Download Présentation d`Adriana Matiz

A MEDICAL HOME MODEL
FOR CHILDREN WITH SPECIAL HEALTH
CARE NEEDS
Adriana Matiz MD
Associate Professor of Pediatrics
Columbia University Irving Medical Center
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Our Community
Northern Manhattan
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Community Data- Census 2015
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66% Hispanic
54% foreign-born
52% Spanish-only
56% Low acculturation score
43% have a household income <$20,000 USD
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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”
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Asthma
Autism
ADHD
Complex congenital heart
disease
Multiple Organ Involvement
Seizures
Gastrostomy, Tracheostomy
Neural tube defects
Chronic Lung
Diabetes
Disease
Genetic Syndromes
Cerebral Palsy
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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
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Latino Children in the US
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•
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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
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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
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© Copyright 2011 NewYork-Presbyterian Hospital
Special Kids Achieving Their Everything
(SKATE)
University
Improved care for
high-risk & high-cost
pediatric
populations
w/specialized needs
Inter-disciplinary
team -based visits
for patients
w/complex medical,
behavioral &
social morbidities
Goal of 25%
reduction in
Community
MDs
preventable
ED visits
& inpatient
re-admissions
Community based
non-physician care
for stable patients in
need of chronic
disease monitoring
(CHWs, CBOs)
Intensive Care
Coordination
Outcomes Evaluation
Funding from Medicaid Reform in New York
Program
Management
Program Manager
Physician Leads
Care
Management
Care Managers
3 FTE
Community Health
Workers (CHWs)
4 FTE
Psychiatric NPs
3 FTE
Information
Technology
Patient Registry
Tailored
appointments
Integrated CHW
findings in EMR
Adapted EMR
Interdisciplinary
In
Team Meetings
Pediatric Care Managers
 Navigation
– 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
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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
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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
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Population
4600
4400
4200
4000
Patients
3800
3600
54%
46%
3400
Males
N=8162
March 2017
Females
Age Distribution
4000
3500
3000
2500
2000
1500
44%
46%
1000
500
10%
0
0-7 years
8-17 years
18-65 years
Risk Stratification
60
50
40
30
20
Risk Level
50%
36%
10
0
Level 1
Level 2
7.5%
6.5%
Level 3A
Level 3B
Pediatric Practices
1400
1200
1000
Level 1
800
Level 2
600
Level 3A
Level 3B
400
200
0
Audubon
Broadway
Rangel
WHFHC
Risk Stratification
12% have a care
manager
Risk Level
6.5%
7.5%
Level 1
50%
36%
Level 2
Level 3A
Level 3B
CHW Cases
40
35
30
25
20
15
10
5
0
Level 2
N=76
Level 3A
Level 3B
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
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Patient/Family
Diagnosis understanding
Knowledge on accessing care
Medication management
Confidence in selfmanagement
 Level of distress
 School connectivity
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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.
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CONTACT INFORMATION
Adriana Matiz MD
Associate Professor, Columbia University Irving Medical Center
Medical Director -- Center for Community Health Navigation
[email protected]
212 342-1917
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