How Confident Are You in This Estimate? (Scale 1-10; 10 high): (low) (high) How Confident Are You in This Estimate?

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1 On-Site Medical Home Practice/Clinic Assessment Checklist Illinois Medical Home Project (IMHP), Phase II, IL Chapter of the American Academy of Pediatrics (focusing on Children with Special Health Care Needs) Note: Questions should be answered in relation to physicians and staff participating in the project only. If possible, the lead physician involved in the project plus one other member of the staff should complete the interview portion (nurse, front office staff, care coordinator, etc.) CYSHCN are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. Examples of chronic conditions that could be included in this group include, but are not limited to, diabetes, asthma, cystic fibrosis, cerebral palsy, Down syndrome, sickle cell anemia, muscular dystrophy, spina bifida, hydrocephalus, obesity, ADHD, involvement in early intervention programs. (Age range: Include children and youth birth through 21 years of age.) Date: / / Completed by: Name of Practice/Clinic: Address: City: State: Zip: Phone: Fax: Describe Practice/Clinic Setting (circle one): Ground Level Upper Level Lower Level Describe Your Practice/Clinic Type/Model (check all that apply): Pediatric practice/clinic Family practice/clinic Estimate # of Total Patients Served by this Practice/Clinic (average per year): Estimate # of Children (birth through 21 years) Served by this Practice/Clinic (average per year): _ Estimate # of Weekly Pt Visits (incl. night and weekend): Estimate # of CYSHCN (as defined above): Hospital-based pediatric clinic Public health clinic (federally qualified health center) Public health clinic (such as an ambulatory clinic) How Confident Are You in This Estimate? (Scale 1-10; 10 high): (low) (high) How Confident Are You in This Estimate? (Scale 1-10; 10 high): (low) (high) How Confident Are You in This Estimate? (Scale 1-10; 10 high): (low) (high) How Confident Are You in This Estimate? (Scale 1-10; 10 high): (low) (high)

2 Number of Providers MD s Full Time: Part time: Population Served - Race/Ethnicity: Population Served - Insurance: Population Served- Other characteristics: ARNP s Full Time: Part Time: Non-Hispanic White: % Non-Hispanic Black: % Asian (incl. Indian): % Hispanic: % PA s Full Time: Part Time: Native Hawaiian/Pacific Islander: % Native American/Alaska Native: % Mixed Race: % (Above should sum to 100% - mutually exclusive) Public insurance only Self Pay/No Pay: % (Medicaid/All Kids/KidCare): % Both Private and Public: % Private insurance only: % Other: % (Above should sum to 100% - mutually exclusive) DSCC Children: % OR Known Number: Percent Homeless (if known) % Other (specify) Full Time: Part Time: Are these data estimated or from hard data? (check one): Estimated Hard Data Are these data estimated or from hard data? (check one): Estimated Hard Data Are these data estimated or from hard data? (check one): Estimated Hard Data Languages spoken By practice/clinic staff (# of staff) By families population served (%) English (skip English for staff) % Spanish # % Chinese # % Korean # % Hebrew # % Hindi # % Polish # % Other 1 (specify) specify, # specify, % Other 2 (specify) specify, # specify, % Other 3 (specify) specify, # specify, % 2

3 Are translation services available? Yes No If yes, please explain: How familiar is the entire office with the AAP policy statement on the Medical Home published in July 2002 in Pediatrics? (1= not familiar, 2= a little familiar, 3 = somewhat familiar, 4 = very familiar) Not;Little;Some:Very 3

4 Practice/Clinic Environment Assessment of This part of the checklist may be completed by the surveyor without the assistance of office staff. ACCESSIBLE: Physical 1 = Not at All Accessible; 2 = Somewhat Accessible; 3 = Mostly Accessible; 4 = Totally Not;Some;Most:Tot. Accessible 1. How wheel chair accessible is the facility? (ramp, width of doorway, etc.) 2. How accessible is the bathroom for children with disabilities? (size of stall, hand rails, etc.) 3. How accessible are the elevators for children with disabilities? NA Elev. not needed (NA Elev. not needed = missing, NA No elevator=0) NA No elevator 4. Are elevators currently operating? (NA = missing) NA OTHER ENVIRONMENTAL ISSUES: 1 = Not at all thorough/do not exist; 2 = Somewhat thorough; 3 = Mostly Thorough; or 4 = Not;Some;Most:Tot. Totally thorough 1. How thorough is the bulletin board in the waiting room announcing health related community events? 2. How thoroughly does the practice/clinic display pictures, posters and other materials that reflect the cultures and ethnic backgrounds of children and families served by the practice/clinic? 3. How thoroughly does the practice/clinic display magazines, brochures, and other printed materials in reception areas that are of interest to and reflect the different cultures of children and families served by the practice/clinic? Give examples of materials provided in waiting area: 4. How thoroughly does the practice/clinic ensure that toys and other play accessories in reception areas and those, which are used during assessment, are representative of the various cultural and ethnic groups within the local community and the society in general? Give examples of toys available: 4

5 In-Office Practice/Clinic Assessment of List Practice/Clinic Staff Involved With Completing Checklist: Role: Physician Nurse Care coordinator Admin staff Other (specify) Role: Physician Nurse Care coordinator Admin staff Other (specify) Role: Physician Nurse Care coordinator Admin staff Other (specify) The questions below are organized by 6 of the 7 facets of the Medical Home Model put forth by the AAP. CYSHCN are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. Instructions: Answer each of the following questions utilizing the response choices provided below. When applicable, apply the scale as follows (except where a different scale is indicated.): 1 = None of the Time; 2 = Some of the Time; 3 = Most of the Time; or 4 = All of the Time. ACCESSIBLE: Patient 1. Are insurance plans (public, private) accepted? Circle One If not all plans are accepted, please explain: _ 2. How often does practice/clinic accept Medicaid/All Kids/KidCare patients? 3. How often does practice/clinic accept new Medicaid/All Kids/KidCare patients on an ongoing basis? If none of the time please explain method to limit: 4. If a patient s insurance changes to Medicaid/All Kids/KidCare how often do you continue to see him or her? 5. If a patient s private insurance changes to a plan you do not accept, how often do you continue to see him or her? _ 5

6 6. How often are families who ask given access to their medical records? 7. How often are families given any written material indicating that they can have access to their medical records? 8. How often are families able to speak to a physician when needed? 9. How often are practice/clinic physicians available by phone 24 hours a day, 7 days a week, 365 days a year? 10. How often does the practice/clinic staff assist with getting children with disabilities in and out of the facility when needed? 11. Is the location of the practice/clinic accessible by public transportation within four blocks? 12. Is there a computer in the practice/clinic available for families to research health information? If yes, how much of the time is the computer operational? FAMILY-CENTERED 1. In the past three years, how many times has the practice/clinic surveyed families to determine their level of satisfaction with the practice/clinic? 1 = never; 2 = 1x; 3 = 2x; 4 = 3x 2. How frequently can the family select the provider of their choice (if doctor is in the office) for sick visits? 3. How frequently can the family select the provider of their choice (if doctor is in the office) for well visits? 4. How frequently does the practice/clinic query families of CYSHCN regarding special issues or concerns for the visit when they call to schedule an appointment? 5. How frequently does the practice/clinic automatically schedule extra time for an office visit for CYSHCN who have complex medical conditions? CONTINUOUS 1. How frequently does the practice/clinic assist adolescents with special needs by providing information and consultation on transition to adult health care? If none, skip to question #4. 2. How frequently does the practice/clinic assist adolescents with special needs by providing information and consultation on transition to adult health care that is specifically tailored to the adolescent? 3. How frequently does the practice/clinic assist adolescents with special needs by providing information and consultation on transition to adult health care that is specifically tailored to the adolescent with the Not Applicable Not Applicable Not Applicable 6

7 whole family in mind? 4. How frequently do practice/clinic physicians participate in hospital or rehabilitation discharge planning? Estimate what percent of the time do practice/clinic physicians participate in hospital or rehab discharge planning: 1 = 0%; 2 = 1-49%; 3 = 50-89%; 4 = % 5. Estimate what percent of your practice/clinic s families have left your practice/clinic within the past year. Reasons (other than moving): 6. How frequently do you attempt to learn why families might leave your practice/clinic? Please explain: COMPREHENSIVE 1. How often does the practice/clinic follow the AAP guidelines for health supervision visits (periodicity schedule)? Not Applicable % 2. How often does the practice/clinic perform in-office developmental assessments using standardized screening instruments like the PEDS or ASQ? If other screening instruments are used, please list them: _ Describe when the practice/clinic performs developmental assessments: _ 3. How often does the practice/clinic provide vision screening when appropriate? 4. How often does the practice/clinic routinely provide patient and parent anticipatory guidance around the following topics? Nutrition Tobacco Cessation Age appropriate Injury Prevention 7

8 5. Do you have handout information about the public resources listed below? If yes, how often are they provided to families who need the information? Medicaid/All Kids/KidCare (0=No) Waivers (clarify) (0=No) Early Intervention Programs (0=No) DSCC (0=No) SSI (0=No) WIC (0=No) 6. How often do practice/clinic physicians develop a problem list or medical history outline for medically complex children seen by this practice/clinic that is readily available in the patient s chart? 7. How often does the office implement pediatric clinical practice/clinic guidelines developed by organizations such as American Academy of Pediatrics, American Academy of Family Physicians, Agency for Healthcare Research and Quality? Can you list the top three utilized by this practice/clinic? How often are each implemented? Is there a resource library in the practice/clinic available to families? If yes, what percent of families utilize the library on a given visit? None of the families/some of the families/most of the families/all of the families What percent of families utilize the library at some point during the year? None of the families/some of the families/most of the families/all of the families Who maintains the library? 8

9 COORDINATED 1. Has the practice/clinic implemented a system to identify its special needs population prior to scheduled appointments? If yes, what system is used and how often is it used? 0=N/A (no system) system: 2. Does the practice/clinic have a care coordinator or some other person designated to assist families of CYSHCN? 3. How often does the practice/clinic develop informal chronic condition management care plans for CYSHCN? If none, skip to #8. 4. How often does the practice/clinic develop formal (written) chronic condition management care plans for CYSHCN? If none, skip to #8. 5. How often are written plans provided to families? 6. Are written care plans routinely updated? 7. How often does the practice/clinic initiate communication with specialists? 8. How often do specialists follow-up with practice/clinic regarding referrals? 9. When appropriate, how often does the practice/clinic make referrals to the Early Intervention, Child and Family Connections Program? If yes, estimate how many referrals were made to the program in the past 12 months. Describe method(s) used to make referral: 10. When appropriate, how often does the practice/clinic make referrals to the community Head Start program? If yes, estimate how many referrals were made to the program in the past 12 months. Describe method(s) used to make referral: # # 11. How often does the practice/clinic assist families with requesting IEPs or 504 plans? 12. How accessible is the practice/clinic to parents and schools when IEPs or written care plans are not implemented or services are not meeting the child and family s needs? 13. How often are informal clinical evaluation and progress reports provided to the practice/clinic by OTs, PTs, and speech therapists? 14. How often are formal written clinical evaluation and progress reports provided to the practice/clinic by OTs, PTs, and speech therapists? 9

10 15. Protocols to refer to appropriate specialists are in place for infants who fail: a. N/B metabolic screening b. N/B hearing screening 16. How frequently does the practice/clinic provide families-in-need with information regarding support groups and other family resources? 17. Does the practice/clinic have access to a local directory or database of community resources for children and families with SHCN? If yes, how often is the resource provided to families? 18. Is a central record or database containing pertinent information, including hospitalizations and specialty care, maintained at the practice/clinic? CULTURALLY EFFECTIVE 1. How often does the practice/clinic use bilingual staff or trained/certified interpreters for office visits when children and families have limited English proficiency? 2. If your practice/clinic provides families with written information, how often are these materials written in families native languages? Give examples of types of communications provided such as brochures or bulletin board announcements. QUALITY IMPROVEMENT 1. Does the practice/clinic currently have a process in place for doing quality improvement (QI)? If no, stop here. If yes, how thoroughly are families from the practice/clinic involved with the QI process? 2. How thoroughly have QI goals and objectives been developed for this practice/clinic? 10

11 3. How thoroughly has the practice/clinic developed QI measures? If yes, describe what measures are used and how they are being tracked for QI purposes: 11

12 SCORING SUMMARY SCORE Num of Q Actual Total Percent 4 ACCESSIBLE: Physical 16 % If elevator NA (not needed) 8 % If elevator NA (no elevator) 12 % 4 OTHER ENVIRONMENTAL ISSUES 16 % 13 ACCESSIBLE: Patient 52 % 5 FAMILY-CENTERED 20 % 5 CONTINUOUS 20 % If 1,2,3 NA 8 % If 4 NA 16 % If 1,2,3,4 NA 4 % 20 COMPREHENSIVE 80 % 20 COORDINATED 80 % 2 CULTURALLY EFFECTIVE 8 % 4 QUALITY IMPROVEMENT 16 % 77 TOTAL COMMENTS: Developed by Kathy Sanabria, MBA, and Charles N. Onufer, MD, FAAP, Fall 2004 Rev.AK Revised by Wendy Guo 08/15/2005 Revised by Andrew Cooper and Kathy Sanabria 2/14/

13 Screener revised by Kathy Sanabria 3/30/2006; Rest revised by Andrew Cooper 6/14/