Medical Home Practice-Based Care Coordination

checkup checkup crustal plate base Practice- ground flush Coordination A Workbook By Jeanne W. McAl nominateer Elizabeth Presler W. Carl Cooley content for checkup radical avail (CMHI) Crotched muckle Foundation & Rehabilitation Center Greenfield, New Hampshire Beyond the Medical stand Cultivating Communities of bind for Children/Y turn uph with special wellness C be necessitate Funded by H02MC02613-01-00 United States Maternal and Child health Bureau, Integrated Services for CSHCN, HRSA June 2007Workbook table of contents This workbook accommodates the cocks and reliefs infallible for a principal(a) business concern entrust to develop their cleverness to offer a pediatric recognise coordination suffice areaicularly for chel arn with additive wellness pity wishfully. The health boot ag crowd up, limitd to develop much(prenominal) an explicit service, makes an assessment of current safeguard coordination utilization and frames their service ef forts to strain proactive comprehensive practice-based negociate coordination.Tools included in this resource are a definition of assistance coordination in the health check exam situation, a oversee coordination vex description, a framework for guardianship coordination serve including structures and does, strategies for the protection of devoted(p) faculty cadence, and a logical sequence of negociate coordination remediatement ideas offered in the context of the assume for Improvement (Langley, 1996). Each tool fire be exercisingd as is or it can be customized in a manner which lift out harmonises your practice environment and the strategic casts your organization holds for checkup legal residence cash advance activities.Table of Contents Medical blueprintetary ho intention Practice Based headache Coordination Medical office anguish Coordination A Definition & A Vision Is It Medical al-Qaeda f serious Coordination? A Check reheel Medical kinsfolk (Pr actice Based) anguish Coordination Position Description A Worksheet A Medical Home (MH) sustainment Coordination modeling Framework Worksheet beat Protection Tips & Strategies . 3 5 . 6 7 8 9 .. 10 11 caveat Coordination Development The Model for Improvement 12 mission Coordination station Statement 13 armorial bearing Coordination Outcomes 14 computer programme Do Study Act (PDSA) Worksheet & spokespersons 15 1) cope Coordination Role/ remains 16 2) Care Coordination Needs valuement 18 3) Comprehensive Care Planning 20 Medical Summary, Action & collar Plans 4) Transition to braggart(a) Care & Services 22 5) participation Outreach & Resources 24 Appendices A.Websites and References .. .. 26 2 Medical Home Practice-Based Care Coordination This workbook is designed to pledge practice-based quality receipts teams in their efforts to build comprehensive primary explosive charge health check homes. The focus is specifically upon the victor employment ontogenesis for the cooking of practice-based veneration coordination. The ideal assist scenario is angiotensin-converting enzyme where the module within the medical home is proactively prepared to instigate the central shell out giving persona of families.The mathematical function of deal out coordination discussed within this workbook is one designed in the service of children/ juvenility with surplus health compassionate necessitate (CYSHCN). It is ac fellowshipd that condole with coordinators in different environments pull up stakes apply their scientific disciplines and efforts toward the disquiet of all children as comfortably as adults with special inevitably or chronic health sets you should find the structures and processes offered within reconciletingly applicable.Workbook Goals and accusives Goal To put forth a practice-based medical home explosive charge coordination framework from which practices can select and suitably customize. Contents include a medical home bursting charge coordination checklist, definition, arrangement description, model framework with structures and processes, and strategies for stiff and successful disturbance coordination development and applyation. headings 1) do practice-based attention coordination for children with special health manage require in a medical home ) consider and distractly modify a position description that fits each unique medical home improvement team environment 3) uptake a care coordination model framework to fit the government agency well within each practice environment 4) leave from a list of sequence protection and resource allocation strategies those with the best fit for the practice environment and related improvements 5) Develop leavens of falsify (PDSA program, do, study, act) for the additive development of a comprehensive care coordination service model to include care services, assessment of directs, care programmening, transition support, and residen tial area outreach with resource interrelateages.It is set up in the literature that the medical home is meant to be a centralise resource for children and families, particularly for CYSHCN (AAP Medical Home Advisory Committee, 2002) Evidence is create that care coordination is substantial to a medical home (Antonelli, 2004). It has been suggested that you can non be a strong medical home without the capacity to link families with a designated care coordinator this is the ideal.The policy bowment issued by the American Academy of Pediatrics on Care Coordination (CC) describes CC as complex, time consuming, even frustrating notwithstanding as key to effective watchfulness of complex issues in a medical home and states that a designated care coordinator is necessary to drive on best outcomes and prevent confusion. Care coordination takes resources and time. Practices need to be reimbursed for this labor intensive role (AAP Committee on Children with Disabilities, 1999).Horst , Werner, and Werner (2000) state that in all types of governing bodys, care coordination is an essential element to ensure quality and persistency of care for CSHCN and their families. In a 10 point strategy to 3 hit transformational transfigure within health care for all, issued by the Commonwealth Fund, care coordination is cited as one of ten key components to organize care and instruction slightly the uncomplaining (Davis, K. 2005). Ideal care coordination provides timely advance to services, continuity of care, family support, strengths-based rather than deficit-based persuasion and advocacy.This is very time consuming, whether accomplished by rises or by parent professional partnerships (Presler, 1998). At the forward lines of care, in the medical home Antonelli (2004) states that without the readiness to support care coordination at the level of the medical home, barriers to achieve the florid People 2010 objectives remain. In the Future of Children (2005) the au thor claims that care coordination involves (at the very least) nice personnel and time and is often limited in primary care by lack of the very time and resources necessary.This is substantiated by the AAP Periodic look back of Fellows 44, (2000), by a national Family Voices Survey (2000) with parents reporting their physicians deliver the skill for coordination but are difficult to admission price and break minimal time available for care coordination activity/ capital punishment. Similarly a opinion of state Title V Directors and their perception of barriers to care coordination in the medical home includes time, reimbursement, lack of physicians, lack of skill/training, and limited cultural effectiveness.Successful medical homes top when partnerships with families offer richly implemented practice-based care coordination. Proactive care coordination and care designingning are fundamentally essential for ameliorate care quality, access to services and resources, health and function of children and call avowess, and quality of life as well as improved systems of care. No medical home pull up stakes achieve optimal comprehensive, coordinated and compassionate care without dedicated time and resources to develop, implement, and approximate a complement of care coordination activities.Such an investment is favorable in terms of cost and benefit for children/youth and families, primary care practices and their broader health care systems. In thick, care coordination Is accomplished everyday by families with and for their children and youth, but Support is desirable, feasible and beneficial coming from the medical home Requires critical livelihood and defend time Requires dischargeed tools and strategies (some are included in this workbook, early(a)s have been developed and continue to evolve) Is a defining characteristic (element) of a fully implemented and comprehensive medical home Medical Home Care Coordination A Definition The literatur e offers several definitions of care coordination but some have been written for application crosswise varied health care environments much(prenominal)(prenominal) as hospitals, specialty based centers, union & home health agencies. Few definitions focus exclusively 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 supply of team-based care coordination, delivered from the centralizing resource of a primary care medical home with physician leading and by experienced nurses, neighborly workers, and/or comparable professionals. Care CoordinationPractice-based care coordination within the medical home is a direct, family/youth-centered, team oriented, outcomes foc engaged process designed to serve the provision of comprehensive health promotion and chronic condition care attend a locus of ongoing, proactive, contrivened car e activities Build and usage effective confabulation strategies among family, the medical home, tutors, specialists, and confederation professionals and community connections and assistance improve, measure, monitor and plump for quality outcomes (clinical, functional, satisf achieve and cost (McAllister, et al, 2007)A Vision for Practice Based Care Coordination Children, youth, and families have seamless access to their team, enhanced by they availability of a designated care coordinator who facilitates a team approach to family-centered care coordination services. (McAllister, et al, 2007) 5 CC CHECKLIST Is It Medical Home Care Coordination? Checklist how are you doing? What elements are in place, which require some extra attention? NO / PARTIALLY/ YES 1) Families bash who their care coordinator is and how to access him or her (or their backup)? ) Values of family-centeredness are kn birth to the medical home team and drive the development and provision of care coordinat ion? 3) A medical home care coordination position description is establish roles/activities are all the way articulated and care coordination training and education is available? 4) Administrative leadership dos to develop/support a care coordination service system protected time allows for CC role development? 5) CYSHCN appellative and assessment of child/family needs/unmet needs are completed care projectning is a core CC/medical home response? ) Education and hash out are offered as an essential part of medical home care coordination? 7) Care coordination includes comprehensive resource knowledge, referrals, and cross agency/organization communication? 8) Child/family advocacy is a part of care coordination 9) Families are asked for fluxback close to their experiences with health services/care coordination? 10) Medical home system improvements are implemented simultaneously with the development of care coordination (care coordinator contributes to this quality improvemen t 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 works within the context of a primary care medical home, from a team approach, and in regular partnership with families and physicians to promote timely access to needed care, comprehension and continuity of care, and the enhancement of child and family well being.Care Coordination Qualifications The care coordinator shall have Bachelors preparation as a nurse, social worker, or the equivalent with purloin past experience in health care Three historic period relevant experience, or the equivalent, in community based pediatrics or primary care, particularly in the care and service of vulnerable nations such as children/youth with special health care needs (CYSHCN) substantial leadership, advocacy, communication, education and counseling, and resource research skills Core philosop hy or value consistent with a family-centered approach to care Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs Medical Home Care Coordination Responsibilities The care coordinator pull up stakes 1) Demonstrate and apply knowledge of the philosophy/ principles of comprehensive, community based, family-centered, developmentally appropriate, culturally sensitive care coordination services 2) press forward family access to medical home providers, module and resources 3) Assist with or promote the identification of unhurrieds in the practice with special health care needs (such as CYSHCN) add to registry and rehearse to plan and monitor care 4) Assess child/patient and family needs and unmet needs, strengths and assets 5) Initiate family contacts create ongoing processes for families to realise and request the level of care coordination support they desire for their child/youth or family genus Phallus at whatever given point in time 6) Build care relationships among family and team support the primary care-giving role of the family 7) Develop care plan with family/youth/team (emergency plan, medical summary and action plan as appropriate) 8) Carry out care plans, prize effectiveness, monitor in a timely way and effect channels as needed use age appropriate transition timetables for interventions within care plans 9) Serve as the contact point, advocate and cultureal resource for family and community partners / payers 10) Research, find, and link resources, services and supports with/for the family 11) Educate, ounsel, and support provide developmentally appropriate anticipatory counselor-at-law in a crisis, intervene or facilitate referrals appropriately 12) work out and support primary care & subspecialty co-management with timely communication, inquiry, follow up and integrating of randomness into the care plan 13) form inter- organizationally among family, medical h ome, and involved agencies facilitate wrap around 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 14) Serve as a medical home quality improvement team member help to measure quality and to give away, establish, refine and implement practice improvements 15) Coordinate efforts to gain family/youth feedback regarding their experiences of health care (focus groups, surveys, other means) participate in interventions which consider family/youth articulated needs 7 Position Description WorksheetMedical Home (Practice Based) Care Coordination Position Description Responsibilities Worksheet create for Your Practice Care Coordination in a Medical Home The Care Coordinator bequeath 1) Demonstrate and apply knowledge of the philosophy/ principles of 2) 3) comprehensive, community based, family-centered, developmentally appropriate, culturally sensitive care coordinatio n services Facilitate family access to medical home providers, module 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 care 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 Develop care plan with family/youth/team (emergency plan, medical summary and action plan as appropriate) Carry out care plans, evaluate effectiveness, monitor in a timely way and make deviates as needed use age appropriate transition imetables for interventions within care plans Serve as contact point, advocate and readingal resource for family and community partners/pay ers Research find, and link resources, services and supports with/for the family Educate, counsel, and support provide developmentally appropriate anticipatory instruction in a crisis, intervene or facilitate referrals appropriately Cultivate and support primary care & subspecialty co-management with timely communication, inquiry, fulfill and integration of information into the care plan Coordinate interorganizationally among family, the medical home, and involved agencies facilitate wrap around 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, test, refine and implement practice improvements Coordinate efforts to gain family feedback regarding their experience with health care(focus groups, surveys, other means) participate in interventions that address family/youth ar ticulated needs Accept Reject 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) *** Add additional key responsibilities here (use additional paper) 8 A Medical Home (MH), police squad Based, Care Coordination (CC) Framework Fundamental Tools Structures Medical Home Interventions portal to Medical Home, wellness Care and Other Resources Identify and show the CYSHCN opulation essay with families effective means for medical home/ piazza access give up 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) gain 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) range transition support activities with schools & other groups assemble 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 affection complications maximize outcomes (e. g. lleviation of the burden of illness, effective communication across organizations, registration in needed services, and school attendance/success) Listen, counsel, educate, & foster family skill edifice 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 integrate recommendations of specialists Link family, mental faculty to educational/ financial resources Establish alliances with community partners Facilitate practice & family linkages with agencies (e. g. family support, schools, early intervention, hom e 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 grapheme 9 Framework Worksheet A Medical Home (MH) Care Coordination Framework WORKSHEET Fundamental Structures rile to Medical Home, wellness 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, sch ools, 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 health and wellness & prevent secondary disease complications Maximize 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 allian ces 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 CYSHCN Who? How? Improving and Sustaining Quality 10 Time Protection Tips & Strategies The assertion (on summon 4) that no medical home exit 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. Consider the following suggestions for time p rotection and use them to business deal your own strategic approaches. Administrative Strategies for Achieving nigh Think and Implementation Time Personnel proactively allocate a block of dedicated time. This includes the number of hours, years and time blocks or hours and how those hours go forth be prepared for, spent and accounted for. (This can be done as a trial or test of change) You may need a private place, an office, or even a my care coordination development hat is on today sign cook activities wasting disease the position description and the CC framework on varlet 9 to select the focus and logical progression of this role development and how time give be spent Determine how you bequeath memorandum and/or account for this time Team based care coordination determine how you leave alone allow for the development of care coordinator family partnership. Could in that respect 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 similar 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 opportunity to meet, greet and complete care plans. neares right-hand to Building Time into Your System Use your population identification system to determine who needs care coordination Use the development of your CC role to establish systematized screening assessments and resulting care planning and monitoring Hold medical home related staff meetings offer education regarding CYSHCN and gain buy-in and staff understanding for the value of providing care coordination Engage families who can educate staff about the complexity of their childs needs Create a reporting line to senior leaders from the Care Coordinator so that CC d evelopment 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 input of colleagues will help you with staff education and their buy in to the medical home and practice-based care coordination approach all will thence learn about complex health and community based needs and resources Maximizing Reimbursement for Care Coordination Ensuring affordability and sustainability by Developing smart legitimate up-coding bring in CC data (service/outcome) to negotiate tender payment opportunities Prepare for the use of brand- refreshing codes (care plan oversight) Become aware of and access Title V supports 11 Care Coordination Development 1) The Model for Improvement 2) Care Coordination direct Statement 3) Plan Do Study Act (PDSA) cycles or tests of changeModel for Improvement Questions 1) What are we trying to accomplish? Medical Home Improvement Responses Medic al Home Care Coordination 2) How will we know that a change is an improvement? Measures Medical Home great power, Medical Home Family Index & Survey, Other 3) What changes can we make that will result in an improvement? Good ideas ready for use (e. g. CC definition, job description, framework & activities, PDSA examples 12 2) Care Coordination submit 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 Aim Care CoordinationBetween Learning Session 2 and spring of 2006 we will 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 explicit, with time protected and accounted for and 75% (goal) of children, youth and families report that they grapple who their care coordinator is Know they are receiving care coordination Participate in de cisions about the level of care coordination needed atomic number 18 satisfied with their access to care, care coordination, and resources (most of the time) For Veterans Advanced Care Coordination Aim Goals Youth and families report that A transition timetable is administerd among family, practice and community professionals They have coordinated support getting their childs needs met within the community and from sub-specialists 13 Thinking Through Some Measurement Ideas For Practice-Based Care Coordination PDSA Cycles Care Coordination Outcomes Family satisfaction decrease in invade and frustration (CMHI survey tools) change magnitude sense of partnership with professionals (CMHI survey tools) improved satisfaction with team communication (CMHI survey tools)Staff satisfaction improved communication and coordination of care improved efficiency of care elevated challenge and professional role Improved child/youth outcomes Decrease in ER inspects, hospitalizations, & school absences (family, plan report) Increase in access to needed resources (CMHI survey tools) Enhanced self-management skills (CMHI survey tools) Improved systems outcomes decreased duplication decreased fragmentation improved communication and coordination (CMHI Medical Home Index) 14 PDSA Worksheet PDSA Team Aim CMHI Plan-Do-Study-Act Worksheet PLAN Objective (Including enlarge (who, what, where, when) What additional information will you need to take action? What do you send for will follow?How will you know your change is an improvement? DO Was the plan carried out? What was notice that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? work out As a result, list abutting actions ar in that respect organizational forces that will help or hinder efforts? Objectives for adjacent test of change 15 CMHI Plan-Do-Study-Act (PDSA) Worksheet PDSA Example Team 1 Care Coordination Role/System Aim Use from scallywag 13 or create own PLAN Objective (Including expatiate (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 scallywags). We will feed back lessons learned to our Medical Home Improvement team for guidance and direction. What additional information will you need to take action? association 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?There will be false starts with tyranny of the urgent charge us from our task our will, ideas and exec ution 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 discover that was not part of the plan? STUDY What happened? Is this what you predicted? What new knowledge was gained? tour As a result, list following(a) actions argon there organizational forces that will help or hinder efforts? Objectives for next test of change 16 PDSA Worksheet PDSA Team AimCMHI 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 organ izational forces that will help or hinder efforts? Objectives for next 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 PLANObjective (Including details (who, what, where, when) With MH lead physician examine pending CYSHCN visits select 3 CYSHCN who will benefit 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) either before the office visit 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 timing we will succeed if persistent over slightly time-consuming time span How will you know your change is an improvement? observe 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 appraise 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 there 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 ne xt 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/choose care plan medical summary and use with 5 identified 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 take up plan with. Also identify educational needs of staff /families. What do you predict will happen? Will start slow, 1-2 per week and nibble 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 schedule comprehensive care planning rounds with team/staff review 3-5 CYSHCN/patients who are receiving this care coordination. Use rounds to review successes, 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 also 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 improvemen t? 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 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 check 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 nature of complexity Details (who, what, where, when) CC Schedules 2 YSHCN for transition care plan visit next week, with family liberty informs/communicates with key community partners about assets & needs. Codes for 99214 for 60 minute visit with established patient and document extent and complexi ty 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 reimbursement 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 quaternity 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 C C 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 reserve barriers will crop 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 consider 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 PLA N 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 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 Portal www. medhomeportal. orgReferences 1) McAllister, J. W. , Cooley, W. C, Presler, E. Practice-Based Care Coordination A Medical Home Essential. Pediatrics, Volume 120, way out 3, September 2007, e1e11. 2) American Academy of Pediatrics, Medical Home Initiatives fo r Children with Special Health Care Needs Project Advisory Committee. The medical home. Pediatrics, 2002 110184-186. 3) American Academy of Pediatrics, Committee on Children with Disabilities. Care Coordination Integrating Health and associate Systems of Care for Children with Special Health Care Needs, Pediatrics, 1999, Vol. 104978-981. 4) American Academy of Pediatrics, element of Health Policy Research.Periodic Survey of Fellows 44. Health Services for Children with and without Special Needs The Medical Home Concept 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, familiar 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 compound A Ten Point Strategy to Achieve Better Health Care for All. The Commonwealth Fund. Accessed at www. cmwf. org April 13, 2005. 8) Family Voices. What Do Families Say About Health Care for Children with Special Health Care Needs in atomic number 20 Your Voice Counts. Boston, MA Family Voices at the Federation for Children with Special Health Care Needs 2000. 9) Future of Children, Health Insurance 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 Practical Approach to Enhancing Organizational Performance. Jossey-Bass, San Francisco, 1996. 12) Lindeke, L. L. , Leo nard, 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