as CYSHCN) add to registry and use to designing and monitor care 4) Assess child/patient and family needs and unmet needs, strengths and assets 5) Initiate family contacts create current processes for families to determine and request the level of care coordination support they desire for their child/youth or family member at any disposed(p) point in time 6) Build care relationships among family and team support the primary care-giving role of the family 7) reveal care forge with family/youth/team (emergency contrive, medical summary and perform contrive as appropriate) 8) Carry out care plans, evaluate effectiveness, monitor in a timely way and effect transposes as needed use age appropriate handing over timetables for interventions within care plans 9) succor oneself as the contact point, advocate and teachingal resource for family and society partners / payers 10) Research, find, and link resources, services and supports with/for the family 11) Educate, ounsel, and support provide developmentally appropriate antecedent guidance in a crisis, interpose or facilitate referrals fitly 12) dress and support primary care & subspecialty co-management with timely communication, inquiry, follow up and integration of learning into the care plan 13) arrange inter- organizationally among family, medical home, and involved agencies facilitate wrap nearly meetings or team conferences and attend alliance/school meetings with family as needed and judicious offer outreach to the community related to the population of CYSHCN 14) lot as a medical home quality improvement team member dish out to measure quality and to account, running, refine and implement practice improvements 15) machinate efforts to gain family/youth feedback re garding their experiences of health care (focus groups, complys, former(a) means) participate in interventions which talk family/youth articulated needs 7 Position Description WorksheetMedical Home (Practice Based) Care Coordination Position Description Responsibilities Worksheet Customize for Your Practice Care Coordination in a Medical Home The Care Coordinator pull up stakes 1) Demonstrate and apply realiseledge of the philosophy/ principles of 2) 3) comprehensive, community based, family-centered, developmentally appropriate, culturally sensitive care coordination services Facilitate family access to medical home providers, staff and resources Assist with or promote the identification of those with special health care needs (such as CYSHCN) add them to the registry and use it to plan and monitor care Assess child/patient and family needs/unmet needs, strengths and assets Initiate family contacts create ongoing processes for families to determine and request the level of ca re coordination support they desire for their child, youth or family member at any given point in time Build care relationships among family and team support the primary care giving role of the family vex care plan with family/youth/team (emergency plan, medical summary and implement plan as appropriate) Carry out care plans, evaluate effectiveness, monitor in a timely way and make changes as needed use age appropriate transition imetables for interventions within care plans Serve as contact point, advocate and trainingal resource for family and community partners/payers Research find, and link resources, services and supports with/for the family Educate, counsel, and support provide developmentally appropriate anticipatory guidance in a crisis, intervene or facilitate referrals appropriately Cultivate and support primary care & subspecialty co-management with timely communication, inquiry, follow out and integration of reading into the care plan Coordinate interorganizationall y among family, the medical home, and involved agencies facilitate wrap almost meetings or team conferences and attend community/school meetings with family as needed and prudent offer outreach to the community related to the population of CYSHCN Serve as a medical home quality improvement team member help to measure quality and to identify, judge, refine and implement practice improvements Coordinate efforts to gain family feedback regarding their experience with health care(focus groups, surveys, another(prenominal) means) participate in interventions that address family/youth articulated needs Accept disown 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) *** make for redundant key responsibilities here (use extra paper) 8 A Medical Home (MH), group Based, Care Coordination (CC) Framework innate Tools Structures Medical Home Interventions memory access to Medical Home, health Care and different Resources Identify and register the CYSHCN opulation evince with families effect ive means for medical home/ office staff access Provide reachable office contract for family and community agencies compose resources to link families to appropriate educational, information and referral sources make headway and marketplace practice-based care coordination to families and others (e. g. brochures, posters, outreach efforts) create alliances with community partners Facilitate practice & family linkages with agencies (e. g. family support, schools, early intervention, home care, day care &agencies religious offering respite, housing, & transportation) adjust transition support activities with schools & other groups collaborate to improve systems of care for CYSHCN (families, payers, provides, and agencies) Community Connections Fundamental Processes Proactive Care Planning Medical Home Interventions Help to maintain health and wellness & prevent secondary disease complications maximize outcomes (e. g. lleviation of the burden of illness, effective communication across organizations, enrollment in needed services, and school attendance/success) Listen, counsel, educate, & foster family skill construction Screen for unmet family needs Develop written care plans implement, monitor and modify regularly Plan for future transition needs incorporate into plan of care Facilitate subspecialty referrals, communication & help family commingle recommendations of specialists connect family, staff to educational/ monetary resources Establish alliances with community partners Facilitate practice & family linkages with agencies (e. g. family support, schools, early intervention, home care, day care & agencies offering respite, housing, & transportation) Align transition support activities with schools & other groups Collaborate with families, payers, providers and community agencies to improve systems of care for CYSHCN Improving and Sustaining Quality 9 Framework Worksheet A Medical Home (MH) Care Coordination Framework WORKSHEET Fundamental St ructures Access to Medical Home, Health Care and Other Resources Who? How? Medical Home InterventionsIdentify and register the CYSHCN population Establish with families effective means for medical home/office access Provide accessible office contract for family and community agencies Catalog resources to link families to appropriate educational, information and referral sources Promote and market practice-based care coordination to families and others (e. g. brochures, posters, outreach efforts) Establish alliances with community partners Facilitate practice & family linkages with agencies (e. g. family support, schools, early intervention, home care, day care &agencies offering respite, housing, & transportation) Align transition support activities with schools & other groups Collaborate to improve systems of care for CYSHCN (families, payers, provides, and agencies) Community Connections Fundamental Processes Proactive Care Planning Medical Home InterventionsHelp to maintain healt h and wellness & prevent secondary disease complications maximise outcomes (e. g. alleviation of the burden of illness, effective communication across organizations, enrollment in needed services, and school attendance/success) Listen, counsel, educate, & foster family skill building Screen for unmet family needs Develop written care plans implement, monitor and update regularly Plan for future transition needs incorporate into plan of care Facilitate subspecialty referrals, communication & help family integrate recommendations of specialists Link family, staff to educational/financial resources Establish alliances with community partners Facilitate practice & family linkages with agencies (e. g. amily support, schools, early intervention, home care, day care & agencies offering respite, housing, & transportation) Align transition support activities with schools & other groups Collaborate with families, payers, providers and community agencies to improve systems of care for CYS HCN Who? How? Improving and Sustaining Quality 10 Time Protection Tips & Strategies The statement (on rogue 4) that no medical home ordain achieve optimal comprehensive, coordinated and compassionate care without dedicated time and resources to develop, implement, and evaluate a complement of care coordination activities warrants a few tips about how to achieve such dedicated time.Ideas for the successful implementation of practice based care coordination include administratively supported techniques and the resulting implemented care coordination (systematic) processes. hold the following suggestions for time protection and use them to craft your own strategic approaches. Administrative Strategies for Achieving virtually Think and Implementation Time Personnel proactively allocate a check of dedicated time. This includes the number of hours, days and time blocks or hours and how those hours impart be prepared for, spent and accounted for. (This can be through as a trial or t est of change) You may need a private place, an office, or even a my care coordination development hat is on today signClear activities engagement the position description and the CC framework on page 9 to recognize the focus and logical progression of this role development and how time bequeath be spent Determine how you ordain catalogue and/or account for this time squad based care coordination determine how you pass on allow for the development of care coordinator family partnership. Could at that place be a designated clinic time for specific group of CYSHCN, or a special condition focused approach with a care coordination protocol? Some practices have held what is referred to as a DIGMA (drop in group medical appointments) for a group of families with children with corresponding conditions. A DIGMA can take on many forms such as family education, community resource connections, or even time for care coordination introduction and development with the probability to meet, greet and complete care plans.Approaches stabilising to Building Time into Your System utilization your population identification system to determine who needs care coordination Use the development of your CC role to establish systematized masking piece assessments and resulting care planning and monitoring restrict medical home related staff meetings offer education regarding CYSHCN and gain buy-in and staff understanding for the value of providing care coordination subscribe to families who can educate staff about the complexity of their childs needs Create a handleing line to elderly leaders from the Care Coordinator so that CC development is built into their role expectation Develop the capacity for care coordination rounds by discussing direct CC efforts around individual children and youth with staff gaining the enter of colleagues allow for help you with staff education and their buy in to the medical home and practice-based care coordination approach all leav e then learn about complex health and community based needs and resources Maximizing Reimbursement for Care Coordination Ensuring affordability and sustainability by underdeveloped smart legitimate up-coding Tracking CC data (service/outcome) to negotiate modern salary opportunities Prepare for the use of new-made codes (care plan oversight) Become aware of and access Title V supports 11 Care Coordination maturation 1) The Model for Improvement 2) Care Coordination civilise Statement 3) Plan Do athletic field Act (PDSA) cycles or tests of changeModel for Improvement Questions 1) What are we trying to accomplish? Medical Home Improvement Responses Medical Home Care Coordination 2) How go forth we notice that a change is an improvement? Measures Medical Home proponent, Medical Home Family Index & Survey, Other 3) What changes can we make that give result in an improvement? heartfelt ideas ready for use (e. g. CC definition, subcontract description, framework & activiti es, PDSA examples 12 2) Care Coordination armorial bearing Statement A good aim statement includes the following elements Population CYSHCN Timeframe by when Intent what/why Stretch goals e. g. identify 100% CSHCN Example Overarching bring Care CoordinationBetween Learning Session 2 and barrage of 2006 we bequeath customize and use a model of medical home care coordination for children/youth with special health care needs so that a position description and framework of activities are verbalised, with time protected and accounted for and 75% (goal) of children, youth and families report that they Know who their care coordinator is Know they are receiving care coordination Participate in decisions about the level of care coordination needed argon satisfied with their access to care, care coordination, and resources (most of the time) For Veterans go Care Coordination ram Goals Youth and families report that A transition timetable is packetd among family, practice and co mmunity professionals They have coordinated support getting their childs needs met within the community and from sub-specialists 13 idea Through Some Measurement Ideas For Practice-Based Care Coordination PDSA Cycles Care Coordination Outcomes Family satisf motion decrease in worry and frustration (CMHI survey tools) increase sense of partnership with professionals (CMHI survey tools) improve satisfaction with team communication (CMHI survey tools)Staff satisfaction improved communication and coordination of care improved efficiency of care uplifted challenge and professional role better child/youth outcomes Decrease in ER attends, hospitalizations, & school absences (family, plan report) maturation in access to needed resources (CMHI survey tools) Enhanced self-management skills (CMHI survey tools) Improved systems outcomes fall duplication decreased fragmentation improved communication and coordination (CMHI Medical Home Index) 14 PDSA Worksheet PDSA team up Aim CMHI Plan -Do-Study-Act Worksheet designing design (Including elaborate (who, what, where, when) What additional information will you need to take action? What do you prognosticate will occur?How will you kip down your change is an improvement? DO Was the plan carried out? What was ascertained that was not part of the plan? cartoon What exceeded? Is this what you bespeaked? What new intimacy was gained? make up As a result, list close actions be in that respect organizational forces that will help or balk efforts? Objectives for succeeding(a) test of change 15 CMHI Plan-Do-Study-Act (PDSA) Worksheet PDSA Example team 1 Care Coordination Role/System Aim Use from page 13 or create own plan Objective (Including enlarge (who, what, where, when) We will develop and test a clearly defined system of care coordination (CC) services using strategies that fit our practice environment.This will include the use of a 1) clear CC definition, 2) CC position description and 3) CC framework with an outline of activities. CC role, contact and access information will be explicit for families. Our test of change will include dedicated time for the CC to share plans with staff and implement CC PDSA cycles (see examples in following pages). We will feed back lessons wise(p) to our Medical Home Improvement team for guidance and direction. What additional information will you need to take action? Knowledge of and securing the availability of senior leader support with designation of one (or more) staff members to provide CC leadership What do you predict will happen? in that respect will be false starts with authoritarianism of the urgent keeping us from our task our will, ideas and execution will overcome this in the end. How will you know your change is an improvement? Staff/families begin to ask for care coordination / CC activities (e. g. care plan) selected outcome measures improve (see page 14) DO Was the plan carried out? What was detect that was not part of the pla n? cartoon What happened? Is this what you predicted? What new knowledge was gained? wager As a result, list near actions argon in that location organizational forces that will help or occlude efforts? Objectives for bordering test of change 16 PDSA Worksheet PDSA group AimCMHI Plan-Do-Study-Act Worksheet aim Objective (Including detail (who, what, where, when) What additional information will you need to take action? What do you predict will happen? How will you know your change is an improvement? DO Was the plan carried out? What was observe that was not part of the plan? correction What happened? Is this what you predicted? What new knowledge was gained? flirt As a result, list succeeding(prenominal) actions argon on that point organizational forces that will help or hinder efforts? Objectives for attached test of change 17 CMHI Plan-Do-Study-Act Worksheet PDSA Example Team 2 Care Coordination Needs Assessment Aim Use from page 13 or create own programObjective (I ncluding details (who, what, where, when) With MH lead physician review unfinished CYSHCN watchs select 3 CYSHCN who will get ahead from an assessment for care coordination. By a workweek from next Tuesday complete an assessment (e. g. parent/youth screening tool in appendices behind page 26) each before the office higgle or by pre-visit phone call. Begin care planning process with child/youth and family What additional information will you need to take action? Listing of pending CYSHCN visits from the CYSHCN list or registry What do you predict will happen? Some false starts finding the right CYSHCN and with time we will succeed if persistent over slightly longer time get over How will you know your change is an improvement?Follow up with 3 families in 2 weeks to determine if pre-visit assessment and follow-up planning are helpful and what needs to be added/improved review value with lead physician as well. DO Was the plan carried out? What was observed that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? ACT As a result, list next actions Are thither organizational forces that will help or hinder efforts? Objectives for next test of change 18 PDSA Worksheet PDSA Team Aim CMHI Plan-Do-Study-Act Worksheet PLAN Objective (Including details (who, what, where, when) What additional information will you need to take action? What do you predict will happen?How will you know your change is an improvement? DO Was the plan carried out? What was observed that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? ACT As a result, list next actions Are there organizational forces that will help or hinder efforts? Objectives for next test of change 19 CMHI Plan-Do-Study-Act Worksheet PDSA Example 3 Comprehensive Care Planning Team Aim Use from page 13 or create own PLAN Objective (Including details (who, what, where, when) 1) Develop/ lease care plan medic al summary and use with 5 place CYSHCN/week. 2) Add an emergency plan if warranted. ) Study provider and family feedback and integrate to improve the plan and the process for plan use. Create immediate action plan for how to meet resource, educational and other needs of CYSHCN/patient and family 4) Use lessons learned to share, engage, educate and spread medical home to staff. What additional information will you need to take action? Sample care plans to choose from using team priorities identified CYSHCN with pending visit to initiate plan with. Also identify educational needs of staff /families. What do you predict will happen? Will start slow, 1-2 per week and pick up speed to reach 5. Value will result in better preservation of care coordinator time to complete plans, thus increased use of CC and team process.Ultimately, we may register comprehensive care planning rounds with team/staff review 3-5 CYSHCN/patients who are receiving this care coordination. Use rounds to review s uccesses, challenges, needs of child/family with staff and address questions. How will you know your change is an improvement? Review with families for benefit, follow up in 4-6 weeks review too with staff DO Was the plan carried out? What was observed that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? ACT As a result, list next actions Are there organizational forces that will help or hinder efforts? Objectives for next test of change 20 PDSA Worksheet PDSA Team Aim CMHI Plan-Do-Study-Act Worksheet PLANObjective (Including details (who, what, where, when) What additional information will you need to take action? What do you predict will happen? How will you know your change is an improvement? DO Was the plan carried out? What was observed that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? ACT As a result, list next actions Are there organizational forces that wil l help or hinder efforts? Objectives for next test of change 21 CMHI Plan-Do-Study-Act Worksheet PDSA Example 4 Transition to Adult Care & Services Up-coding to maximize reimbursement Team Aim Use from page 13 or create own PLANObjective Have MD & Care Coordinator jointly see (2) YSHCN & family for transition visit use a transition assessment (timetable) checklist to guide the visit and align activities with community partners. Bill for visit document constitution of complexity Details (who, what, where, when) CC Schedules 2 YSHCN for transition care plan visit next week, with family permission informs/ leaves with key community partners about assets & needs. Codes for 99214 for 60 minute visit with established patient and document result and complexity of the visit What additional information will we need to take action? Extract from list of CYSHCN youth over 14 due for visit communicate with family and learn community partners Clarify with senior leaders ability to track reim bursement results for these visits What do we predict will happen? (E. g.May take time to match YSHCN with open slots will need to follow up with payers for denials and use documentation to justify activities). How will you know your change is an improvement? Review with family staff community partners. Select other ongoing measures (p14) DO Was the plan carried out? What was observed that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? ACT As a result, list next actions Are there organizational forces that will help or hinder efforts? Objectives for next test of change 22 PDSA Worksheet PDSA Team Aim CMHI Plan-Do-Study-Act Worksheet PLAN Objective (Including details (who, what, where, when) What additional information will you need to take action? What do you predict will happen?How will you know your change is an improvement? DO Was the plan carried out? What was observed that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? ACT As a result, list next actions Are there organizational forces that will help or hinder efforts? Objectives for next test of change 23 CMHI Plan-Do-Study-Act Worksheet PDSA Example 5 Community Outreach / Resources Team Aim Use from page 13 or create own PLAN Objective (Including details (who, what, where, when) Plan for care continuity across the medical home, school, and community agencies with 4 families and children/youth over the next four weeks.Use a selected communication strategy (fax back, email, NCR paper, electronic forum, other) to centralize key information with strengths, goals, care plans, access information, and releases fostering cross organizational communication the CC performs as a hub of the wheel function in these activities. What additional information will you need to take action? Identification of children/youth and families in need of transition and/or community-based coordination identification of key community partners consensus on communication strategy What do you predict will happen? Territorial barriers will result up and family will need to be front and central to the process.How will you know your change is an improvement? Review with family and agencies whether there has been improved care communication, also cope other systematized outcome measures (see page 14). DO Was the plan carried out? What was observed that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? ACT As a result, list next actions Are there organizational forces that will help or hinder efforts? Objectives for next test of change 24 PDSA Worksheet PDSA Team Aim CMHI Plan-Do-Study-Act Worksheet PLAN Objective (Including details (who, what, where, when) What additional information will you need to take action?What do you predict will happen? How will you know your change is an improvement? DO Was the plan carried out? What was observed that w as not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? ACT As a result, list next actions Are there organizational forces that will help or hinder efforts? Objectives for next test of change 25 Appendices A. Key Websites for Care Coordination Tools 1) Center for Medical Home Improvement (CMHI) www. medicalhomeimprovement. org 2) National Center for Medical Home Initiatives (AAP) www. medicalhomeinfo. org 3) Utah Medical Home opening www. medhomeportal. orgReferences 1) McAllister, J. W. , Cooley, W. C, Presler, E. Practice-Based Care Coordination A Medical Home Essential. pediatrics, Volume 120, Number 3, September 2007, e1e11. 2) American Academy of Pediatrics, Medical Home Initiatives for Children with specific Health Care Needs ensure Advisory Committee. The medical home. Pediatrics, 2002 110184-186. 3) American Academy of Pediatrics, Committee on Children with Disabilities. Care Coordination Integrating Health and Related Sys tems of Care for Children with modified Health Care Needs, Pediatrics, 1999, Vol. 104978-981. 4) American Academy of Pediatrics, Division of Health insurance policy Research.Periodic Survey of Fellows 44. Health Services for Children with and without special Needs The Medical Home imagination Executive Summary. Elk Grove Village, Illinois American Academy of Pediatrics 2000. Available at www. aap. org/research/ps44aexs. htm. Accessed April, 2005. 5) Antonelli, R. , Antonelli, D. , Providing a Medical Home The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice. Pediatrics (Supplement) 2004 Vol. 113 1522-1528 6) Cooley, W. C. and McAllister, J. W. Building Medical Homes Improvement Strategies in Primary Care for Children with Special Health Care Needs. Pediatrics (Supplement) 2004 113 1499-1506. ) Davis, K. , Transformation potpourri A Ten Point strategy to Achieve Better Health Care for All. The Commonwealth Fund. Accessed at www. cmwf. org Apri l 13, 2005. 8) Family Voices. What Do Families introduce About Health Care for Children with Special Health Care Needs in California Your Voice Counts. Boston, MA Family Voices at the Federation for Children with Special Health Care Needs 2000. 9) Future of Children, Health policy for Children Care of children with Special Health Care Needs. Key Indicators of Program Quality. Available at www. futureofchildren. org/information2827/Accessed April 13, 2005. 10) Horst, , Werner, R. , & Werner, C. 2000) Case management for children and families Journal of Child and Family Nursing, 3, 5-14. 11) Langley, G. J. , et al. The Improvement Guide A serviceable Approach to Enhancing Organizational Performance. Jossey-Bass, San Francisco, 1996. 12) Lindeke, L. L. , Leonard, B. J. , Presler, B, Garwick, A, Family-centered Care Coordination for Children with Special Health Care Needs across Settings. Journal of Pediatric Health Care, Vol. 16, No. 6, November/December, 2002, 290-297 ** 13) Presler , B. (1998, March/April) Care Coordination for Children with Special Health Care Needs. Orthopedic Nursing, (Supplement), 45-51. 26 CMHI Center for Medical Home Improvement (CMHI) Crotched Mountain Foundation Greenfield, New Hampshire 2007 27