A MEDICAL HOME MODEL FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS Adriana Matiz MD Associate Professor of Pediatrics Columbia University Irving Medical Center
Our Community Northern Manhattan
Community Data- Census 2015 66% Hispanic 54% foreign-born 52% Spanish-only 56% Low acculturation score 43% have a household income <$20,000 USD
Children with Special Health Care Needs (CSHCN) those who have or are at increased risk for a chronic physical, developmental or emotional condition and who also require health and related services of a type or amount beyond that required by children generally
Asthma ADHD Autism Complex congenital heart disease Multiple Organ Involvement Gastrostomy, Tracheostomy Chronic Lung Disease Diabetes Genetic Syndromes Seizures Neural tube defects Cerebral Palsy Prematurity
WHY? CSHCN comprise 15-18% of all children in US (12.5 million) CSHCN account for 80% of pediatric health care expenses CSHCN have grown by 30% in the past 20 years due to improved medical care and testing Account for >2.5 times the number of school absences, 2x as many unmet health needs, >5 times as many hospital days/ 1000 children
Latino Children in the US Fastest growing minority population in the US (16%-2011) Multiple health disparities, health access and socioeconomic challenges Patient and family-centered care can help to address health disparities and improve population health
National Survey of CSHCN, 2009/2010
Case Patient Y born with prenatally diagnosed TEF, VSD s/p TEF repair and at age 3 mos suffered esophageal rupture subsequent critical course and major complications 9 months admission at Children s Hospital discharged with: esophageal stricture G tube and J tube chronic lung disease global developmental delay hypertension
Special Kids Achieving Their Everything (SKATE) Improved care for high-risk & high-cost pediatric populations w/specialized needs University Goal of 25% reduction in preventable Community ED visits MDs & inpatient re-admissions Inter-disciplinary team -based visits for patients w/complex medical, behavioral & social morbidities Community based non-physician care for stable patients in need of chronic disease monitoring (CHWs, CBOs) Outcomes Evaluation Intensive Care Coordination
Funding from Medicaid Reform in New York Program Management Care Management Information Technology Program Manager Physician Leads Care Managers 3 FTE Community Health Workers (CHWs) 4 FTE Psychiatric NPs 3 FTE In Interdisciplinary Team Meetings Patient Registry Tailored appointments Integrated CHW findings in EMR Adapted EMR
Navigation Pediatric Care Managers Coordinate appointments and procedures Home care services Pharmacy and supply needs Connect to child welfare agencies, schools, insurance companies Medication reconciliation Accompany to appointments Coordinate multidisciplinary meetings
Pediatric Psychiatry Nurse Practitioners Diagnose Short-term therapy Coordinate referral to acute service or longitudinal therapy Coordinate with school based psych Support pediatrician medication management
Community Health Workers (CHW) Hospital-Community partnership model Bilingual Peer-level culturally-sensitive education and support Trained on CSHCN topics Disease based, services (disability resources and special education) Social needs which compete with self-management and coordination of care Housing, literacy, food insecurity, immigration
Population 4600 4400 4200 4000 3800 3600 54% 46% Patients 3400 Males Females N=8162 March 2017
Age Distribution 4000 3500 3000 2500 2000 1500 44% 46% 1000 500 0 10% 0-7 years 8-17 years 18-65 years
Risk Stratification 60 50 40 30 20 50% 36% Risk Level 10 0 7.5% 6.5% Level 1 Level 2 Level 3A Level 3B
Pediatric Practices 1400 1200 1000 800 600 400 Level 1 Level 2 Level 3A Level 3B 200 0 Audubon Broadway Rangel WHFHC
Risk Stratification 12% have a care manager Risk Level 6.5% 7.5% 36% 50% Level 1 Level 2 Level 3A Level 3B
CHW Cases 40 35 30 25 20 15 10 5 0 Level 2 Level 3A Level 3B N=76
Metrics Program Social determinants Housing, access to care, food insecurity Goal attainment Provider and family Social service referrals Number of monthly contacts ED and hospitalization Patient/Family Diagnosis understanding Knowledge on accessing care Medication management Confidence in selfmanagement Level of distress School connectivity
Preliminary Outcomes and Next Steps RN Care Managers 160 patients CHWs 76 families 183 service referrals mostly for food insecurity, housing, and English as Second Language classes Analyze ED and hospitalizations, primary care visits and subspecialty visits
Lessons Learned Identifying and risk stratifying a population is essential to understand their needs and allocate resources. CHWs and Practice-based RN care managers support families experience in the medical home. The medical home model needs to be flexible and evolving as it adapts to changing resource opportunities but remain grounded in its core mission to support families.
CONTACT INFORMATION Adriana Matiz MD Associate Professor, Columbia University Irving Medical Center Medical Director -- Center for Community Health Navigation lam2048@columbia.edu 212 342-1917 25