bringing the medical home…home: a state specific model march 3, 2005 carol dorros, md margo...

Bringing the Medical Home…Home:A State Specific Model

March 3, 2005

Carol Dorros, MD

Margo Chiappinelli, AuD

First Connections Training and Resource Project for Newborn Hearing Screening

A RI Department of Education and RI Department of Health Collaboration. Supported in Act, Health Resource and Services Administration, Department of Health and Human Services part by project 1 H61 MC 00009 from the Maternal and Child Health program (Title V, Social Security Project funds managed by The Hearing Rehabilitation Foundation.)

Acknowledgements and Thanks

Ellen Kurtzer-White, Au.D.* Project Director, First Connections

Marianne Ahlgren, Ph.D, CCC-A Project Coordinator, First Connections

Mary Catherine Hess, MAAdministrator, RIHAP

Betty Vohr, MDMedical Director, RIHAP

American Academy of Pediatrics * deceased

Presentation Objectives

• Present Rhode Island’s newly developed algorithm for medical home providers

• Present the process of its development

• Discuss gaps identified and opportunities/solutions for strengthening our EHDI system

Background

Literature and the RI experience indicate that the EHDI system needs refinement to better respond to significant issues for families:

The emotional response to diagnosis Availability and access to expert services Increased stress and delays in services

when system is fragmented

Background

• AAP recommends a Medical Home for all children with special health care needs. (AAP position statement RE9902, 1999)

• A medical home is defined as an approach to providing health care services where care is:

- accessible- family-centered- continuous- comprehensive

- coordinated- compassionate- culturally competent

Background

Joint Commission on Infant Hearing recommends a Medical Home for all children with hearing loss.(AAP position statement, SO 60016, 2002)

“Pediatricians and other primary care providers, working in partnership with parents and other health-care professionals, make up the infant’s “medical home.”

RI Medical Home Task Force for Children with Hearing Loss

Goals:

• Identify strengths and barriers in the RI EHDI system

• Refine the system into one that is better informed, competent and linked.

• Develop a medical home model specifically for RI’s infants with hearing loss.

Task Force Development

• Multidisciplinary team of stakeholders

• Met monthly

• Total of approximately 2 years

Initial 1 ½ years examining current system

-Identifying system strengths/barriers

-Defining roles of professionals involved

Algorithm development took 8 months

Task Force Participants

• Audiologists (community and hospital based)• Members of the Deaf Community• Early Intervention Administrators • Family Guidance Providers • Otolaryngologist• Parents• Pediatricians ( PCPs and hospital based)• Rhode Island Hearing Assessment Program Admin.• Rhode Island Dept. of Health Admin.

Working Towards a Solution…

A State Specific Algorithm

Algorithm Goals

Specifically designed for RI PCPs in order to enhance the effectiveness of the medical home and provide a more seamless experience for families.

Physicians requested: One page document Defining flow of the RI EHDI system Defining roles/responsibilities of partners Local resource names and phone numbers

Algorithm Development

• Stakeholders met monthly for a period of about 8 months

• Revised the AAP/NCHAM algorithm to reflect the specific process and resources in RI

• Systematically discussed all language, information

and process for inclusion, exclusion or modification

• Decisions all made by a consensus model

BirthScreen

RIHAP*(401-277-3700)

Identify a Medical Home for every infant

PCP InformedPhone family to encourage themto follow through with rescreen

Pass

MissedIncomplete

Did Not PassRIHAP contacts family

and schedulesa rescreen

3

Hospital-based Inpatient Screening(OAE/AABR)

Results sent to PCP

At least 2 screeningattempts recommendedprior to discharge

Gap: Unclear language within algorithm

Solutions:

Clarified that screening “results are sent to PCP” rather than the “medical home”

Changed “Refer” to “Did not Pass”to clarify meaning to target audience

A t le a s t 2 s c re e n inga tte m p ts re c o m m e n d e dp rio r to d is ch a rge

H ospital-based Inpatient S creening(O A E /A A B R )

R e s u lts s e n t to P C P

MissedIncomplete



Pass

Gap: Responsibilities/Roles unclear

Solutions:

• Added header line with partners responsible for each stage of process

• For infants who do not pass the initial screen, the algorithm identifies who makes referral for re-screen

RIHAP contacts family and schedulesa re-screen.

• To support the medical home, developed PCP action point

Phone family to encourage them to follow through with re-screen.

Ongoing Care of All Infants

Ongoing Care of All Infants

Provides opportunity to remind PCPs about:

• Elements of comprehensive care related to hearing, vision, speech, language and overall development

• Monitoring for hearing loss that may occur out of the newborn period

• Risk indicators for late-onset hearing loss that require referral for audiologic monitoring

Before 1 Month

Birth

A t le a s t 2 s c re e n inga tte m p ts re c o m m e n d e dp rio r to d is ch a rge

H os pita l-ba sed Inpatient S cree ning( O A E /A A B R )

R es u lts s ent to P C P

Screen RIHAP*(401-277-3700)

Identify a Medical Home for every infant

Before 1 MonthRe-screen

RIHAP

Outpatient Screening

(OAE/AABR*)

Results sent to PCP

PCP Informed

Phone family to encourage themTo follow through with rescreen

Pass

Did not passRIHAP recommendsdiagnostic testing

Home births

Pass

MissedIncomplete



PCP Informed

Phone family to identify an audiologist and support need for

follow-through

Gap: Unclear roles/responsibilities

Solutions:• For infants who do not pass the re-

screen, the algorithm identifies who is responsible for next step RIHAP recommends diagnostic testing

• Added a PCP action point to support the medical home

PCP phones family to identify anAudiologist and support the need for follow-through

Before 3 Months

Before 3 Months Referred for Diagnostics Follow-up Every child with suspected hearing loss Every child identified with a permanent hearing loss

Pediatric Audiologic Evaluation

RIHAP can be contacted for a list of Pediatric Audiologists, 401-277-3700, Fax 401-276-7813

Otoscopic inspection

Child & family history

Middle ear function

OAE*

ABR*

Frequency-specific tone bursts

Air & bone conduction

Audiologist counsels parents about results and recommendations

NormalHearing

HearingLoss

PCP sets up an appointment with family to review the results, intervention

benefits, and follow-up.

Audiologist reports diagnosis to RIHAP (401-277-3700)

Audiologist refers for early intervention and family support:Specific Early Intervention Program ***Family Guidance Program (401-222-4013) PCP initiates medical evaluation

PCP refers to otolaryngologistFor evaluation, to recommend treatment, and to provide clearance for amplification

Partners in Care inform family(Audiologist, ENT, Family Guidance Program, others)about communication, amplification and cochlear implants

Community Audiologist Hearing Loss Professionals and Organizations

Results to PCP

Results Sent to PCPSupport follow-up, with Audiology, EI, and Family Guidance Program.



HearingLoss



Results to PCP

Diagnosis: Hearing LossGap: Lack of family-centered communication

Solution:

• Address emotional distress of family

• Emphasize hope, not necessarily technical information

• Allow the family to indicate how much information they can take in at the time of diagnosis

• Recognize that the family may need time to process information.

Family-centered communication between audiologists & families promotes a more satisfying and successful interaction



HearingLoss



Results to PCP

Diagnosis: Hearing LossGap: Meaningful Communication from Audiologist to PCPReports from the audiologist to the PCP about diagnostic results provide an opportunity for team building and decreased fragmentation of care

Solution:

Communication to PCP should:

• Describe the degree, type of HL & implications for social and academic development

• Use non-technical language

• Specify interventions and services needed

What audiologist has done What PCP needs to do

Diagnosis: Hearing LossGap: Unclear roles/ responsibility for PCP

Solution:

PCP Action Point

• PCP needs to be informed of plans and issues

• Allows PCP to support family & assist in facilitating follow-up



HearingLoss



Results to PCP

Before 3 Months Referred for Diagnostics Follow-up Every child with suspected hearing loss Every child identified with a permanent hearing loss


RIHAP can be contacted for a list of Pediatric Audiologists, 401-277-3700, Fax 401-276-7813

Otoscopic inspection

Child & family history

Middle ear function

OAE*

ABR*

Frequency-specific tone bursts

Air & bone conduction


NormalHearing

HearingLoss







Community Audiologist Hearing Loss Professionals and Organizations

Results to PCP


Follow-up: Permanent HLGap: Unclear roles and responsibilities

Solutions:

• Identified responsible parties (titles and phone numbers) and expected actions

• Changed “advise family” to “Partners in care inform family”

• Developed PCP action point






Follow-up: Permanent HLGap: Lack of communication among partners

Solution:

PCP Action Point

• Only if PCP informed, can he/she support the family in their journey

• Ongoing communication among partners in care maximizes the opportunity to create the most effective MH

Audiologist reports diagnosis to RIHAP

Audiologist refers for early intervention and family support: PCP initiates medical evaluation

PCP refers to otolaryngologist

Partners in Care inform family

Results Sent to PCP

Support follow-up with Audiology, Early

Intervention,and Family Guidance Program

Before 6 Months

Before 6 MonthsContinued Follow-up

Every child identified with a permanent hearing loss

Audiologists/Early Intervention Programs/ Medical Specialists

Continued enrollment in Early Intervention and Family Guidance Program

Provide services until transition to school system at 3 years of age

Medical Evaluations

To determine etiology and identify related conditions

Genetic

Ophthalmologic (annually)

Developmental pediatrics, neurology, cardiology, and nephrology (as needed)

Pediatric Audiological Services

Hearing Aid fitting and Monitoring

Behavioral Audiometry (starting at age 6 months)

Ongoing monitoring

RI AlgorithmHow are we using it?

• Distributed to all RI PCPs and partners in care

• To be included with all results sent to PCPs regarding:

– Initial screen “Did Not Pass”

– Infants identified at at birth with risk factors for late onset HL

• Educational programs for partners in care

• A phone survey through RIHAP will be ongoing to document questions or comments regarding the algorithm

Conclusions

Developing a state specific algorithm is a very worthwhile exercise

The process facilitates communication among partners in care

Provides a succinct illustration of state specific EHDI system flow

Defines roles of partners in the medical home

Identifies gaps in the system

Identifies opportunities for improvement

Special ThanksFirst Connections Training and

Resource Project:Project DirectorEllen Kurtzer-White, AuDProject CoordinatorMarianne Ahlgren, PhD, CCC-APrincipal InvestigatorPeter Simon, MD, MPH

Other Medical Home for Hearing Loss in Children Task Force Members:

Robert Burke, MD, MPHMemorial Hospital of RI

Brian Duff, MDUniversity Otolaryngology

Deborah Garneau, MAOffice of Families Raising Children with Special Needs

Ellen Gurney, MD

Providence Community Health Centers

Mary Catherine Hess, MA

RI Hearing Assessment Program

Kerri Hicks

Parent

Mary Jane Johnson, MEd

Family Guidance Program

Jennifer LeComte, MA

Family Guidance Program

Deborah Lyons, MS, CCC-A

RI Hospital Dept of Audiology

Cheryl McDermott, MS, CCC-A


Courtney O’Neill, MS, CCC-A


Betty Vohr, MD


bringing the medical home…home: a state specific model march 3, 2005 carol dorros, md margo...

Documents

pass slide

birth slide

competent slide

deceased slide

month slide

discharge slide

fragmented slide

ehdi system slide