AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
SHARON FLEISCHFRESSER: Next I'm going to talk about a medical home approach to creating an environment of change. I think at the beginning when folks were introducing themselves and talking a little bit about some activities they were involved in, in their state, a number of folks mentioned working on medical home. So this is probably some things that you've already been involved in. How many of the states here are involved in the learning collaborative or the national, in 2003, 2004, and the current? Minnesota , anyone else? Any other states? Pardon.
UNKNOWN SPEAKER: Pennsylvania .
SHARON FLEISCHFRESSER: Pennsylvania , okay. Well I'm going to talk about what we did in Wisconsin and I'm really intrigued to learn more about what you folks are doing as well. I'm just going to skip some of this, pieces about medical home and the background, we've talked about it before, but I think there is an importance when you're trying to do something at the State level. The credibility of folks knowing that this is actually a national initiative and happening all across the country and we certainly use that and it was a requirement as well as a Title V program to look at medical home. What we struggled with was how to do that at a State level, but in particular how to do that in a community, and more particularly in a practice. We had a vision that we felt every child with special healthcare needs would have access to a medical and dental home and that actually has changed for our state because the vision is now that every child with our without a special healthcare needs and my goal would be that for every person in the state of Wisconsin would have access to a medical and dental home.
We've talked about the system being seamless, care coordinated, and integrated and I think one of the key pieces for us was the families and providers working in partnership. And I think in the primary care practice level where I think there's always been an interest in working with families, but actually working as teams on an equal footing was new. Also we wanted to make sure that our providers had skills and resources in order to do this and provide the services that we've talked about. We've talked a lot about partnerships. Our partnerships really have evolved as well with the medical home project. Again, in Wisconsin we were one of the states that participated in a mentorship meeting and really to get ourselves to the mentorship meeting. It was sponsored by the National American Academy of Pediatrics and also the Maternal Child Health Bureau, but what it did in order for Wisconsin to participate, we had to pull a large group of folks together and develop some ownership in creating a team to start working on this. So in the sense it helped to be a starting point for us.
Our MCH advisory, which is made up of about close to 75 people that--it's a Maternal Child Health and Children with Healthcare Needs advisory group and it really is a cross section of Wisconsin and includes kind of the usual suspects, if you will, but it includes a large percentage of families. It also includes the religious community, legal. It really is quite broad and that group came together and decided the concepts of medical and dental home would be a major activity for our advisory committee but also for our state activities. So it provided some, I think, ownership of the issue. We decided to participate in the National Medical Home Learn collaborative and for folks who aren't familiar with this they're currently in the second cycle of doing that. In 2003/2004, do I have that right, what year is it? They solicited states and Wisconsin was one of 11 states. And I think again I mentioned that we, as a state, were interested in really working in the primary care practice level, but really didn't know how to take the concepts of Medical Home, which you've heard, you know, accessible, comprehensive, et cetera, but how do you really translate those in a way into a practice where a physician maybe seeing 20 to 30, maybe 40 patients a day and how do we really make it real in a practice.
So instead of just going and talking about we wanted to really try to translate it in some to reality in the practice setting. We were also looking for ways to connect to our program, our Title V Program, more closely with the primary care community. Folks are familiar with the structure. Each state had three primary care teams. It's made up of a parent of a child or youth with special healthcare needs, a primary care physician, and a nurse or a care coordinator in the practice. We discovered that most practices, and I think we talked about this earlier, don't have a care coordinator. That's really a nonexistent entity but it's someone who is assigned that duty and it may change from day to day. Again I mentioned that for many of these it was the first time that a parent might have been involved in working directly with the primary care team. They are from that practice, so the practice itself would select the parent and sometimes it was the first time these folks--I mean they had seen each other in the office setting but not in any other setting where they're working as a team together.
And we really try to recruit practices that were very different, rural practices, urban, inner city, populations served. We were looking for a little diversity in our practices. We also put together a state team, which was made up of myself, from the Title V Program and a health educator from our program, but we also got our Medicaid medical director to attend, which was fairly phenomenal in itself for the department to support that person attending the meetings, et cetera, and also had the lead for care coordination. In Wisconsin the Children's Hospital in Milwaukee sees about 60 to 70% of all the specialty care in the state, really gets funneled through that agency and its satellite (inaudible) providers. So the person who was the lead for care coordination was part of our team as well. Here's our practices, and again, they're fairly diverse. What did we learn from participation in the national collaborative? Well we actually pulled our team together and we did what was a Wisconsin team retreat, probably too late in the process.
We should've did the team retreat at the very beginning, but we had in mind that we would want to do a replication in Wisconsin and we really want to hear from them what they thought we should do differently or what they had learned. What we heard from the practices was that really the learning collaborative was a great framework for working together. They really liked working with the other practices and each other. That each practice team really embraced the idea of parents as partners, but said we need more. So one parent partner in a learning collaborative isn't enough. We need to have really a much bigger team. We also learned that--we kind of jumped in and did this and we discovered that the teams need nurturing, so there really needed to be regular contact and skilled facilitation of the team meetings. It was, for many, the first time, and you heard Rich talk and the Arizona team talk about quality improvement process while, I think, you know, in a primary care setting that the administrators and people in charge may talk about quality, improvement practice, and projects, but at the practice level for individuals, many of them, this was their first entrée into quality improvement and, in fact, it sometimes it had a negative connotation, like, oh, no not that again. So—
UNKNOWN SPEAKER: That's because they're used to it coming from the top, right?
SHARON FLEISCHFRESSER: Right, right, instead of being driven by what they wanted. And so we felt that they needed to have facilitation and people to help guide that process a little bit. We were blown away, frankly, by it, because we thought we were doing such a good job by the fact that folks really knew very little about state programs and community resources. And that practices did need technical assistance really related to practice type things, like reimbursement strategies, so bringing in billing experts, knew very, very little about transition. It wasn't even on the radar screen. Our replication is we're currently, in 2004 we recruited 10 primary care practices and I think Minnesota has done, what 15, and a number of states have recruited a number of practices. We continued the structure of using our Title V, our state team, our central office team, our Children's Hospital. Our Medicaid director doesn't go to each meeting. She's come to a number of them but we, on a regular basis are continuing to work with Medicaid. And our practices, again, were we worked with both pediatricians and family physicians.
We felt that was a real weakness in our first participation in the national that there really needed to be more involvement of family practice. Again we each practice has a medical home facilitator. We used the medical home index. I didn't bring copies of the tool, but at the end I have all the places where you can access it. It's all online and we use that at the very beginning. The practice facilitator met with the practice team and they went through that index and they really used it as a tool to identify areas for improvement and that also became our baseline score. And then we continued by connecting the facilitator. Our facilitators came from our Regional Children with Special Healthcare Needs Centers and I'll show you a map. We have five of them, so we saw that as a natural and it's a parent run regional center. Their job is to connect providers and families to resources and to provide parent-to-parent support and so it seemed like a real natural that our facilitators were from our regional centers. Here they are and as you can see our practices are linked and clustered around our regional centers.
Our learning sessions, we had three of them; we really modeled it after the national. The first is kid of medical home 101. The Continuous Quality Improvement Plan New Study Act focused on financing for learning session two and learning session three was transitions. Between each learning session the teams met every two to four weeks, some better than others, but we had monthly conference calls to touch base, sharing. It was a great way. We also developed a list serve, so people could post questions. It was our own internal list serve and actually I would highly recommend. We used our national centers that are funded through MCHB, like the Medical Homes Center at the AAP was very helpful. They host our list serve. We couldn't get it through the bureaucratic system that we would have our own little list serve but the AAP sponsored it for us. Our transition, we have a healthy ready to work grant in our state plus the national office, so I would encourage folks to use those national centers that are out there and being funded through MCHB.
Practice change, we really focused for them a little bit about what the areas of practice changed. They used the index but work with family support activities. All of them did something related to families and I think that was because families were such an intricate part of the team. They all needed to do something related to identification of children with special healthcare needs in their practice. It was intriguing to find out most practices did not know who the kids with special healthcare needs in their office were. They may have a little list, folks that they saw frequently but really didn't have a good concept of who those children were and could recall them in a way that was efficient for the practice and they all worked on developing care plans. Very quickly, some of practice changes; another piece I was really surprised by is we really did this on a shoestring. We didn't have an additional grant. The practice teams all volunteered. We provided support to the families for their participation, but that, frankly, was it. The piece in recruiting, some kind of lessons learned, was to talk to their administration. So we go approval from the administrators in their organizations as part of the recruitment, so they knew they were doing it and they made a commitment for these individuals' time, but it's a volunteer army.
UNKNOWN SPEAKER: Sharon .
SHARON FLEISCHFRESSER: Yes? Time?
UNKNOWN SPEAKER: I'm sorry, but that's just a wonderful example of the anyway principle, you know? You don't have the money, you don't have this, you don’t have this, but you need to do this so let's do it.
SHARON FLEISCHFRESSER: Yeah.
UNKNOWN SPEAKER: And somehow it works out and—
SHARON FLEISCHFRESSER: Right, we did it on the cheap.
UNKNOWN SPEAKER: --which is a great example of that, just a really great example of that.
SHARON FLEISCHFRESSER: And I was surprised by how practices even would say I can--you don't--you know our practice will put money towards participation.
UNKNOWN SPEAKER: Right, if they value it they will pay for it.
SHARON FLEISCHFRESSER: Yeah. Some of the practices changes we saw were, for example, once you identify who kids with special healthcare needs are in your practice you can use that for scheduling accommodations and families are why am I waiting 30 minutes in the office in the waiting room where I could directly into the exam room and a lot of very simple changes that really didn't cost anything but made a big difference to the practice and so you can see the list. All of them focused on family support activities, again, identification, care coordination, and we always said if you're going to make a change think about how one change can make multiple benefits and also start small. Our scores, we did after the learning collaborative. We did medical home indexes and if you look at the national what happened in Wisconsin really, you could superimpose the slides, really saw all of the practices had changes in all the areas in the medical home index.
It was very valuable; again, for us at the state level because I think it really gave us a view of, from a practice perspective and family perspective, how primary care is delivered and I think that's really vital for Title V agencies. Our next steps, all of our practices, again, have volunteered to continue and some of them actually are bringing partners. Again, they will continue to work on identification, care planning, family support. Our last learning session--I see these folks trying to connect them more to the advocacy arena. They are very interested in working with our Governor. We've connected a number of our pediatric practices to our pediatric counsel. They've gone and met with our Governor to talk about medical home, so it is fairly amazing how just a little bit of nurturing goes a very long way. Our main focus for this next year will be spread and again cultural effectiveness, primary and (inaudible) care relationships. And the last slide for you just has a list of web sites. In particular if you go to medicalhomeinfo.org it has absolutely everything in there. All the tools that providers have developed through the national collaborative, but also states keep feeding it, so it's--and then NICU, of course, also has information there as well.