Journal of Social Work in Disability & Rehabilitation, 14:61–75, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 1536-710X print=1536-7118 online DOI: 10.1080/1536710X.2015.989562
Patient-Centered Medical Homes for Patients with Disabilities BRIGIDA HERNANDEZ, MARCO DAMIANI, T. ARTHUR WANG, and CAROLYN DRISCOLL YAI Network, New York, New York, USA
PETER DELLABELLA Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, New York, USA
NICOLE LEPERA Philadelphia Consultation Center, Philadelphia, Pennsylvania, USA
MICHAEL MENTARI Asian Pacific Counseling and Treatment Centers, Los Angeles, California, USA
The patient-centered medical home is an innovative approach to improve health care outcomes. To address the unique needs of patients with intellectual and developmental disabilities (IDDs), a large health care provider reevaluated the National Committee for Quality Assurance’s 6 medical home standards: (a) enhance access and continuity, (b) identify and manage patient populations, (c) plan and manage care, (d) provide self-care and community support, (e) track and coordinate care, and (f) measure and improve performance. This article describes issues to consider when serving patients with IDDs. KEYWORDS accommodations, health care, health promotion, intellectual and developmental disabilities, intellectual disability, medical home, medical social workers, patient-centered
With the United States aiming to improve the quality and affordability of health care, the patient-centered medical home (PCMH) has been receiving more and more attention as an innovative approach to primary care (National Address correspondence to Brigida Hernandez, PhD, Director of Research, YAI Network, 460 W. 34th Street, New York, NY 10001, USA. E-mail: [email protected] 61
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Committee for Quality Assurance [NCQA], 2011). Using a partnership framework that is patient-centered, the medical home seeks to replace episodic and fragmented care with care that is continuous, coordinated, and comprehensive. Central to the medical home is an ongoing and supportive patient–physician relationship that works collaboratively to improve the delivery and quality of care. Specific goals include increasing patient access, experience, and satisfaction; better managing of chronic conditions; improving health outcomes; and reducing the overall cost of care. The NCQA is a nonprofit organization that oversees the application process for practices seeking PCMH recognition. This article describes how a health care organization that serves primarily patients with intellectual and developmental disabilities (IDDs) reevaluated NCQA’s medical home standards to address the unique needs of this population. The lessons learned from this process are presented herein. Initially advanced by the American Academy of Pediatrics during the 1960s, the current iteration of the medical home principles seeks to address the needs of all patient populations. In 2007, four major physician groups (the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association) issued the following Medical Home Joint Principles: 1. A personal physician is provided to each patient and this physician provides continuous and comprehensive care. 2. The personal physician directs a team of providers who collectively take responsibility for the patient’s ongoing care. 3. A whole person orientation is used by the personal physician who understands and respects each patient’s unique needs, beliefs, cultural values, and preferences. 4. The physician-led care team is responsible for coordinating and integrating care across multiple providers including specialists, hospitals, home health agencies, and nursing homes. 5. Quality and safety are assured through the use of evidence-based practices, information technology, clinical decision support, and review of quality indicators such as performance measures and patient feedback. 6. Enhanced access to care is provided through flexible scheduling, expanded hours of operation, and options for communication, including secure e-mail and patient portals. 7. Payment reflects the added value provided to patients who have a PCMH (including care coordination and use of information technology).
MEDICAL HOME OUTCOMES Although outcomes associated with PCMHs are still emerging in the United States, preliminary findings have been positive. For instance, Reid et al.
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(2009) found that providers working in medical homes reported more supportive work environments and stronger patient relationships when compared to providers not working in medical homes. Furthermore, patients endorsed greater satisfaction with care coordination, provider relationships, and participation in decision-making processes. In a review of 40 studies, continuity of care, a core element of medical homes, was associated with improved preventative care, reduced hospitalizations, and greater patient satisfaction (Saultz & Albedaiwi, 2004; Saultz & Lochner, 2005). Currently, numerous states are promoting PCMHs and providing incentive programs to motivate and reward practice change. Takach (2011) found that most of these states used standards established by the NCQA to officially recognize practices as medical homes and their preliminary outcomes were promising (i.e., expanded access to services, increased use of evidence-based care, and reduced health care costs). As examples, the Geisinger Health System of Pennsylvania, a large integrated delivery system, implemented a medical home model in several primary care practices. Results from a pre–post controlled cohort study showed an 18% decrease in hospital admissions; significant improvements in preventative, coronary artery disease, and diabetes care; and 7% savings in medical costs (Grumbach & Grundy, 2010). Community Care of North Carolina also reported positive experiences with a medical home approach including improvements in asthma and diabetes care, decreased emergency room visits and hospitalizations, and over $160 million in cost savings (Steiner et al., 2008).
HEALTH CARE NEEDS OF INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES The PCMH framework might be particularly useful for health care organizations serving individuals with IDDs. When compared to the general population, this group experiences poorer health outcomes and inadequate access to health care services (Hayden, Kim, & DePaepe, 2005; Krahn, Hammond, & Turner, 2006). In a review of the literature representing multiple countries, individuals with IDDs had relatively high rates of various health conditions involving vision, hearing, oral health, behavioral health, mental health, epilepsy, respiratory issues, fractures, and skin conditions (Krahn et al., 2006). In addition, when compared to the general public, those with IDDs were four times more likely to have a chronic disease (Wilson & Goodman, 2011) and preventable mortality (Horwitz, Kerker, Owens, & Zigler, 2000). Individuals with IDDs also struggle with risk factors associated with chronic conditions including poor nutrition, obesity, and sedentary lifestyles (Rimmer & Hsieh, 2011). Although more at risk for chronic diseases, those with IDDs experience greater difficulty accessing appropriate health care services (U.S. Public Health Service, 2002).
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When providers consider health care disparities associated with individuals with IDDs, it is apparent that there is a dire need for systematic change and a medical home approach might be worth implementing. In other words, patients with IDDs might benefit from a health care model that (a) provides a personal physician, (b) is physician directed, (c) focuses on the whole person, (d) provides care that is coordinated, (e) ensures quality and safety, (f) is accessible, and (g) provides payments to providers for coordinating care and achieving measurable quality improvements.
THE MEDICAL HOME AND PATIENTS WITH IDDS The application of medical home standards to practices serving patients with IDDs requires additional considerations to adequately address the needs of this population. Typically, individuals with IDDs (especially those with moderate, severe, and profound disabilities) rely on family members, residential group home staff, community service coordinators, and other service providers to (a) schedule and navigate appointments, (b) provide personal and medical histories, and (c) follow up with aftercare instructions. Recognizing that family members and service providers are critical supports, practices need to develop strong partnerships with multiple stakeholders who could change over the course of a patient’s life span. Moreover, individuals with IDDs tend to experience behavioral, health, and psychosocial issues that require services from multiple providers who might be ill equipped to provide appropriate care to this group. For instance, Krahn et al. (2006) found that providers were concerned about patients with IDDs and providing continuous care, communicating effectively, and possessing sufficient knowledge of disability-specific resources and issues (e.g., sexuality, behavioral problems, psychiatric issues). Established in 1997, Premier HealthCare (PHC) provides specialized services to approximately 8,000 individuals with intellectual disabilities, autism spectrum disorders, Down syndrome, cerebral palsy, and other developmental disabilities. Primarily funded by Medicaid and Medicare, services include primary and specialty medical care, rehabilitation, psychiatry, mental health services, social work, and dentistry. PHC is recognized by NCQA as a Level 3 PCMH, and to achieve this recognition the organization reexamined NCQA’s six medical home standards to address the needs of a unique patient population.
NCQA PATIENT-CENTERED MEDICAL HOME RECOGNITION NCQA is a nonprofit organization whose mission is to improve health care through the administration and management of voluntary accreditation, certification, distinction, and recognition programs. The Physician Practice
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Connections PCMH is one such program, and by the end of 2010, more than 1,500 sites across the United States (representing almost 7,700 providers) received this recognition (National Committee for Quality Assurance, 2011). The application process is Web-based and requires practices to gather data and provide documentation related to six medical home standards: (a) enhancing access and continuity, (b) identifying and managing patient populations, (c) planning and managing care, (d) providing self-care and community support, (e) tracking and coordinating care, and (f) measuring and improving performance. For each standard, points are earned based on specific criteria. Higher overall scores result in higher recognition levels (i.e., Level 1, Level 2, and Level 3). To facilitate the medical home application process, PHC established a standing Medical Home Committee to review the NCQA standards and determine their applicability for patients with IDDs. During this process, a number of initiatives were undertaken to establish a medical home for patients with IDD and the lessons learned are discussed next.
Enhancing Access and Continuity Medical home practices enhance access and continuity of services by providing routine and urgent care, clinical advice during and after hours, and electronic access. This standard also encompasses continuity of care with the same provider, ability to choose a provider, a team-based approach to care, and services that are culturally and linguistically appropriate. To more clearly understand access and continuity issues for patients with IDDs, focus groups were conducted with PHC health care providers, managers, and support staff. The groups discussed access delays, access barriers, and access improvements. From the focus groups, the organization learned that the IDD community experiences access and continuity issues that are seemingly unique. First, they struggle with reliable transportation, especially when paratransit services are used. Transportation was also a significant health care barrier in the Krahn et al. (2006) review. In response, health care organizations need to anticipate a certain number of late arrivals and missed appointments each day and be flexible with scheduling. Second, the referral and intake process for patients seeking health care services often entails complex eligibility requirements as determined by the New York State Office for People with Developmental Disabilities. As core components of the eligibility process, psychosocial and psychological evaluations can unintentionally delay needed services by weeks. To address this potential access barrier, a work group can be established to streamline the eligibility process (e.g., eliminating redundant paperwork, reducing the number of office visits related to eligibility). Third, some individuals with IDDs might be receiving supports from numerous individuals (family members, residential staff, and service
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providers), and the personal and medical histories they provide could be limited or inaccurate. Therefore, it is critical to establish long-term and collaborative relationships with multiple stakeholders. These relationships are particularly important to ensure compliance with medications and future appointments. Maintaining relationships with supports can be challenging, though, when patients move from their primary residence or experience provider turnover. Hence, it is critical to use a team-based approach that involves patients as much as possible in the management of their own health care. A team-based approach to managing patient care improves continuity, patient satisfaction, and the overall quality of care (Hern, Talen, Babiuch, & Durazo-Arvizu, 2009). Such an approach involves educating both clinical and nonclinical staff on involving family members and service providers in care management and considering the unique needs of patients with IDDs (e.g., reducing communication barriers and using calming techniques during periods of agitation).
Identifying and Managing Patient Populations Medical home practices are expected to collect demographic and clinical data on their patient population to clearly understand and manage needs. Such an analysis allows the practice to identify at-risk patients, which in turn enables proactive reminders and alerts. Electronic health records (EHRs) provide an effective and efficient mechanism to collect and analyze demographic and clinical data. Based on evidence-based guidelines, practices can systematically identify high-risk patients. In the case of PHC, the most common primary diagnoses were diabetes, hypertension, and hyperlipidemia, a finding that is consistent with prior research related to individuals with IDDs (Levy et al., 2006; Tyler, Schramm, Karafa, Tang, & Jain, 2010). Having such knowledge allows health care providers to identify at-risk patients who could benefit from more intense, evidence-based interventions. EHRs also assist practices in proactively reminding patients of clinically important preventative services such as annual visits, flu vaccinations, and well-child visits. However, it is important to note that EHRs are costly to implement and many practices have not made the electronic shift. One way to access similar data is by reviewing financial reports to determine primary diagnoses most commonly treated and billed; often, these records are stored electronically.
Planning and Managing Care Within medical homes, practices develop individualized care management plans for patients who are identified with high-risk conditions or complex health care needs. The care management plan emphasizes evidence-based guidelines, previsit planning, patient progress toward treatment goals, and barriers toward achieving goals. Medications are also reconciled and electronic prescribing is used.
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To realize this goal, health care practices might need to develop new policies and procedures. For example, PHC’s Medical Home Committee worked with senior physicians to develop a care management tool that targets the conditions of diabetes, hypertension, and hyperlipidemia. Initially, the tool was embedded in the standard progress note and prompted providers to review evidence-based guidelines, current medications, barriers to care, and missed appointments with high-risk patients (see Figure 1). Thus far, the care-management tool is used on an individual patient level, with the goal of aggregating data when the EHR is fully implemented. In addition, electronic prescribing helps to manage care further by making medication and formulary information readily available.
Providing Self-Care and Community Support For this standard, medical home practices are expected to assess patients’ self-management abilities and counsel them on healthy behaviors by developing individualized care plans and providing information on relevant community resources. Embedded in this standard is patient-centeredness, whereby patients work in partnership with providers to learn about and monitor health as well as to decide on treatment options. This standard is particularly relevant for the IDD community given that historically their independence and self-determination have not been fostered (Krahn et al., 2006). Although individuals with disabilities might rely on others (i.e., family members, professional staff) for support, health care organizations need to provide accommodations that promote full inclusion. In particular, newly hired medical staff might not be familiar with disability-related accommodations and resources; therefore, it is important to provide such information during orientation and training. For instance, when developing self-care plans, patients’ language and communication preferences should be assessed (e.g., concrete language, nonverbal signage, pictorial displays). To facilitate self-management plans for patients with diabetes, hypertension, and hyperlipidemia, PHC created a Health Education and Resource Sheet using materials available to the public from the New York City Department of Health and Mental Hygiene (see Figure 2). Images depicting healthy lifestyle choices from the Department’s Web site are displayed, along with relevant phone numbers, Web sites, and PHC support services. During medical visits, providers use the sheet as a care management tool to communicate with patients, family members, and service providers.
Tracking and Coordinating Care Medical home practices are expected to track and coordinate referrals related to specialty visits, lab and imaging testing, aftercare facilities, emergency room visits, and hospitalizations.
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FIGURE 1 Care Management Tool (embedded in clinic progress note).
Comprehensive care coordination is a core element of the PCMH and associated with better health outcomes, improved patient satisfaction, and better quality and efficiency of care (Abrams & Crow, 2011). Often,
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FIGURE 2 Premier HealthCare’s Health Education and Resource Sheet. (Color figure available online.)
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individuals with IDDs have complex health care needs that require coordinated care across numerous service providers and settings (including residential group homes). In addition, a wide range of community supports and services are needed to maintain and improve their health (Rich, Lipson, Libersky, & Parchman, 2012). Electronic health solutions (including electronic medical records, patient portals) are designed to coordinate care and track referrals. However, these electronic systems are costly to purchase and, when available, might not be fully accessible for people with IDDs. Even when electronic solutions are in place, they might not be effectively used. More and more, primary care practices are employing care coordinators (e.g., nurses, social workers) to work with high-risk patients. Essential to the PCMH team, care coordinators connect patients and families with services needed to achieve and maintain optimal health outcomes (Dockter & Ressler, 2010). Typically, care coordinators are assigned patient panels, facilitate communication between patients and the primary care team, develop personalized care plans, and provide continuity of care following ER visits and hospitalizations. Effective care coordination is associated with better outcomes and increased patient satisfaction (Abrams & Crow, 2011).
Measuring and Improving Performance The medical home framework places great emphasis on the use of data to measure and improve performance and patient experiences. To demonstrate performance, practices track data on emergency room visits and hospitalizations (with the expectation that there will be reductions in both areas over time). In addition, vulnerable patient populations (including those with IDDs) are identified to improve their access to health care services. With regard to patient experiences, NCQA offers additional credit for using the PCMH version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. The benefits of a standardized instrument include the ability to conduct national benchmarking. However, completing the CAHPS survey could be challenging for individuals with IDDs, given its length, wording of items, and complex response scale (Hartley & MacLean, 2006). Responding to the needs of those with IDDs, PHC developed a 14-item survey to assess patient access, communication preferences, self-management of health care, and overall satisfaction. In addition, the items and response scale were worded with brevity and concreteness in mind. Specifically, the survey uses three possible responses (Yes, Sometimes, No). The survey was also translated into Spanish and back-translated for language congruence (Brislin, 1970; Chapman & Carter, 1979). The survey is administered to patients, family members, and service providers (see Figure 3). With data in hand, organizations are better positioned to make operational decisions and improve the quality of care. In addition to data based on patient experiences, as previously mentioned, medical home
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FIGURE 3 Premier HealthCare Patient Feedback Survey.
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practices are expected to track data on their patient population, emergency room visits, and hospitalizations.
IMPLICATIONS FOR PRACTICE Individuals with IDDs represent a unique patient population for health care providers. To date, research has shown that general practitioners are ill prepared to address the complex needs of this community (Lennox, Diggens, & Ugoni, 1997; Phillips, Morrison, & Davis, 2004). Not surprisingly, patients with IDDs are not receiving adequate health care and are experiencing a range of disparities (Krahn et al., 2006; Scheepers et al., 2005). In addition, health care costs associated with this group have proven to be challenging for federal and state payers (Hemp & Braddock, 2003). As more and more practices adopt medical home standards, they might find the following recommendations useful: 1. Establish a Medical Home Committee that includes an interdisciplinary team and senior management who have direct experiences with patient care. Meet regularly and review the medical home standards and their relevance to the disability community served. Engage other primary care and support staff, as needed, to identify priorities and strengthen buy-in. Contact local practices that have already been recognized as medical homes to learn from their experiences. 2. Listen to your providers and support staff to identify ‘‘unique’’ access and continuity barriers for individuals with IDDs (e.g., unreliable transportation, complex intake and referral process, reliance on supports). Provider feedback can be obtained via focus groups, individual interviews, and surveys. 3. Obtain feedback from your patients, family members, and service providers. Adapt or develop surveys that assess key principles of a medical home in formats and languages that are accessible to individuals with a wide range of disabilities. Contact your regional Disability and Business Technical Assistance Center for information on accommodations.1 4. Assess the health care needs of your patient population. Even without an EHR, there might be ways within your organization (e.g., billing records) to review patient data to identify unique risk factors for those with disabilities. 5. For high-risk patients, develop educational interventions that are patientcentered and inclusive to the fullest extent possible. Engage patients in collaborative partnerships by assessing their abilities and establishing accessible means of communication (e.g., verbal, nonverbal, pictorial, trained translators). 1
Regional Disability and Business Technical Assistance Centers can be found at http:// wdcrobcolp01.ed.gov/Programs/EROD/org_list.cfm?category_cd=DBT
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6. Engage family members and service providers in collaborative partnerships as needed to ensure that preventative health care is sought, chronic conditions are treated and monitored, appointments are kept, and aftercare instructions are followed. 7. Educate and keep both staff and patients informed of medical home progress. Use multiple media and formats (e.g., departmental meetings, electronic newsletters, posters) to disseminate information.
CONCLUSION It is important to acknowledge that the journey toward a medical home is continuous and involves staff at multiple levels. As members of a multidisciplinary team, social workers are well positioned to address nonmedical factors contributing to patients’ overall health (e.g., unemployment, homelessness, debt, familial stress). With their clinical training and experience, social workers are also able to play a critical role as organizations seek to achieve and maintain medical home recognition by doing the following: . . . . . . .
Conducting initial assessments (particularly with high-risk patients). Developing case management and care coordination plans. Working with interdisciplinary teams to coordinate care. Working with patients on health promotion and disease self-management plans. Providing therapeutic and support services. Assisting with transitional plans following a hospitalization. Maintaining linkages with community-based resources (National Association of Social Workers, 2011).
Also integral to the medical home model is a fundamental change in reimbursement. Fortunately, the New York State Department of Health provides Medicaid Medical Home Incentive payments based on providers’ level of NCQA recognition (New York State Department of Health, 2009). In truth, not every practice will have the financial resources to purchase, implement, and maintain an EHR system; however, the lack of an EHR system should not hinder medical home initiatives and the potential to improve health care outcomes for the IDD community.
REFERENCES Abrams, M., & Crow, K. (2011, October 21). Measuring care coordination in medical homes. Retrieved from http://www.commonwealthfund.org/publications/blog/ 2011/oct/measuring-care-coordination-in-medical-homes
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Brislin, R. (1970). Back-translation for cross-cultural research. Journal of CrossCultural Psychology, 1, 185–216. Chapman, D. W., & Carter, J. F. (1979). Translation procedures for the cross-cultural use of measurement. Educational Evaluation and Policy Analysis, 1, 71–76. Dockter, K., & Ressler, K. (2010). The fundamentals of care coordination within the medical home. Retrieved from http://www.ndcpd.org/ndis/pdf/Modules/ MODULE%201%20Care%20Coordination%20Final.pdf Grumbach, K., & Grundy, P. (2010). Outcomes of implementing patient-centered medical home interventions: A review of the evidence from prospective evaluation studies in the United States. Retrieved from http://www.pcpcc.net/files/ evidence_outcomes_in_pcmh.pdf Hartley, S. L., & MacLean, W. E. (2006). A review of the reliability and validity of Likert-type scales for people with intellectual disability. Journal of Intellectual Disability Research, 50, 813–827. Hayden, M. F., Kim, S., & DePaepe, P. (2005). Health status, utilization patterns, and outcomes of persons with intellectual disabilities: Review of the literature. Mental Retardation, 43, 175–195. Hemp, R., & Braddock, D. (2003). Ten questions: On the role of Medicaid for persons with developmental disabilities in the United States. Retrieved from https:== www.cu.edu/ColemanInstitute/stateofthestates/Medicaid_10_questions.pdf Hern, T., Talen, M., Babiuch, C., & Durazo-Arvizu, R. (2009). Patient care management teams: Improving continuity, office efficiency, and teamwork in a residency clinic. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2931176/ Horwitz, S. M., Kerker, B. D., Owens, P. L., & Zigler, E. (2000). The health status and needs of individuals with mental retardation. New Haven, CT: Yale University School of Medicine. Krahn, G. L., Hammond, L., & Turner, A. (2006). A cascade of disparities: Health and healthcare access for people with intellectual disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 12, 70–82. Lennox, N. G., Diggens, J. N., & Ugoni, A. M. (1997). The general practice care of people with intellectual disability: Barriers and solutions. Journal of Intellectual Disability Research, 41, 380–390. Levy, J. M., Botuck, S., Damiani, M. R., Levy, P. H., Dern, T. A., & Freeman, S. E. (2006). Medical conditions and healthcare utilization among adults with intellectual disabilities living in group homes in New York City. Journal of Policy and Practice in Intellectual Disabilities, 3, 195–202. National Association of Social Workers. (2011, April). The medical home model: What is it and how do social workers fit in? Practice Perspectives, 10, 1–6. National Committee for Quality Assurance. (2011). NCQA patient-centered medical home 2011. Retrieved from http://www.ncqa.org/Portals/0/Programs/ Recognition/2011PCMHbrochure_web.pdf New York State Department of Health. (2009). New York State Medicaid update: Announcing New York Medicaid’s statewide patient-centered medical home incentive program. DOH Medicaid Updates, 25. Retrieved from http://www. health.ny.gov/health_care/medicaid/program/update/2009/2009-12spec.htm
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Phillips, A., Morrison, J., & Davis, R. W. (2004). General practitioners’ educational needs in intellectual disability health. Journal of Intellectual Disability Research, 48, 142–149. Reid, R. J., Fishman, P. A., Yu, O., Ross, T. R., Tufano, J. T., Soman, M. P., & Larson, E. B. (2009). Patient-centered medical home demonstration: A prospective, quasi-experimental, before and after evaluation. The American Journal of Managed Care, 15, 71–87. Rich, E., Lipson, D., Libersky, J., & Parchman, M. (2012). Coordinating care for adults with complex care needs in the patient-centered medical home: Challenges and solutions (AHRQ Pub. No. 12–0010). Rockville, MD: Agency for Healthcare Research and Quality. Rimmer, J., & Hsieh, K. (2011). Longitudinal Health and Intellectual Disability Study (LHIDS) on obesity and health risk behaviors. Retrieved from http:// www.rrtcadd.org/Research/page196/assets/Longitudinal%20Health.pdf Saultz, J. W., & Albedaiwi, W. (2004). Interpersonal continuity of care and patient satisfaction: A critical review. Annals of Family Medicine, 2, 445–451. Saultz, J. W., & Lochner, J. (2005). Interpersonal continuity of care and care outcomes: A critical review. Annals of Family Medicine, 3, 159–166. Scheepers, M., Kerr, M., O’Hara, D., Bainbridge, D., Cooper, S. A., Davis, R., . . . Wehmeyer, M. (2005). Reducing health disparity in people with intellectual disabilities: A report from Health Issues Special Interest Research Group of the International Association for the Scientific Study of Intellectual Disabilities. Journal of Policy and Practice in Intellectual Disabilities, 2, 249–255. Steiner, B. D., Denham, A. C., Ashkin, E., Newton, W. P., Wroth, T., & Dobson, L. A. (2008). Community Care of North Carolina: Improving care through community health networks. Annals of Family Medicine, 6, 361–367. Takach, M. (2011). Reinventing Medicaid: State innovations to qualify and pay for patient-centered medical homes show promising results. Health Affairs, 30, 1325–1334. Tyler, C. V., Schramm, S., Karafa, M., Tang, A. S., & Jain, A. (2010). Electronic health record analysis of the primary care of adults with intellectual and other developmental disabilities. Journal of Policy and Practice in Intellectual Disabilities, 7, 204–210. U.S. Public Health Service. (2002). Closing the gap: A national blueprint for improving the health of individuals with mental retardation (Report of the Surgeon General’s Conference on Health Disparities and Mental Retardation). Retrieved from http://www.surgeongeneral.gov/topics/mentalretardation/retardation.pdf Wilson, P. M., & Goodman, C. (2011). Evaluation of a modified chronic disease self-management programme for people with intellectual disabilities. Journal of Nursing and Healthcare of Chronic Illness, 3, 310–318.
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Patient-Centered Medical Homes for Patients with Disabilities BRIGIDA HERNANDEZ, MARCO DAMIANI, T. ARTHUR WANG, and CAROLYN DRISCOLL YAI Network, New York, New York, USA
PETER DELLABELLA Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, New York, USA
NICOLE LEPERA Philadelphia Consultation Center, Philadelphia, Pennsylvania, USA
MICHAEL MENTARI Asian Pacific Counseling and Treatment Centers, Los Angeles, California, USA
The patient-centered medical home is an innovative approach to improve health care outcomes. To address the unique needs of patients with intellectual and developmental disabilities (IDDs), a large health care provider reevaluated the National Committee for Quality Assurance’s 6 medical home standards: (a) enhance access and continuity, (b) identify and manage patient populations, (c) plan and manage care, (d) provide self-care and community support, (e) track and coordinate care, and (f) measure and improve performance. This article describes issues to consider when serving patients with IDDs. KEYWORDS accommodations, health care, health promotion, intellectual and developmental disabilities, intellectual disability, medical home, medical social workers, patient-centered
With the United States aiming to improve the quality and affordability of health care, the patient-centered medical home (PCMH) has been receiving more and more attention as an innovative approach to primary care (National Address correspondence to Brigida Hernandez, PhD, Director of Research, YAI Network, 460 W. 34th Street, New York, NY 10001, USA. E-mail: [email protected] 61
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Committee for Quality Assurance [NCQA], 2011). Using a partnership framework that is patient-centered, the medical home seeks to replace episodic and fragmented care with care that is continuous, coordinated, and comprehensive. Central to the medical home is an ongoing and supportive patient–physician relationship that works collaboratively to improve the delivery and quality of care. Specific goals include increasing patient access, experience, and satisfaction; better managing of chronic conditions; improving health outcomes; and reducing the overall cost of care. The NCQA is a nonprofit organization that oversees the application process for practices seeking PCMH recognition. This article describes how a health care organization that serves primarily patients with intellectual and developmental disabilities (IDDs) reevaluated NCQA’s medical home standards to address the unique needs of this population. The lessons learned from this process are presented herein. Initially advanced by the American Academy of Pediatrics during the 1960s, the current iteration of the medical home principles seeks to address the needs of all patient populations. In 2007, four major physician groups (the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association) issued the following Medical Home Joint Principles: 1. A personal physician is provided to each patient and this physician provides continuous and comprehensive care. 2. The personal physician directs a team of providers who collectively take responsibility for the patient’s ongoing care. 3. A whole person orientation is used by the personal physician who understands and respects each patient’s unique needs, beliefs, cultural values, and preferences. 4. The physician-led care team is responsible for coordinating and integrating care across multiple providers including specialists, hospitals, home health agencies, and nursing homes. 5. Quality and safety are assured through the use of evidence-based practices, information technology, clinical decision support, and review of quality indicators such as performance measures and patient feedback. 6. Enhanced access to care is provided through flexible scheduling, expanded hours of operation, and options for communication, including secure e-mail and patient portals. 7. Payment reflects the added value provided to patients who have a PCMH (including care coordination and use of information technology).
MEDICAL HOME OUTCOMES Although outcomes associated with PCMHs are still emerging in the United States, preliminary findings have been positive. For instance, Reid et al.
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(2009) found that providers working in medical homes reported more supportive work environments and stronger patient relationships when compared to providers not working in medical homes. Furthermore, patients endorsed greater satisfaction with care coordination, provider relationships, and participation in decision-making processes. In a review of 40 studies, continuity of care, a core element of medical homes, was associated with improved preventative care, reduced hospitalizations, and greater patient satisfaction (Saultz & Albedaiwi, 2004; Saultz & Lochner, 2005). Currently, numerous states are promoting PCMHs and providing incentive programs to motivate and reward practice change. Takach (2011) found that most of these states used standards established by the NCQA to officially recognize practices as medical homes and their preliminary outcomes were promising (i.e., expanded access to services, increased use of evidence-based care, and reduced health care costs). As examples, the Geisinger Health System of Pennsylvania, a large integrated delivery system, implemented a medical home model in several primary care practices. Results from a pre–post controlled cohort study showed an 18% decrease in hospital admissions; significant improvements in preventative, coronary artery disease, and diabetes care; and 7% savings in medical costs (Grumbach & Grundy, 2010). Community Care of North Carolina also reported positive experiences with a medical home approach including improvements in asthma and diabetes care, decreased emergency room visits and hospitalizations, and over $160 million in cost savings (Steiner et al., 2008).
HEALTH CARE NEEDS OF INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES The PCMH framework might be particularly useful for health care organizations serving individuals with IDDs. When compared to the general population, this group experiences poorer health outcomes and inadequate access to health care services (Hayden, Kim, & DePaepe, 2005; Krahn, Hammond, & Turner, 2006). In a review of the literature representing multiple countries, individuals with IDDs had relatively high rates of various health conditions involving vision, hearing, oral health, behavioral health, mental health, epilepsy, respiratory issues, fractures, and skin conditions (Krahn et al., 2006). In addition, when compared to the general public, those with IDDs were four times more likely to have a chronic disease (Wilson & Goodman, 2011) and preventable mortality (Horwitz, Kerker, Owens, & Zigler, 2000). Individuals with IDDs also struggle with risk factors associated with chronic conditions including poor nutrition, obesity, and sedentary lifestyles (Rimmer & Hsieh, 2011). Although more at risk for chronic diseases, those with IDDs experience greater difficulty accessing appropriate health care services (U.S. Public Health Service, 2002).
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When providers consider health care disparities associated with individuals with IDDs, it is apparent that there is a dire need for systematic change and a medical home approach might be worth implementing. In other words, patients with IDDs might benefit from a health care model that (a) provides a personal physician, (b) is physician directed, (c) focuses on the whole person, (d) provides care that is coordinated, (e) ensures quality and safety, (f) is accessible, and (g) provides payments to providers for coordinating care and achieving measurable quality improvements.
THE MEDICAL HOME AND PATIENTS WITH IDDS The application of medical home standards to practices serving patients with IDDs requires additional considerations to adequately address the needs of this population. Typically, individuals with IDDs (especially those with moderate, severe, and profound disabilities) rely on family members, residential group home staff, community service coordinators, and other service providers to (a) schedule and navigate appointments, (b) provide personal and medical histories, and (c) follow up with aftercare instructions. Recognizing that family members and service providers are critical supports, practices need to develop strong partnerships with multiple stakeholders who could change over the course of a patient’s life span. Moreover, individuals with IDDs tend to experience behavioral, health, and psychosocial issues that require services from multiple providers who might be ill equipped to provide appropriate care to this group. For instance, Krahn et al. (2006) found that providers were concerned about patients with IDDs and providing continuous care, communicating effectively, and possessing sufficient knowledge of disability-specific resources and issues (e.g., sexuality, behavioral problems, psychiatric issues). Established in 1997, Premier HealthCare (PHC) provides specialized services to approximately 8,000 individuals with intellectual disabilities, autism spectrum disorders, Down syndrome, cerebral palsy, and other developmental disabilities. Primarily funded by Medicaid and Medicare, services include primary and specialty medical care, rehabilitation, psychiatry, mental health services, social work, and dentistry. PHC is recognized by NCQA as a Level 3 PCMH, and to achieve this recognition the organization reexamined NCQA’s six medical home standards to address the needs of a unique patient population.
NCQA PATIENT-CENTERED MEDICAL HOME RECOGNITION NCQA is a nonprofit organization whose mission is to improve health care through the administration and management of voluntary accreditation, certification, distinction, and recognition programs. The Physician Practice
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Connections PCMH is one such program, and by the end of 2010, more than 1,500 sites across the United States (representing almost 7,700 providers) received this recognition (National Committee for Quality Assurance, 2011). The application process is Web-based and requires practices to gather data and provide documentation related to six medical home standards: (a) enhancing access and continuity, (b) identifying and managing patient populations, (c) planning and managing care, (d) providing self-care and community support, (e) tracking and coordinating care, and (f) measuring and improving performance. For each standard, points are earned based on specific criteria. Higher overall scores result in higher recognition levels (i.e., Level 1, Level 2, and Level 3). To facilitate the medical home application process, PHC established a standing Medical Home Committee to review the NCQA standards and determine their applicability for patients with IDDs. During this process, a number of initiatives were undertaken to establish a medical home for patients with IDD and the lessons learned are discussed next.
Enhancing Access and Continuity Medical home practices enhance access and continuity of services by providing routine and urgent care, clinical advice during and after hours, and electronic access. This standard also encompasses continuity of care with the same provider, ability to choose a provider, a team-based approach to care, and services that are culturally and linguistically appropriate. To more clearly understand access and continuity issues for patients with IDDs, focus groups were conducted with PHC health care providers, managers, and support staff. The groups discussed access delays, access barriers, and access improvements. From the focus groups, the organization learned that the IDD community experiences access and continuity issues that are seemingly unique. First, they struggle with reliable transportation, especially when paratransit services are used. Transportation was also a significant health care barrier in the Krahn et al. (2006) review. In response, health care organizations need to anticipate a certain number of late arrivals and missed appointments each day and be flexible with scheduling. Second, the referral and intake process for patients seeking health care services often entails complex eligibility requirements as determined by the New York State Office for People with Developmental Disabilities. As core components of the eligibility process, psychosocial and psychological evaluations can unintentionally delay needed services by weeks. To address this potential access barrier, a work group can be established to streamline the eligibility process (e.g., eliminating redundant paperwork, reducing the number of office visits related to eligibility). Third, some individuals with IDDs might be receiving supports from numerous individuals (family members, residential staff, and service
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providers), and the personal and medical histories they provide could be limited or inaccurate. Therefore, it is critical to establish long-term and collaborative relationships with multiple stakeholders. These relationships are particularly important to ensure compliance with medications and future appointments. Maintaining relationships with supports can be challenging, though, when patients move from their primary residence or experience provider turnover. Hence, it is critical to use a team-based approach that involves patients as much as possible in the management of their own health care. A team-based approach to managing patient care improves continuity, patient satisfaction, and the overall quality of care (Hern, Talen, Babiuch, & Durazo-Arvizu, 2009). Such an approach involves educating both clinical and nonclinical staff on involving family members and service providers in care management and considering the unique needs of patients with IDDs (e.g., reducing communication barriers and using calming techniques during periods of agitation).
Identifying and Managing Patient Populations Medical home practices are expected to collect demographic and clinical data on their patient population to clearly understand and manage needs. Such an analysis allows the practice to identify at-risk patients, which in turn enables proactive reminders and alerts. Electronic health records (EHRs) provide an effective and efficient mechanism to collect and analyze demographic and clinical data. Based on evidence-based guidelines, practices can systematically identify high-risk patients. In the case of PHC, the most common primary diagnoses were diabetes, hypertension, and hyperlipidemia, a finding that is consistent with prior research related to individuals with IDDs (Levy et al., 2006; Tyler, Schramm, Karafa, Tang, & Jain, 2010). Having such knowledge allows health care providers to identify at-risk patients who could benefit from more intense, evidence-based interventions. EHRs also assist practices in proactively reminding patients of clinically important preventative services such as annual visits, flu vaccinations, and well-child visits. However, it is important to note that EHRs are costly to implement and many practices have not made the electronic shift. One way to access similar data is by reviewing financial reports to determine primary diagnoses most commonly treated and billed; often, these records are stored electronically.
Planning and Managing Care Within medical homes, practices develop individualized care management plans for patients who are identified with high-risk conditions or complex health care needs. The care management plan emphasizes evidence-based guidelines, previsit planning, patient progress toward treatment goals, and barriers toward achieving goals. Medications are also reconciled and electronic prescribing is used.
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To realize this goal, health care practices might need to develop new policies and procedures. For example, PHC’s Medical Home Committee worked with senior physicians to develop a care management tool that targets the conditions of diabetes, hypertension, and hyperlipidemia. Initially, the tool was embedded in the standard progress note and prompted providers to review evidence-based guidelines, current medications, barriers to care, and missed appointments with high-risk patients (see Figure 1). Thus far, the care-management tool is used on an individual patient level, with the goal of aggregating data when the EHR is fully implemented. In addition, electronic prescribing helps to manage care further by making medication and formulary information readily available.
Providing Self-Care and Community Support For this standard, medical home practices are expected to assess patients’ self-management abilities and counsel them on healthy behaviors by developing individualized care plans and providing information on relevant community resources. Embedded in this standard is patient-centeredness, whereby patients work in partnership with providers to learn about and monitor health as well as to decide on treatment options. This standard is particularly relevant for the IDD community given that historically their independence and self-determination have not been fostered (Krahn et al., 2006). Although individuals with disabilities might rely on others (i.e., family members, professional staff) for support, health care organizations need to provide accommodations that promote full inclusion. In particular, newly hired medical staff might not be familiar with disability-related accommodations and resources; therefore, it is important to provide such information during orientation and training. For instance, when developing self-care plans, patients’ language and communication preferences should be assessed (e.g., concrete language, nonverbal signage, pictorial displays). To facilitate self-management plans for patients with diabetes, hypertension, and hyperlipidemia, PHC created a Health Education and Resource Sheet using materials available to the public from the New York City Department of Health and Mental Hygiene (see Figure 2). Images depicting healthy lifestyle choices from the Department’s Web site are displayed, along with relevant phone numbers, Web sites, and PHC support services. During medical visits, providers use the sheet as a care management tool to communicate with patients, family members, and service providers.
Tracking and Coordinating Care Medical home practices are expected to track and coordinate referrals related to specialty visits, lab and imaging testing, aftercare facilities, emergency room visits, and hospitalizations.
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FIGURE 1 Care Management Tool (embedded in clinic progress note).
Comprehensive care coordination is a core element of the PCMH and associated with better health outcomes, improved patient satisfaction, and better quality and efficiency of care (Abrams & Crow, 2011). Often,
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FIGURE 2 Premier HealthCare’s Health Education and Resource Sheet. (Color figure available online.)
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individuals with IDDs have complex health care needs that require coordinated care across numerous service providers and settings (including residential group homes). In addition, a wide range of community supports and services are needed to maintain and improve their health (Rich, Lipson, Libersky, & Parchman, 2012). Electronic health solutions (including electronic medical records, patient portals) are designed to coordinate care and track referrals. However, these electronic systems are costly to purchase and, when available, might not be fully accessible for people with IDDs. Even when electronic solutions are in place, they might not be effectively used. More and more, primary care practices are employing care coordinators (e.g., nurses, social workers) to work with high-risk patients. Essential to the PCMH team, care coordinators connect patients and families with services needed to achieve and maintain optimal health outcomes (Dockter & Ressler, 2010). Typically, care coordinators are assigned patient panels, facilitate communication between patients and the primary care team, develop personalized care plans, and provide continuity of care following ER visits and hospitalizations. Effective care coordination is associated with better outcomes and increased patient satisfaction (Abrams & Crow, 2011).
Measuring and Improving Performance The medical home framework places great emphasis on the use of data to measure and improve performance and patient experiences. To demonstrate performance, practices track data on emergency room visits and hospitalizations (with the expectation that there will be reductions in both areas over time). In addition, vulnerable patient populations (including those with IDDs) are identified to improve their access to health care services. With regard to patient experiences, NCQA offers additional credit for using the PCMH version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. The benefits of a standardized instrument include the ability to conduct national benchmarking. However, completing the CAHPS survey could be challenging for individuals with IDDs, given its length, wording of items, and complex response scale (Hartley & MacLean, 2006). Responding to the needs of those with IDDs, PHC developed a 14-item survey to assess patient access, communication preferences, self-management of health care, and overall satisfaction. In addition, the items and response scale were worded with brevity and concreteness in mind. Specifically, the survey uses three possible responses (Yes, Sometimes, No). The survey was also translated into Spanish and back-translated for language congruence (Brislin, 1970; Chapman & Carter, 1979). The survey is administered to patients, family members, and service providers (see Figure 3). With data in hand, organizations are better positioned to make operational decisions and improve the quality of care. In addition to data based on patient experiences, as previously mentioned, medical home
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FIGURE 3 Premier HealthCare Patient Feedback Survey.
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practices are expected to track data on their patient population, emergency room visits, and hospitalizations.
IMPLICATIONS FOR PRACTICE Individuals with IDDs represent a unique patient population for health care providers. To date, research has shown that general practitioners are ill prepared to address the complex needs of this community (Lennox, Diggens, & Ugoni, 1997; Phillips, Morrison, & Davis, 2004). Not surprisingly, patients with IDDs are not receiving adequate health care and are experiencing a range of disparities (Krahn et al., 2006; Scheepers et al., 2005). In addition, health care costs associated with this group have proven to be challenging for federal and state payers (Hemp & Braddock, 2003). As more and more practices adopt medical home standards, they might find the following recommendations useful: 1. Establish a Medical Home Committee that includes an interdisciplinary team and senior management who have direct experiences with patient care. Meet regularly and review the medical home standards and their relevance to the disability community served. Engage other primary care and support staff, as needed, to identify priorities and strengthen buy-in. Contact local practices that have already been recognized as medical homes to learn from their experiences. 2. Listen to your providers and support staff to identify ‘‘unique’’ access and continuity barriers for individuals with IDDs (e.g., unreliable transportation, complex intake and referral process, reliance on supports). Provider feedback can be obtained via focus groups, individual interviews, and surveys. 3. Obtain feedback from your patients, family members, and service providers. Adapt or develop surveys that assess key principles of a medical home in formats and languages that are accessible to individuals with a wide range of disabilities. Contact your regional Disability and Business Technical Assistance Center for information on accommodations.1 4. Assess the health care needs of your patient population. Even without an EHR, there might be ways within your organization (e.g., billing records) to review patient data to identify unique risk factors for those with disabilities. 5. For high-risk patients, develop educational interventions that are patientcentered and inclusive to the fullest extent possible. Engage patients in collaborative partnerships by assessing their abilities and establishing accessible means of communication (e.g., verbal, nonverbal, pictorial, trained translators). 1
Regional Disability and Business Technical Assistance Centers can be found at http:// wdcrobcolp01.ed.gov/Programs/EROD/org_list.cfm?category_cd=DBT
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6. Engage family members and service providers in collaborative partnerships as needed to ensure that preventative health care is sought, chronic conditions are treated and monitored, appointments are kept, and aftercare instructions are followed. 7. Educate and keep both staff and patients informed of medical home progress. Use multiple media and formats (e.g., departmental meetings, electronic newsletters, posters) to disseminate information.
CONCLUSION It is important to acknowledge that the journey toward a medical home is continuous and involves staff at multiple levels. As members of a multidisciplinary team, social workers are well positioned to address nonmedical factors contributing to patients’ overall health (e.g., unemployment, homelessness, debt, familial stress). With their clinical training and experience, social workers are also able to play a critical role as organizations seek to achieve and maintain medical home recognition by doing the following: . . . . . . .
Conducting initial assessments (particularly with high-risk patients). Developing case management and care coordination plans. Working with interdisciplinary teams to coordinate care. Working with patients on health promotion and disease self-management plans. Providing therapeutic and support services. Assisting with transitional plans following a hospitalization. Maintaining linkages with community-based resources (National Association of Social Workers, 2011).
Also integral to the medical home model is a fundamental change in reimbursement. Fortunately, the New York State Department of Health provides Medicaid Medical Home Incentive payments based on providers’ level of NCQA recognition (New York State Department of Health, 2009). In truth, not every practice will have the financial resources to purchase, implement, and maintain an EHR system; however, the lack of an EHR system should not hinder medical home initiatives and the potential to improve health care outcomes for the IDD community.
REFERENCES Abrams, M., & Crow, K. (2011, October 21). Measuring care coordination in medical homes. Retrieved from http://www.commonwealthfund.org/publications/blog/ 2011/oct/measuring-care-coordination-in-medical-homes
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Brislin, R. (1970). Back-translation for cross-cultural research. Journal of CrossCultural Psychology, 1, 185–216. Chapman, D. W., & Carter, J. F. (1979). Translation procedures for the cross-cultural use of measurement. Educational Evaluation and Policy Analysis, 1, 71–76. Dockter, K., & Ressler, K. (2010). The fundamentals of care coordination within the medical home. Retrieved from http://www.ndcpd.org/ndis/pdf/Modules/ MODULE%201%20Care%20Coordination%20Final.pdf Grumbach, K., & Grundy, P. (2010). Outcomes of implementing patient-centered medical home interventions: A review of the evidence from prospective evaluation studies in the United States. Retrieved from http://www.pcpcc.net/files/ evidence_outcomes_in_pcmh.pdf Hartley, S. L., & MacLean, W. E. (2006). A review of the reliability and validity of Likert-type scales for people with intellectual disability. Journal of Intellectual Disability Research, 50, 813–827. Hayden, M. F., Kim, S., & DePaepe, P. (2005). Health status, utilization patterns, and outcomes of persons with intellectual disabilities: Review of the literature. Mental Retardation, 43, 175–195. Hemp, R., & Braddock, D. (2003). Ten questions: On the role of Medicaid for persons with developmental disabilities in the United States. Retrieved from https:== www.cu.edu/ColemanInstitute/stateofthestates/Medicaid_10_questions.pdf Hern, T., Talen, M., Babiuch, C., & Durazo-Arvizu, R. (2009). Patient care management teams: Improving continuity, office efficiency, and teamwork in a residency clinic. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2931176/ Horwitz, S. M., Kerker, B. D., Owens, P. L., & Zigler, E. (2000). The health status and needs of individuals with mental retardation. New Haven, CT: Yale University School of Medicine. Krahn, G. L., Hammond, L., & Turner, A. (2006). A cascade of disparities: Health and healthcare access for people with intellectual disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 12, 70–82. Lennox, N. G., Diggens, J. N., & Ugoni, A. M. (1997). The general practice care of people with intellectual disability: Barriers and solutions. Journal of Intellectual Disability Research, 41, 380–390. Levy, J. M., Botuck, S., Damiani, M. R., Levy, P. H., Dern, T. A., & Freeman, S. E. (2006). Medical conditions and healthcare utilization among adults with intellectual disabilities living in group homes in New York City. Journal of Policy and Practice in Intellectual Disabilities, 3, 195–202. National Association of Social Workers. (2011, April). The medical home model: What is it and how do social workers fit in? Practice Perspectives, 10, 1–6. National Committee for Quality Assurance. (2011). NCQA patient-centered medical home 2011. Retrieved from http://www.ncqa.org/Portals/0/Programs/ Recognition/2011PCMHbrochure_web.pdf New York State Department of Health. (2009). New York State Medicaid update: Announcing New York Medicaid’s statewide patient-centered medical home incentive program. DOH Medicaid Updates, 25. Retrieved from http://www. health.ny.gov/health_care/medicaid/program/update/2009/2009-12spec.htm
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Phillips, A., Morrison, J., & Davis, R. W. (2004). General practitioners’ educational needs in intellectual disability health. Journal of Intellectual Disability Research, 48, 142–149. Reid, R. J., Fishman, P. A., Yu, O., Ross, T. R., Tufano, J. T., Soman, M. P., & Larson, E. B. (2009). Patient-centered medical home demonstration: A prospective, quasi-experimental, before and after evaluation. The American Journal of Managed Care, 15, 71–87. Rich, E., Lipson, D., Libersky, J., & Parchman, M. (2012). Coordinating care for adults with complex care needs in the patient-centered medical home: Challenges and solutions (AHRQ Pub. No. 12–0010). Rockville, MD: Agency for Healthcare Research and Quality. Rimmer, J., & Hsieh, K. (2011). Longitudinal Health and Intellectual Disability Study (LHIDS) on obesity and health risk behaviors. Retrieved from http:// www.rrtcadd.org/Research/page196/assets/Longitudinal%20Health.pdf Saultz, J. W., & Albedaiwi, W. (2004). Interpersonal continuity of care and patient satisfaction: A critical review. Annals of Family Medicine, 2, 445–451. Saultz, J. W., & Lochner, J. (2005). Interpersonal continuity of care and care outcomes: A critical review. Annals of Family Medicine, 3, 159–166. Scheepers, M., Kerr, M., O’Hara, D., Bainbridge, D., Cooper, S. A., Davis, R., . . . Wehmeyer, M. (2005). Reducing health disparity in people with intellectual disabilities: A report from Health Issues Special Interest Research Group of the International Association for the Scientific Study of Intellectual Disabilities. Journal of Policy and Practice in Intellectual Disabilities, 2, 249–255. Steiner, B. D., Denham, A. C., Ashkin, E., Newton, W. P., Wroth, T., & Dobson, L. A. (2008). Community Care of North Carolina: Improving care through community health networks. Annals of Family Medicine, 6, 361–367. Takach, M. (2011). Reinventing Medicaid: State innovations to qualify and pay for patient-centered medical homes show promising results. Health Affairs, 30, 1325–1334. Tyler, C. V., Schramm, S., Karafa, M., Tang, A. S., & Jain, A. (2010). Electronic health record analysis of the primary care of adults with intellectual and other developmental disabilities. Journal of Policy and Practice in Intellectual Disabilities, 7, 204–210. U.S. Public Health Service. (2002). Closing the gap: A national blueprint for improving the health of individuals with mental retardation (Report of the Surgeon General’s Conference on Health Disparities and Mental Retardation). Retrieved from http://www.surgeongeneral.gov/topics/mentalretardation/retardation.pdf Wilson, P. M., & Goodman, C. (2011). Evaluation of a modified chronic disease self-management programme for people with intellectual disabilities. Journal of Nursing and Healthcare of Chronic Illness, 3, 310–318.
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