Kent County GSC's medical home effort becoming a model

By Brenda Brissette Mata

Dedication, collaboration and an important coincidence paved the way for Kent County to begin a “medical home” project that is fast becoming a model for other communities and the state.

A medical home is not a building: it’s a team approach to providing health care by ensuring that a child has a single place for immunizations, well-child visits, where records are kept, where they know his or her health history and where care is coordinated rather than scattershot.

Sounds simple, but in these highly mobile times, many children don’t have a medical home.

The Great Start Collaborative of Kent County first began examining the problem in 2007.

“Great Start provided the dollars that allowed us to fund a study showing the higher costs our state pays every year for hospital admissions of publically-insured children compared to those with commercial insurance,” said Judy Freeman, director for the Kent GSC.

A coincidence aids the effort

During the research phase of its examination, committee member Dr. Tom Peterson, a Kent County pediatrician, noted that his brother-in-law had helped develop a program in Colorado that was successfully improving access to primary healthcare for children with Medicaid.

“Even before I was on the Kent County committee, (my brother-in-law Dr. Jim Todd) suggested we could do something like that in Michigan,” Tom Peterson said.

Dr. Todd was soon in Michigan presenting his thoughts to the committee. And soon thereafter, the committee decided Kent County needed a similar medical home model.

A coalition of businesses, healthcare providers and foundations then helped launch the Children’s Healthcare Access Program (CHAP) in 2008.

CHAP is operated by First Steps, a community-based early childhood non-profit organization that works closely with the Kent GSC. A primary goal of CHAP is to ensure that every child in Kent County, and eventually the state of Michigan, has a quality medical home.

Maureen Kirkwood was hired in 2008, while the project was still in concept form, to lead Kent County’s CHAP. One of her first steps was to travel to Colorado to learn more about CCHAP and the medical home project.

“CHAP works on a number of different levels to direct services to families, to help them get better access to health care,” Kirkwood said. “If transportation is necessary to get a child to the doctor, we provide it. We provide education to families so that they can understand which situation calls for a visit to a doctor instead of an emergency room.”

Like the Colorado program, the Kent County CHAP promotes access to medical homes for children with Medicaid by offering enhanced Medicaid reimbursement to participating practices, as well as coordinating access to many other healthcare and community resources.

While Medicaid is a federal program, Colorado’s program is run differently than Michigan’s.

“We had to adapt to the specific situation we have here in Michigan regarding Medicaid,” Kirkwood said. “Here (in Michigan) we have managed care. In other words, the health plans are very involved in the delivery of care to the children enrolled in their plans. Priority Health, a locally-based health plan and Kent County’s largest Medicaid managed care provider, is a founding partner of CHAP, and has been involved from the beginning in the development of the program, and has been a strong supporter of the project throughout.”

The keys to success

One of the key factors in CHAP’s early success is that Priority Health agreed to pay participating physicians an enhanced rate in exchange for opening to additional Medicaid patients. In addition, Priority developed a “pay-for-performance” incentive structure to reward CHAP practices for improving child health outcomes and lowering ER and in-patient rates.

Technically, every child in Michigan on Medicaid is assigned a primary care provider, but as Kirkwood explained, many families don’t have good access and often end up using emergency rooms for primary care treatment. Part of the goal of CHAP was to decrease emergency room visits and in-patient hospital admissions, which are costly, while also improving the overall health of children on Medicaid in Kent County.

Several factors contribute to the limited access for children with Medicaid. For one, Medicaid reimbursement rates are very low, which means that many private physicians are reluctant to take on new Medicaid patients.

“What happens is that private physicians take a few Medicaid patients, here and there,” Kirkwood explained, “but the vast majority in Kent County are assigned to large federally-funded and teaching clinics.”

Hospitals, clinics and federally-qualified health centers are overwhelmed with the number of children that need to be seen, which is very costly for the state.

“Simple things such as ear infections, if seen in the emergency room instead of a child’s medical home can be much more costly,” Kirkwood said. “A visit to an emergency room can cost four to five times what it would cost to be taken care of at a doctors’ office.”

At heart, CHAP is about improving the health outcomes of children on Medicaid while better utilizing existing resources and decreasing costs. It is estimated that the savings could be between $150 and $200 million a year statewide if publicly-insured children had the same hospitalization rate as privately insured children in Michigan. Kent County CHAP is beginning to reduce the disparity. In the first year of the project, emergency department visits declined nine percent at participating providers, and in-patient hospital admissions dropped three percent.

CHAP is using a number of different strategies to do that, including offering referrals, support services, and home-based education to families and provider education and training for the participating practices so they can improve efficiencies and incorporate medical home services.

If a child is missing well-child visits, CHAP will talk with the family about the importance of preventive health care and make sure a visit to the medical home is scheduled.

CHAP staff will make a home visit if a child has been to the emergency room for a situation that wasn’t really an emergency. They’ll help the family understand when and how to use a medical home.

According to Kirkwood, the first year of CHAP showed that asthma case management is hugely important.

The Kent County CHAP asthma education team now helps families learn how to use preventive measures when it comes to asthma and also how to assist children with medication. That education means fewer trips to the hospital, and ultimately lower costs.

But is it working?

So how has CHAP worked from a money perspective? After its first year – even after paying enhanced reimbursements and other provider incentives - Priority Health discovered it had not lost money. It then decided to continue the program and offer the enhanced reimbursement and incentives for two more years.

“The last half of 2008 we were getting organized and ramped up and accustomed to working together in this collaborative way,” Kirkwood said. “What is important is to see if we can sustain the success.”

Plans are in place to include more practices and to add additional Medicaid health plans. The hope is that the program eventually will become self-sustaining.

Other communities have taken note of the successes in Kent County. Shiawassee, Wayne and Kalamazoo Counties have plans underway to replicate medical home locally.

Pediatrician involvement will be key, according to Dr. Peterson.

“It is imperative that we get other doctors fired up about this. You can’t implement these programs without a pediatrician on board.”

“You get pediatricians talking to each other and the word spreads,” Peterson said. “One of the most unique parts of this project is that we have folks working together, that have never worked this way - federal clinic and teaching managers, nursing clinic managers, doctors. When I was in practice for 15 years, I never met with these people. One of the beauties of this project is that it integrate all these systems.”

The Early Childhood Investment Corporation is funding Kent CHAP to develop a CHAP Medical Home Toolkit so other communities can learn how to implement the program.

“We want to share some of the nuts and bolts that we have learned,” Kirkwood said.


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