DRAFT: The Role of National Standards for Systems of Care for CYSHCN In Improving Quality of Care and Access to June 18, 2015 Medical Homes Texas Primary Care and Health Home Summit 1 Meredith Pyle, Senior Program Manager for CYSHCN; mpyle@amchp.org or 202-266-5255
Today s Learning Objectives Session participants will be able to: 1. Describe the ideal components of an effective system of care for CYSHCN; 2. Identify ways in which standards regarding medical home are relevant and applicable to their work and/or experience with systems of care; 3. Use the National Standards for Systems of Care for CYSHCN to identify critical elements for pediatric medical/health homes.
Today s Learning Objectives 1. What are the ideal characteristics of a system of care for CYSHCN? 2. How are these Standards relevant and applicable to you and your work? 3. How can you use these Standards to identify critical elements for pediatric medical/health homes?
TERMINOLOGY
A Tiered Approach to Services for CYSHCN Requires Definition Complex Chronic Episodic Chronic Non-Chronic 7
Public Health Definition - Children and Youth with Special Health Care Needs (CYSHCN) Federal Definition: Have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions require health and related services of a type or amount beyond that required by children generally
Practice Level vs. System Level Standards Clinical Practice Health Plans Systems of Care NCQA Recognition NCQA Accreditation CYSHCN National Standards X
Why National Standards? Need for focus on unique needs of CYSHCN and their families Rapidly changing health care environment e.g., service delivery system, new payment models Shifts of CYSHCN population to managed care arrangements Changing role of Title V programs ACA opportunities Long-standing recommendations on need for standards 12
How were the CYSHCN Standards Developed? Background White Paper Standards developed based upon work including: Managed care contracting standards (i.e. GWU Pediatric Purchasing Specifications) National standards (e.g. NCQA medical home) State standards in use National frameworks (e.g. family engagement, transitions, respite care) Literature research Over 30 interview with key informants at the national and state level National Work Group guidance and input 13
National Work Group Included Representatives from: Federal and state Maternal and Child Health/CYSHCN Programs Family Voices National Centers for CYSHCN Children s Hospital Association and Children s Hospitals Centers for Medicare and Medicaid Services National Association of Medicaid Directors AMCHP National Academy for State Health Policy Policy and health scientists AAP and other pediatricians Lucile Packard Foundation for Children s Health 14
http://www.amchp.org/aboutamchp/newsletters/member-briefs/documents/standards%20charts%20final.pdf 15
Turn to Page 7 in your Standards Book 16
National Standards for Systems of Care for Children and Youth with Special Health Care Needs What: the consensus of national experts across multiple systems Why: designed to help communities and states build and improve systems of care for CYSHCN Screening, Assessment and Referral Family Professional Partnerships Eligibility and Enrollment Transition to Adulthood Access to Care Health Information Technology Medical Home: Pediatric Preventive and Primary Care; Care Coordination; Pediatric Subspecialty Care Community-based Services and Supports: Respite Care; Palliative and Hospice Care; Home-based Services Quality Assurance and Improvement Insurance and Financing Disclaimer: The National Standards are meant to supplement, not substitute, federal statute and regulatory requirements under Medicaid, the ACA and other relevant laws and are intended for use or adaptation by a wide range of stakeholders at the national, state and local levels.
Connecting The Standards: Medical Home National Standards MCH Performance: Percent of CYSHCN having a medical home Medicaid/ ACA: Health Homes Healthy People 2020: Maternal, Infant and Child Health -medical home; family-centered, coordinated systems AAP/AAFP: Joint Principles of the Patient Centered Medical Home National Standards Medical Home NCQA: Patient Centered Medical Home Requirements
Medical Home CYSHCN will receive family-centered, coordinated, ongoing comprehensive care within a medical home model. 29 Standards focus on: Medical team; care coordination 24-7 access; additional time for visits Prevention and Treatment Relevant System Partners: Health Plans/Insurers Health Care Providers State (Medicaid, Title V, Legislature) Families Routine, emergent and urgent needs are met
Pgs 12-13 in Book Primary Care Medical Home: Overall (10 Standards) Families 1. Provide access to health care services 24 hours, #s seven days 1 a week 6 2. Provide health care services that encourage the family to share in decision making, and provide feedback 3. Perform 2 comprehensive 7 health assessments 4. Promote an integrated, team-based model of care coordination 5. Develop, 3 maintain, and 8 update a comprehensive, integrated plan of care that has been developed with the family and is shared with families and providers 6. Support 4 self-management 9 of CYSHCN s health and health care 7. Promote quality of life, health development and behaviors 5 across all life 10 stages 8. Integrate care with other providers; effective info sharing with families and providers 9. Active care tracking that includes proactive reminders to families and clinicians of services needed via a registry or other mechanism 10. Provide effective, evidence-based care 2. Provide health care services that encourage the #s family to share 2 in decision making, and provide feedback 5. Develop, maintain, and update a comprehensive, integrated plan of care that has been developed 5 with the family and is shared with families and providers 6. Support self-management of CYSHCN s health and health 6 care 8. Integrate care with other providers; effective info sharing with families and providers 9. Active care tracking that includes proactive reminders to families and clinicians of services needed via a registry or other mechanism 8 9
Pgs 13-14 in Book Medical Home: Pediatric Preventive and Primary Care (9 Standards) Health Plans/Insurers 3. All children, #s including CYSHCN, have access to medically 3 necessary and preventive services to promote optimal health 5. Reasonable 5 access to routine, episodic, urgent and emergent health care are provided Health Care Providers 1. (PCP) Bright Futures Guidelines for screening and well care including oral and mental health are followed 2. (PCP) Care focuses on overall health, wellness and prevention of secondary conditions 3. All children, including CYSHCN, have access to medically necessary and preventive services to promote optimal health 4. (PCP) All children, including CYSHCN, receive recommended immunizations 5. Reasonable access to routine, episodic, urgent and emergent health care are provided 6. Reasonable wait times and same day appointments are available for physical, oral and mental health care 7. Accommodations for special needs (i.e. home vs. office visits) are available 8. Scheduling systems that recognize additional time in caring 5 for CYSHCN 9. Pre-visit assessments are completed with family to ensure provision of family-centered care and needed referrals #s 1 6 2 7 3 8 4 9 State #s 3. All children, including CYSHCN, have access to medically 3 necessary and preventive services to promote optimal health 5 5. Reasonable access to routine, episodic, urgent and emergent health care are provided
Case Study: Smith and Barksdale Pediatric Primary Care See the handout (pg. 6) Use the 9 standards within the Pediatric Preventive & Primary Care to grade Smith and Barksdale Pediatric Primary Care
Pgs 15-16 in Book Medical Home: Care Coordination (3 Standards) Health Plans/Insurers 1. All CYSHCN have access to #s patient and 1 family-centered care coordination. 3. A plan of care* is jointly developed, shared and implemented among PCP, specialists, family and CYSHCN, and others as needed. 3 Health Care Providers 1. All CYSHCN have access to #s patient and 1 family-centered care coordination. 2. Care Coordinators serve as member 2 of medical home team; assist in managing CYSHCN transitions; and provide appropriate resources to CYSHCN and families. 3 3. A plan of care* is jointly developed, shared and implemented among PCP, specialists, family and CYSHCN, and others as needed. *addresses health problems; identifies strengths and needs of child and family; routinely evaluated and updated; delineates roles of all participating entities State 1. All CYSHCN have access to patient and family-centered care coordination. # 1
Care Coordination Standards: Small Group Discussion Review the Care Coordination Standards on pages 15 16 in your Standards books Consider your experiences with care coordination, either as a professional or as a parent/family member. Discuss with one or two people sitting near you:
Care Coordination Standards: Small Group Discussion Questions Do your patients/your family have access to family-centered care coordination? Do care coordinators serve the functions outlined in standard #2? Are plans of care used? Which of the characteristics described in standard #3 are part of the plans of care?
Pgs 16-17 in Book Medical Home: Pediatric Specialty Care (7 Standards) Health Plans/Insurers 1. Shared management of #s CYSHCN 1 between pediatric primary care and specialty providers is permitted. 4. Pediatric 4 centers of care are available to CYSHCN and their families when needed. 6. Durable 6 medical equipment and home health services are customized for CYSHCN. 7. A full continuum of children s behavioral health services are provided. 7 Health Care Providers 2. Systems such as satellite #s programs, 2 electronic communications, and telemedicine are used to enhance access to specialty 3 care and multidisciplinary teams of pediatric specialty providers. 3. Physical, oral and mental health 4 are coordinated and integrated. 4. Pediatric centers of care are available to CYSHCN and their families 7 when needed. 7. A full continuum of children s behavioral health services are provided. State 2. Systems such as satellite #s programs, 2 electronic communications, and telemedicine are used to enhance 5 access to specialty care and multidisciplinary teams of pediatric specialty providers. 7 5. The system serving CYSHCN includes Title V CYSHCN programs, LENDs and UCEDDs, where available. 7. A full continuum of children s behavioral health services are provided.
Connecting The Standards: Family Professional Partnerships MCH Performance: States Annual MCH Block Grant Report: Narrative section on Family and Consumer Engagement National Standards Medicaid: CAHPS Survey Child Questionnaire - CCC Family Professional Partnerships Healthy People 2020: Maternal Infant and Child Health: CSHCN receive care in familycentered systems Medical Home: Family Medical Home Index and Family Survey
Family Professional Partnerships Families of CYSHCN will partner in decision making at all levels and will be satisfied with the services they receive. 9 Standards focus on: Families are active members of the team Connection with family organizations, peer support Strength-based; Informed Culturally and linguistically appropriate Relevant System Partners: ALL: Health Plans Health Care Providers State (Medicaid, Title V, Legislature) Families
Connecting The Standards: Transition to Adulthood National Standards MCH Performance % YSHCN who received the services necessary to make transitions to adult health care Medicaid: EPSDT Transition to Adulthood Healthy People 2020: Disability and Health; health care provider discussed transition planning ACA: Allows coverage for young adults on their parent s policy
Transition to Adulthood YSHCN receive the services necessary to make transitions to all aspects of adult life, including adult health care, work, and independence. 12 Standards focus on: Youth engagement Transition and transfer of care policies and processes Transition assessment and plan in place and current Coordination between pediatric and adult providers Relevant System Partners: Health Plans Pediatric and Adult Health Care Providers State (Medicaid, Title V, Legislature) YSHCN Families
What are states doing? Texas is developing a strategic plan with their Medical Home Workgroup using the Standards Additional Focus on Family Professional Partnerships Lots of stakeholder education Key Partners: CYSHCN Program, P2P, Medicaid, AAP, Texas Children s Health Plan
Using the Standards 1. Identify CYSHCN as a special population in managed care contracts 2. Reference national system standards in managed care contracts 3. Determine priorities for improvement 4. Monitor adherence to standards & compare performance 5. Guide technical assistance to improve performance 6. Create partnerships among Medicaid, MCOs, Title V, providers, advocates and families to monitor access and quality 32
Utilities A utility is a resource shared by multiple providers or practices in order to achieve efficiencies in practice operation and management and improvements in quality of care. 33
Examples of Shared Practice Resources After hours coverage Patient education Translation services Mental health services Social services Care coordination Patient Surveys Telephone advice lines Microsystem design QI technical assistance Public health services Nutrition counseling 34
THANK YOU! Meredith Pyle The Association of Maternal & Child Health Programs Senior Program Manager for CYSHCN; mpyle@amchp.org or 202-266-5255