Speaker 1: What do we mean by high-performing care coordination in a patient-centered medical home? It is building a patient family-centered medical home that contains all of the components necessary to provide families with the foundation, support, sustainability, and continuity of care they need to thrive. Let's take a look at this house one piece at a time. This house is built on a strong foundation of core values, supported by four pillars, protected by a roof comprised of standards for improvement and evaluating outcomes, enhanced by excellent internal and external communication, accessible. It is available to anyone needing coordination of care, built to code with room to grow, in need of ongoing upkeep and maintenance, and nurtured by compassion. Building a patient and family-centered medical home takes hard work. Remember, care coordination is not a solo effort. It is a team effort involving the patient and family, the care coordinator, the entire staff, which may include registration staff, social workers, medical assistants, nurses, and others, as well as a network of healthcare providers. But care coordinators play a central role as builders. At times, care coordinators function like architects. Sometimes they function like engineers. Architects are skilled at designing things. Engineers are skilled at applying those designs to real-life situations. Why does care coordination matter to families? Because it leads to greater access to community services. Improved skills for self-advocacy and self-care. Opportunities to connect with other families through parent-to-parent support groups and other exchanges of information. Counseling and health education that can provide knowledge to help patients and families maintain a healthy lifestyle. Greater capacity to navigate the system by becoming self-advocates and gaining knowledge about different services and programs in their communities. The medical home is important for payers because it results in optimal quality outcomes. Improved performance on practice quality indicators. Lowered cost of care by preventing unnecessary emergency department visits and over-utilization of services. Timely access to information, such as current improvement quality measures on chronic care management and preventive care services, as well as access to providers' performance reports. Improved patient outcomes and satisfaction through better-coordinated care. And by conducting patient satisfaction surveys, timely access to services, extended hours, same-day appointments, and timely clinical advice during and after office hours. Comprehensive care coordination and the medical home are important for the practice team because they result in effective communication through pre-planning and post-appointment follow-up, for example, that yield more efficient and productive patient encounters. Reduced duplication of effort. One example is by avoiding unnecessary reordering of tests or appointments that could result from a lack of communication. Increased cost effectiveness by scheduling patients for only necessary and missing services. Constantly reviewing processes for best practices and lessons learned and adjusting to changes. Improved staff and provider job satisfaction by creating a sense of efficiency by having open and ongoing communication among team members. In most cases, the services of the care coordinator may not be billable, but their work adds significant value to the efforts of the team. Care coordinators often have their ears to the ground in a way that can uniquely respond to the needs of patients and families. We need an organized system that fosters high-level care coordination, implementation, and sustainability in order to lead to effective teamwork and improve communication among the practice team and partner organizations. Recognizing care coordinators' unique contributions, such as supporting the practice team by serving as a mediator between the patient, family, and practice team, and assisting patients and families in accessing medical and non-medical services, and ultimately job satisfaction for the care coordinator. As architects, care coordinators are in the role of designing the home based on their understanding of the practice structure. As engineers, care coordinators are in the role of linking evidence-based practices as well as local knowledge that comes from experience with programs and approaches that work. Building a care coordination structure requires knowledge of the organization's mission, history, goals, and realities, pair requirements, practice performance goals, NCQA matrix requirements, professional standards, and a toolkit of both existing tools and those created by the care coordinator throughout the process. Now that we have talked about the importance of care coordination in a patient family-centered medical home, we have a better understanding of how to build a solid, sturdy medical home. But it is important to remember that each home has requirements that must be met. All of the components have a purpose, and each is linked to the others. Now let's take a look at each of the components in more detail, starting with a solid foundation of mutually held values. The foundation of comprehensive care coordination in the patient-centered medical home involves sustainability, authenticity, quality, caring, and partnership throughout all states of the medical home implementation and sustainability. The key components to a solid medical home are proactive screening, outreach and education, comprehensive health, mental and behavior services, and social services, and attention to transition of care. Developmentally supportive, patient and family-centered, focused on the family and patient's global needs, and finally, coordinated. All services are coordinated for the patient and family. Now let's talk about the pillars of a patient family-centered medical home. The pillars are support beams, and each is essential and requires careful construction and ongoing maintenance. Each of the four pillars are essential for high-performing care coordination. The pillars offer practice team support and accountability, create interagency partnerships, implement surveillance and tracking systems, such as patient registries, and referral follow-up tracking systems, and implement evidence-based guidelines for consistency and sustainability. The first pillar addresses the practice team and support. It refers to care planning and management. Care coordination is not a solo approach. It should be a team approach. Here's where you can maximize the practice care team support and resources by linking the patient and family with the team. Care coordination is an integral part of the clinical team. Care coordinators are members of the team and serve as mediators between providers and patients and families. Care coordinators participate in huddles, team meetings, and informal conversations regarding their patients and families. The practice needs to develop a commitment to the team approach and team interactions, including engagement with patients and families. Improved practice needs to translate into policies. Organizations have the responsibility to develop, implement, and maintain systems change in order to provide families and patients with a responsible healthcare system. The second pillar relates to community resources through the development and sustainability of partnerships. It is important to know how to create and maintain trusting partnerships with other agencies and providers in order to expand the access to care and services for patients and families. This can be done by connecting the family and patient to resources on the local, state, or national level and finding the appropriate connections for families based on their needs. Developing strategic relationships in order to build integrated networks of services and identifying services that meet patient and family medical and non-medical needs, including cultural and linguistically appropriate care. Cutting through red tape to expedite solutions. As mediators, care coordinators can leverage their connections to access and expedite services for their patients and families. Finding the right go-to people and agencies. This can be achieved through the community partnerships and resources that care coordinators are able to build, as well as knowing where to refer their patients and families. You learn this as you build your structure of services and care. Co-managing care partnerships. This is about developing a co-management agreement between the referring providers and the subspecialists. In many cases, it is necessary and important to have a memorandum of understanding between both providers in order for each party to know and understand their individual responsibilities. The third pillar relates to patient surveillance and tracking systems. It involves utilizing patient registries, screening, and health assessment to identify patients with special needs, high-risk and complex needs, and children and youth with epilepsy and other chronic conditions for care coordination. Tracking systems and databases you might use include those for referrals, tests, and procedures, and flu shots. At the clinical level, information would be organized using electronic health records, managed care plans and performance reports, and up-to-date medication lists and care plans, as well as summer reports from referrals or tests. The fourth pillar refers to evidence-based guidelines. Pediatric physician quality measures, or PPQM, are the health indicators or measures that your practice is focusing on that are of high priority. For example, some practices may be focusing on asthma control, childhood immunizations, or child well-care visits. It is important that you track how well the team incorporates these measures. Be sure to consider the tracking tools you are using and the process you have in place to manage your progress. We have reviewed and explored the key components of a patient- and family-centered medical home, four pillars, a protective roof, effective communication, and full access to care. This well-built home requires compassion in order for it to function well. Compassion is necessary for the patients, for colleagues, and for care coordinators. Communication is essential, whether it is via traditional tools, emails, the patient portal, et cetera. Care coordinators are the heart of the medical home, driving the architecture and engineering of the home, but also providing the compassion necessary to transform the house into a home. They promote efficiency and continuity of care, focus on helping people's needs get met, make it easy to come and go, and create a friendly environment and prepare patients and families for the future. Let's talk about how to assure protection for patients and the practice. There are two ways. Performance improvement. By identifying core measures such as asthma, well-care visits, and others, we can ensure accountability by the practice and providers. Outcome evaluations. How do we evaluate outcomes? A practice's performance is measured at different levels, such as the state and federal level. The practice is held accountable for meeting target goals of care and for reducing costs, as well as for improving quality of care for patients and families. We can use tools such as Continuum Quality Improvement, or CQI, projects that track trends and offer feedback for the effectiveness of our actions and the opportunity of mid-course corrections. Some questions to consider within your practice. How has satisfaction been improved? Conducting patient satisfaction surveys is one way of measuring improvement. Some practices decide to conduct patient satisfaction surveys monthly, quarterly, or annually. Find out what your practice is doing and how after they conduct patient satisfaction surveys. Which specific patient family outcomes measures are useful? For instance, reducing emergency department visits and or reducing days of missed work or school. Evaluation and performance improvement based on the selected measures within the medical home. It also depends what the practice is focusing on, so think about your practice goals. Decreasing costs to the family and to payers is a priority. Outcome measures can inform us about decreased ER use, reduction in unnecessary hospitalizations, as well as fewer missed days from work or school.