Lail-A_Registry_of_CSHCN-FINAL by liaoxiuli


									 Using Registries for the Care of
Children with Special Health Care
         Needs (CSHCN)

           “A Registry of CSHCN in the
           Primary Care Medical Home”

             Jennifer Lail, MD, FAAP
               September 19, 2007
   I have no relevant financial relationships with the
    manufacturers(s) of any commercial products(s)
    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 my presentation.
Learning Objectives
 Utilizethe framework for improving
  care of chronic illness
 Apply a registry for identifying and
  managing children with specific
 Identify the IT resources needed to
  support a registry
Chapel Hill Pediatrics and
Adolescents, P.A.
   Suburban Private Practice, 2 offices
   Duke University and University of NC Medical Centers within 15
   11 MD providers, 6 F.T.E.
   84% Managed Care
   7.6% Private Pay
   8.4% Medicaid
   >30 year history of collaboration with both medical centers
   Office hours 365 days/year
   Evening/weekend office hours
   Nighttime Nurse triage and daytime advice nurses
    Every Child Deserves a Medical
        Home….                         American Academy of Pediatrics

   “Amedical home combines place, process
    and people—

     The central place where primary care is
     The process and scope of care in that
      place, and
     The team of people delivering and
      coordinating care”

    Essential Components of a
      Medical Home System
Ready   Access
Why a Registry?

 Toimprove and streamline clinical care
 processes, especially for our higher-
 need patients

   improve documentation of services
 To
 and to permit data collection for clinical
 and administrative benefit
From Random to Registry
   Represented NC at NICHQ Medical Home Learning Collaborative I with
    12 other states in 2003

   Now over 1050 CSHCN in registry

   Began registry by:
      ~ MD recall
      ~ Computer recall by dx
      ~ Identification in process of care

   Notebooks  Excel  Access  EMR

   Linked registry to appointment scheduling (“SPECIAL”) and care
    coordination services for visible clinical benefit; problem list in chart
    gives summary

   Dx of CSHCN via CAMHI screener
 Staff recognizing a parent when appt. is
 Adequate time scheduled for that child
 Specialist’s records in your hands prior to
  the visit, including lab and X-ray results
 Parent concerns identified before the visit
 Lab slips ready, and EMLA cream on child
  prior to visit
 Help by your staff for families with referrals,
  resources, equipment
Registry - Knowing Who Needs
   Schedulers give adequate time for appointment

   Alerts staff and providers to special needs

   Identifies for Care Coordination and PVC’s = Pre-Visit Contacts

   Helps make and track referrals

   Permits grouping by diagnosis for care planning, screening
    programs and parent support links

   Proactive care for chronic conditions (flu shots, checkups,
    Synagis, SBE prophylaxis changes)
Define CSHCN—CAMHI Screener
 Medicine prescribed  by a doctor
 Condition lasting >1 yr.
 Needs more health care than other
  same-age kids
 Ability limitations
 Special therapy
 Counselling
Care Coordinators Maintain
                                                                                                                   MD requests help by form
                                                                     Date:____________ CC Initials:_______

                              CARE COORDINATION REQUEST
                                                         Make CSHCN / Add to Registry
 Chart Number:______________
 Requesting MD:____________________
                                                                                                                   Care Coordinators enter
 Diagnosis: (1)___________________ (2)___________________ (3)___________________
 Help Requested:
        *Needs appt with specialist:
                                                                                                                    CSHCN in Registry and
                Specialist Name / Location:__________________________________________
                CC Use:___________________________________________________
                                                                                                                    Admin. system (now blended
                CC Use:___________________________________________________
                Urgency: Urgent             ____________
                            Within 1 month ____________
                                                                                                                    in EMR)
                            Next Available ____________
        *Patient Availability:
        *Patient Phone Numbers:
                                                                                                                   This form begins the
                __________________________________________                                                          process for registry,

                                       Care Coordinator Use:
                                                   Referral Needed:_________________________
                                                                                                                    complexity scores, pre-visit
 UNC MRN:___________________                   DUKE MRN:___________________
 Parents’ Contact Info: (mom)_______________ (dad)________________ (home)________________
                                                                                                                    contacts, referrals, support

        Notes / Referral / Request faxed to office _______________________________
        Appt info given to mom / dad ________________________________________
Complexity Scores--
Who needs what?

 More time?
                  HEALTH CARE NEEDS-completed form to Peggy

 Communication
                  Primary CHP Provider: SBH     MI    CM JO AD      SVH
                                       RMC     KS     JL   RSW    KM
                  Diagnoses: 1)

  devices?        3)
                                Description                                          Examples

 Technological
                               1 chronic condition, well-controlled                 Asthma, mild per.
                      1        OR
                               Significant PMH, quiescent or resolved
                                                                                    Repaired VSD
                               1 evolving chronic condition, unstable               Asthma
                      2        2 chronic conditions, both well-controlled

  support?            3
                               2 or more chronic conditions, with either unstable
                                                                                    PCOS +Type 2 DM
                                                                                    Asthma +ADHD

                                                                                    Asthma w/ER visit

                               Any tech. dependent pt.                              (wheelchair, walker, GT,

 Translator?
                      4                                                             MR, Autism, Group Home
                               Mod./severe cognitive delays                         res.

                                                                                    Non-English speaker
                     +1        Language barrier

 Pre-Visit
                     +1        Behavioral Disorder                                  OCD, Anxiety in addition to

                      +1       Family/Social Complications                          Divorce, Horizons

  Contact?                     Total complexity

                  DO YOU WANT A PVC DONE?  YES                                      NO
Care Coordinators Use Registry
for Pre-Visit Contacts
                                        Pre-Visit Contact
   Care coordinator screens schedule
                                        Date of Contact__________________ Date of Appointment_______________________
    for upcoming CSHCN physicals
                                        Patient:________________________________Date of Birth___________ Chart#______

                                        Number where reached:_____________________________________________
   The child’s MD assesses child’s     In order to be prepared for your child’s upcoming visit, we’d like to know:
    complexity and requests PVC         1. Has your child been to the Emergency Room since their last PE @ CHP?           YES      NO

                                        If yes, where?_____________________________________________________________
                                        For what reason?___________________________________________________________
                                        Records of visit?___________________________________________________________
   Care Coordinator makes call to      Outcome/Recommendation?__________________________________________________
    parent.                             2. Has your child been hospitalized since their last PE @ CHP?       YES       NO

                                        If yes, where?_____________________________________________________________
                                        For what reason?___________________________________________________________
   Parent concerns are identified      Records of hospital stay?_____________________________________________________

                                        3. Has your child seen any specialists or therapists (including mental health providers) since their

   Labs (and pain control!) are        last PE @ CHP?       YES      NO

    anticipated and scheduled for       Who?____________________________________________________________________
                                        Specialist note is in chart? YES NO

                                        4. Has your child had any lab data obtained or x-rays performed since their last PE @ CHP?
                                            YES      NO
   Consultant notes are available      What?___________________________________________________________________
                                        Result on chart? YES    NO

   ED and specialty visits are noted   5. Has your child had any evaluations or services at the Children’s Development Services Agency
                                        or school since their last PE @ CHP?      YES       NO

                                        6. Are there any forms or letters you’ll need completed during this visit?     YES       NO

   New issues/special needs are        7. Do you anticipate your child needing lab work at your upcoming visit
                                        If so, arrange Lab Forms and EMLA/Elamax.
                                                                                                                       YES      NO

    anticipated                         8. Are there any major areas of concern or topics you need addressed at this visit?

                                                             Check scheduling to be sure there is adequate time!!!
Other Clinical Registry Uses
 Asthma care template
 ADHD care template
 Family survey
 Invitation to meeting with school
 Chart preparation for EMR
 Potential for help in Disasters (EMS)
 Beginning work on Obesity
 Initiatives on Transition to Adult Care
Administrative Benefits of
 Recall by diagnosis for educational or
  research opportunities
 Recall by diagnosis for Flu shots, Synagis
 Surveillance for annual checkups
 Episodic care is “captured”
 Pay-for-Performance Program
 Documentation of Value of QI efforts with
Registry permits data collection to
document value of Medical Home
                               ER Utilization (PMPY)

 Visits PMPY

                                                         Chapel Hill Pediatrics
                                                         Comparison Group
                      2002   2003          2004   2005
Optimal Registry needs:
   Software for registries compatible and linked with
    office-based management systems
   Funding/support for EMR/data entry for Medical
    Home practices
   On-line data bases of services and supports by dx.
    for parent access
   HIPAA protection for registry use for clinical care
   Pt. care planning capacities by dx
   Electronic care plans
   Electronic capacity to deal with pediatric “high-
    severity, low frequency” diagnoses
Summary of Registry Benefits
 Ready identification of higher-need
  population of patients
 Ability to predict and plan for patient
 Links between practice parameters and care
  protocols and the individual pt.
 Documentation of more intensive service
  for coding and reimbursement
 Potential for tracking QI and Rx efficacy
 Planned care saves healthcare dollars

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