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Building Health in Home Visiting

Colleen Kraft, M.D., FAAPAssociate Professor of Pediatrics, University of Cincinnati

School of Medicine Medical Director, Health Network at Cincinnati Children’s,

Cincinnati Children’s Hospital

Early Experiences are Crucial

• By age 3, 80% of synaptic connections are already made

• By the second decade of life growth levels off and pruning begins

• Increased experiences define the wiring of an infant’s brain

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Human Brain

at Birth6 Years

Old14 Years

Old

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Eco-Bio-DevelopmentalModel of Human Health and Disease

BiologyPhysiologic Adaptations 

and Disruptions 

Life Course Science

The Basic 

Science ofPediatrics

EcologyBecomes biology,

And together they drive development across the lifespan

Critical Concept 

The Science of Early Brain and

Child Development

Epigenetics Physiology of Stress Neuroscience

Education Health Economics

One Science – Many ImplicationsThe critical challenge now is to translate

game-changing advances in developmental scienceinto effective policies and practices for families w/ children

to improve education, health and lifelong productivity

Critical Concept

For young children, Caregivers create the environment for brain

development!

• Caregivers can turn off physiologic stress response by addressing physiologic and safety needs

• Turns off the physiologic stress response by promoting healthy relationships and attachment

• Notes and encourages foundational coping skills as they emerge

Early Childhood professionals are ideally placed!• Promote this sort of “Purposeful” Parenting• Advocate for a public health approach to address toxic stress

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Carilion Clinic-Aetna Partnership

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Carilion Clinic

ACO

Carilion Clinic 

Physicians

Private Practice Physicians

Update: 12/08/2011

Virginia Medicaid Regions

Family-Centered Medical Home

Child and Family

Developmental Services

Home-visitingnetwork

Early Intervention

Child CareResource &ReferralAgency

Early HeadStart& HeadStart

Early ChildMental Health Services

Prevention,BuildingHealth

Acute Care

Chronic Care

Developmental Services

Parenting Support

Lactation Support

Vulnerable children and families

Medically Complex Children

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Medical Home: Pediatric “Extensive” Care

Child and Family

Shared In‐basket with 

EHRHealth 

Concierge; Screening, risk id

Medical or social needs, refer to CHIPCYSHCN, 

refer to CCC , Special  Families

Anticipatory Guidance 

reinforced in‐home

Oral Health Ed, 

Fluoride, dev scr

Home Visiting Partners for Higher Risk Families

• Child Health Investment Partnership of the Roanoke Valley

• Home Visiting with a Health Focus

– Parents As Teachers

– Oral Health

– Asthma Management

– Pregnant Moms

– Behavioral Health

Who are the Home Visitors?

• Team Care– Each team has one RN

– Three “family intervention specialists”• AAS trained

• Trained in Evidence-based model (Parents As Teachers)

• Often from community being served

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Care Management Design

• Home Visiting Contract– Paid per member/per month

• “High Touch”, in-person, in-home

• Data Collected in home– HEDIS metrics

– Health Outcomes

– Reduced costs

Routine Medical/Social Screening

• Screening, Risk Stratification, Communication– Personnel dedicated to this position (health

concierge)

– Ability to connect more important than education

– Could be a family partner

– Becomes a “point of contact” for the practice

– Can sign up families for text4baby and healthychild.org “push” notifications, select blogs, Facebook groups

– Can facilitate appointments or point-of-care referral14

Safe Environment for Every Kid

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Early Childhood support/guidance

• Parents as Teachers

– Parent/Child curriculum

– Frequent Developmental Screening

• Safety

– Sleeping

– Car seats

– Home safety

• Anticipatory Guidance

– Relevance in home setting

Oral Health and Fluoride Varnish

• Begin with a Grin!

Asthma Case Management

• Assess environment, modifications

• Smoking cessation

• Observe inhaler use

• Asthma control assessment

• Asthma action plan and education

• Transportation to visit

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Behavioral Health

• Prenatal to age 7

• Perinatal/postpartum depression screening

• Connection to services for parents and children at‐risk and diagnosed

• Transportation to visits

Results

100% families receive early childhood education

90% 2yr olds UTD on well visits and immunizations

100% children are screened for lead, Hgb, development

100% children have a Dental Home

66% of children have had a dental visit by age 3

97% have had an oral health assessment and fluoride 

varnish

145 children in program 2011‐2012

84% well controlled

84% minimal inhaler use

90% decrease in ED visits

82% decrease in school absence due to asthma

HV/MH Integration in Cincinnati

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DRAFTWhat A Well‐Trained Clinic Will Detect

Maslow’s Hierarchy of Needs

Hunger; homelessness; denial or delay of benefits; 

utility shut offs

Domestic violence; mental health issues; inadequate education 

services

Overwhelmed new parents; lack of 

parenting role models

Unemployment; lack of high school degree; ex‐offender reentry 

issues

Potential Collaborations

Achieving potential

Esteem & Respect

Belonging

Safety

Basic Human Needs

A. Henize (2013)

Using EMR to drive social history screening

Benefits

Housing

Depression

Domestic Violence

All others

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5

10

15

20

25

30

35

40

May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13 Oct‐13 Nov‐13 Dec‐13 Jan‐14 Feb‐14 Mar‐14 Apr‐14

# of referrals/1000 W

ell Child

 Visits

Child HeLP Referrals per 1000 Well Child Visits

PPC Fairfield Hopple

Connecting to Community Services

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KIND (%) No KIND (%) P

Lead complete 81 75 <.01ASQ complete 27 20 <.01≥5 well visits in first 14 months

42 29 <.01

Social risks identifiedFood insecurity 57 10 <.01Parental depression 11 5 <.01Housing issues 15 6 <.01Benefit issues 24 14 <.01Domestic violence issues 5 2 <.01

Referrals to social work 29 18 <.01

Referrals to MLP 15 6 <.01

Preventive services use among children receiving free formula (KIND) vs. who did not (Klein)

Health Network by Cincinnati Children’s

Fee for Service Payments

HNCC Network providers

CCHMC Employed Physicians

Cincinnati Children’sHospital

Quality IncentivesInfrastructure for practice improvement

Variable Capitation

HNCC network

State of Ohio ODJFS

Utilization Mgmt.Medical ManagementFamily Engagement

Medicaid MCO

Risk adjusted PMPM for

defined population

Provider‐SPONSORED

PLANS

CAPITATIONFULL RISK

SHAREDRISK

SHAREDSAVINGS

BUNDLEDPAYMENTS

CLINICAL INTEGRATION

PCMHP4P

PROVIDER-SPONSORED

PLANS

CAPITATIONFULL RISK

SHAREDRISK

SHAREDSAVINGS

BUNDLEDPAYMENTS

PCMHP4P CLINICAL INTEGRATION

PHO

8/22/2014

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Month

ED Visits and Percent Low Acuity (Triage Level 4 & 5) by Month

Number of ED Visits (scale on left) Percent of Visits Low Acuity (scale on right)

Last update: 07-25-14 by H. Atherton Data source: EPIC

PPC

All ED visits are included in this measure, regardless of whether the patient was admitted from the ED or

went home.

Since July 2013 there have been almost 4500 less ED visits by PPC patients

8/22/2014

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8/22/2014

Since March 2013 we have reliably delivered preventive services at almost 29,000 visits

8/22/2014

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Bending the Cost Curve

8/22/2014

Strategies

• Identify roles of all Home Visitors and connection to OB practices;

• Consider using the prevention bundle as a “chronic condition” for PCMH;

• Resources for PCMH: consider how practices link to HV, parent play/support, HNCC if they are in our network

Considerations

• Medicaid Managed Care?

• Children’s Hospital?

• Accountable Care Organization?

• Physician Champion?

• High Medicaid Population?

• Electronic Medical Record sharing?

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Questions?