Central Massachusetts Medical home Network

Moving Forward … Ways of Sustaining Family & Professional Partnerships : 

Moving Forward … Ways of Sustaining Family & Professional Partnerships Central Massachusetts Medical Home Network Initiative Barbara Donati & Beth Pond & Beth Dworetzky June 24, 2008 “Be the change you want to see in the world." Mahatma Gandhi

Central Massachusetts Medical HomeNetwork Initiative(CMMHNI)Stringing the Pearls: Families and Providers as Partners in Expanding Medical Home Capacity in Central Mass www.medicalhomeofcentralmass.org : 

Central Massachusetts Medical HomeNetwork Initiative(CMMHNI)Stringing the Pearls: Families and Providers as Partners in Expanding Medical Home Capacity in Central Mass www.medicalhomeofcentralmass.org

Our Home Sweet Medical Homes : 

Our Home Sweet Medical Homes UMass Memorial Pediatric Primary Care- Worcester Hospital based practice. They have 15,000 patients with 25% having special needs. Nashaway Pediatrics- Clinton Community-based practice within the UMass system. They have 2,800 patients with 33% having special needs South County Pediatrics- Webster. Community-based practice. They have 2,000 patients with 33% having special needs. Quality Kids Kare- Worcester Private community based inner city practice. They have 3,200 patients with 30% having special needs Medical Associates Pediatrics- Leominster Private Community based practice. They have 20,000 patients with 30% having special needs

CMMHNI Parent & Youth Opportunities : 

CMMHNI Parent & Youth Opportunities Quality Improvement Teams Family Based Care Coordination Measurement Study Family & Youth Advisory Panel Parent Advisory Groups Regional Project Consultants Central Mass Partnership

Quality Improvement Teams : 

Quality Improvement Teams Teams consist of a physician or NP, office staff person, care coordinator and/or nurse who performs those duties, and parent(s) Meet monthly to discuss and report on improvement projects along with suggestions from parent groups Pre-visit surveys Suggestion boxes Flagging charts Care plans Talking tools for kids Tracking BMI Special Needs registry

QI-Key Points : 

QI-Key Points If families are engaged in Medical Homes as partners, they can drive QI Practice-based QI is feasible, but resources and training for facilitator is critical and can be deployed across a region.

QI-Challenges and Success : 

QI-Challenges and Success Successes Parent & Professional worked as equal partners Became more aware of non-medical community resources Team work enhanced the quality of care for CYSHCN Each site learned from each other Challenges: Finding time for meetings Finding time to work on projects Follow through on projects All staff on board

Family Based Care Coordination Measurement Study Family & Youth Advisory Panel : 

Family Based Care Coordination Measurement Study Family & Youth Advisory Panel Who are they? The CC Advisory Panel was made up of 2 project staff, 2 parents, a youth and a community partner/Family Voices representative. What did they do? They have helped to develop a tool to measure care coordination activities performed by youth & families with children with special needs. The tool will measure how and what families & youth are doing with their CC efforts, do they do it well, not so well and how does the practice help. Why use families? Because our beloved leader Dr. Richard Antonelli believes that families are his teachers. So who better to advise CMMHNI project staff than the families & youth who are or have been in the trenches.

FCCMS Key Points : 

FCCMS Key Points With assistance from our national advisors the CMMHNI panel took ownership in the development of the tool from start to finish. Everyone had a voice in it’s creation and pilot activities.

Parent Advisory Groups : 

Parent Advisory Groups Each practice has formed or is forming a PAG. Activities include: Open House Presentations/training by CMP partners brochure development to educate/recruit parents Listserv development to share information Development of pamphlets and resources for the practice Parent to parent support The PAG facilitator helps organize & provide ideas for activities. Highly effective strategies: Physician’s invitation to participate Existing PAG members WELCOME new PAG members Mentoring CMP partner involvement in educational, QI activities

PAG-Key Points : 

PAG-Key Points Once the financial and mentoring support of the MH grant ends the only way the groups will sustain themselves, within the practice, is by provider support and encouragement in their efforts.

PAG-Success & challenges : 

PAG-Success & challenges They have all had some success in reaching out to families in need of resources and have formed friendships with others in their practice that they would not have met if not for the parent group. Challenges are the same as everyone’s – it is hard to get folks to come out at night especially if someone is a single parent.

Regional Project Consultants : 

Regional Project Consultants The RPC project is a “across our county” collaborative effort with our Medical Homes Family Leaders. The purpose is to share: Individual site projects and learn from each others’ successes and challenges, parent group activities, quality improvement activities, QI tools, and to work collaboratively on trainings for both families and providers The intended outcome: To teach and inform their Medical Homes on non-medical community resources with hope that the providers will integrate these resources into the care process.

RPC-continued : 

RPC-continued Parent Group & Provider Trainings: In-service trainings on mental health resources with the Parent/ Professional Advocacy League Special Education Basic Rights with the Federation for Children with Special Needs. Public Benefits Training with the MA F2F HIC/MA Family Voices Help with Organizing paperwork with Family TIES of Massachusetts Training on Spanish Translation Software by the MA F2F HIC/MA Family Voices Current project…..creating a list of “free” in-service trainings and workshops so staff and families will have a resource when our work is done.

RPC-Key Points : 

RPC-Key Points This group is a natural parent to parent support vehicle. They are comfortable with each other and work together as a team to help build systems change within their medical home practices and their communities. They have been there, done that so there is trust and respect.

RPC-Success & Challenges : 

RPC-Success & Challenges The group has been successful in planning several in-service trainings for both families and Medical Home providers and staff. No Challenges to report ---yippee

Community : 

Community Community Based Organizations: The Central Massachusetts Partnership for CYSHCN (CMP) works to educate families, community based organizations and the medical community about the strengths and challenges of the current systems of care and build partnerships among Central MA community based agencies, health care professionals and families.

Community Continued : 

Community Continued Membership includes: parents, advocates, researchers, physicians, health care providers, community representatives, state agencies, education and social service providers. CMMHNI and the CMP have very similar missions. This is just a summary of over 20 groups: State agencies: Title V (DPH), Department of Mental Retardation MA Federation for Children with Special Needs Regional Early Intervention Programs and Educational Collaborative Area Health Education Center (AHEC) Nonprofit mental health agencies and coordinating centers Parent-professional advocacy groups for both specific conditions (Autism Resource Center, Mental Health) and more generally (Family TIES of Massachusetts)

Community continued : 

Community continued The CMP in the past has worked on several “projects”. The first, being a Resource Directory of family stories called Family Reflections. Most recently the group has created a unique respite program where families, a community college and a community agency collaboratively applied for a grant to help address the need for respite care for CYSHCN in Central MA. Currently, The CMP is now developing a family leadership working group to provide training and support for families.

Community/CMP-key points : 

Community/CMP-key points Interaction with CBO’s takes time and effort but is best accomplished when focused on specific projects such as See previous slide Collaboratively responding to a RFI for the Mass Mental Health remedy for the Rosie D case. Research partnerships for studies focused on improving care for CYSHCN

Side note to Community : 

Side note to Community CMMHNI project staff Beth and Barbara are not just hired help. They are parents of children with special needs and are parent leaders with many organizations. They are general & advisory board members and workshop presenters to many active groups such as: Mass Families Organizing for Change (parent leadership) Parent/Professional Advocacy League (mental health) Mass Family-to-Family Health Information Center/Mass Family Voices (public benefits & health insurance information) Central Mass Partnership (regional affiliate of statewide MA Consortium for CYSHCN ) Family TIES of Massachusetts (statewide Parent to Parent program) Health Care for All - Watch your Mouth Campaign (oral health) When the grant ends they will still be out working as leaders in the community and will continue to inform the medical homes on non- medical resources and activities.

Moving Forward : 

Moving Forward Opportunities for our Families: Invite families from our pediatric practices and regional PAG leaders to become members of the CMP group Collaborate with regional agencies/organizations Learn about programs and resources in the community and how to navigate them Share information and resources with their practices to help “teach” the staff about available resources in the community Build a pool of “new family leaders”

Sustaining Our Families ……….. : 

Sustaining Our Families ……….. Parent Advisory Group Regional Project Consultants Community Partner

Contact information : 

Contact information Beth Pond & Barbara Donati CMMHNI 104 Leominster Road Sterling, Ma 01564 978-422-5083 beth.pond@umassmed.edu barbara.donati@umassmed.edu Beth Dworetzky FCSN 1135 Tremont Street, Suite 420 Boston Ma 02110 1-800-331-0688 x 210 massfv@fcsn.org