Medical Home Care Coordination Visits Defined What is a Care Coordination Visit? A Care Coordination (CC) visit is neither a Sick Visit nor a routine Well Child visit, but is a 30 minute appointment where the provider and the family can discuss all aspects of the patient s care and address specific concerns the family may have. Ideally, we will try to concentrate these visits during our traditionally slower times of the year Spring and Fall. The idea is for the provider to have the opportunity to better provide preventive care and/or to be more proactive in the care of these more complicated patients. It will also give the provider an update on any new developments in the patient s condition, needs, or care. Some patients may need 2 or more CC visits per year, others may never need one all of their needs being addressed at their routine Well Child visits it will be up to the patient s primary provider to decide how often they would like to see the patient. How will I bill for this visit? These will be Level 4 visits using the patient s primary diagnosis (e.g. CP). This is similar to how we bill our routine asthma checks. To bill this level, please note you will have to meet its criteria, remember this could include a total of 25 minutes documented spent with the provider. There must be a documented exam to bill the patient s insurance. How the visit may go The family will have been sent a Medical Information Update Form (attachment 1) in advance of the visit and should bring it with them. Notice it has all of the information needed to complete the Care Summary (attachment 2) form in the front of all TLC patients charts. You may choose to review this information with the family briefly at the beginning of the visit. It also has a question near the end asking the family to identify ways in which our practice may be able to help them care for their child this may provide you with a good starting point. An example outline follows the visit will be different for each patient but this may help you structure this appointment in your mind beforehand Explain to the family the idea of the CC visit and why we are doing them Review the Parent Questionnaire, including medications. Review the patient s specialists, when the last appointment was and any new developments in that specialist s care for the patient. You may also choose to ask and chart any upcoming studies or labs from that specialist and the next appointment with that specialist. Discuss the family s identified needs (as per their response to this question in the Parent Questionnaire) Review any home nursing, OT/PT, IET, etc the patient may be receiving and its adequacy. End the visit by deciding with the family what issues need follow-up and who will do it. For example, the family may be assigned to centralize all of the patient s medication through one pharmacy to ease in identification of potential drug interactions, the provider may agree to call the Pulmonologist re: the patient s frequent pneumonias, and our Nurse/Care Coordinator may be assigned to investigate new community resources for suction supplies. Developed by Dr. Sean McCormick, PHA April 2007
What and Who is the Care Coordinator? The medical home movement has a lot of literature about this position in a medical home practice. In short, the Care Coordinator is a person in the practice who will be a primary contact person in our practice for the family. Most often this is a Nurse within the practice. Eventually we would like to centralize most of the tasks for our medical home patients through the Care Coordinators e.g. referrals, supply needs, refills, etc. The idea is that one person will be better able to serve these complicated patients and their families as they will be more familiar with their ongoing needs, social/financial situation, etc. It is a type of continuity for the patient among the nursing staff. If after the CC visit there are needs for the patient you think the Care Coordinator may be able to help with, please communicate with them. Some examples of things the Care Coordinator may be able to help with include: IEP/School forms, community resources or support groups, and new vendors for supplies, durable equipment, etc. Our Care Coordinators are compiling a binder to centralize resources for the medical home patients which we anticipate will grow as we have more experience. If you have any resources for PT, OT, supplies or other services you can contribute to this binder, please let them know. Some point of potential frustration: You probably won t be able to solve all of the child s/family s problems or answer all of their questions yourself. But the families will hopefully appreciate any thoughts or recommendations you have as well as any referrals you can them to specialists who can answer their more complex questions. We probably will not be able to do everything that some families would like help with. For example, one commonly identified need is for someone (other than the parents) to manage all communication between specialists and between specialists and the PCP. At this point this is beyond the scope of our Care Coordinator s duties, being too timeconsuming for them to handle. Some families don t want more help. Some families do no like the idea of having another doctor s appointment that they need to go to so they may not be interested in a CC visit. That is fine, they must feel like they have things under good control no problem. (Of course we ll be here if they decide otherwise in the future.) If you think a patient and family would really benefit from a CC visit but they have not called to schedule one, bring it up to them the next time you see them, explaining how it may help their child. I hope the providers and the patients find these CC visits helpful. Please let me know if you have any suggestions about how they could be improved. Developed by Dr. Sean McCormick, PHA April 2007
Dear : Someone from (Office Name) recently spoke to you about your child and his or her special health care needs. Along with trying to identify a regular team of doctors/nurse practitioners to serve your child, we would like to update our records and give you a chance to tell us about your child s unique needs. Please complete this form and return it in the self addressed stamped envelope provided. MEDICAL INFORMATION UPDATE FORM (To be completed by parent or primary caregiver) Date Completed: Child s name Parents: (mom) Address: by: (dad) Phone: Home# ( ) Cell# ( ) Work#( ) Language spoken at home: Who is the child s primary caregiver? (Usually goes to the doctor, handles health concerns?) If this is someone other than a parent, please list his or her name and phone number: Are there any special parking or arrival (waiting/exam room) needs that it would help us to know about? (Please explain) What are your child s health concerns? (Please try to list them in order of importance) 1. 8. 2. 9. 3. 10. 4. 11. 5. 12. 6. 13. What medications does your child take on a regular basis? Does your child have any allergies to medications, foods, or the environment (for example: dust, insects, plants, trees, etc.)?
Please list any hospital stays your child has had in the last year and indicate the reason: Hospitalization Dates Reason for Admission Name of Hospital Does your child receive home nursing care? If yes, please list the agency name, contact person, and phone number: List any special equipment that your child uses. (For example: wheelchair, special formula, apnea monitor) What specialists (for example: Allergist, Cardiologist, etc.) does your child see at least once a year? Doctor s Name Specialty or Services Provided Office Phone Number Does your child receive special services at home, school or through an outside agency (such as physical therapy, speech therapy, or occupational therapy)? Please list them. Does your child have an Individual Educational Plan (IEP) or 504 Plan at school? Who is the main person at the school to contact for this information? School Name and Phone number: Does your child have any restrictions or special needs at school? (For example: adaptive gym, special diet, can t play outside if it is cold?) What do you see as your greatest need in caring for your child? How do you think we can help? We look forward to working with you to provide the best medical home possible for your child. If you have any questions, please feel free to contact: at this phone number: Thank you for completing this form, the staff of Office Name
Name of Office/Practice Address 1 Address 2 City, State, Zip Date: / / New patient Established Patient PATIENT INFORMATION: Name: VISIT SUMMARY Appointment & General Information: (999) 999-9999 Fax: (999) 999-9999 Email address here DOB Weight: lbs. oz. Height: Primary Complaint: Seen by Dr. PATIENT INSTRUCTIONS: Treatment Plan: 1. 2. 3. 4. 5. 6. Follow-up with in Completed by: (The office will call you with all abnormal results. Please allow at least one week for test results.) Patient Name: Name of Office/Practice phone number Parent Name: Just a reminder, please call to schedule a follow-up appointment with during the month of. (Please call at least 3 weeks in advance for appointments)