Synthesis
Langdon: Thank you for your feedback. This next activity is short and the purpose is to reiterate what you heard in the three presentations.
The first two questions are ambiguous. It's up to you to decide what like means to you. I want you to have a conversation in your group of three. Spend more time on what your remaining unanswered questions are.
You can make notes on the back of the assignment sheet. The teams are adjusted based on who is here today.
We'll go until 11:25.
Assignment
In your group of 3 people, please respond to the following questions by writing your thoughts on a white board.
•••
You’ve just participated in three conversations concerning the work done in the prior workshop and the ethnographic research.
Please discuss what you heard, and respond to the following questions:
- What did you like the most about what you heard?
- What concerned you the most?
- What are your remaining unanswered questions?
You have 15 minutes for this activity.
We will discuss your work in the large group when you’re finished.
Team 1: Atman, Best, Caywood
Team 2: Duenas, Jones, Miller
Team 3: Schor, Orr, Dalsey
Team 4: Paradise, Beckett, Douglas
Team 5: Brown, Chabra, Walsh
Team 6: Girling, Lobas, Fujiki
Team 7: Smith, Turchi, Bachman, Klitzman
Langdon
Let's have a conversation about what you've just been talking about?
What did you like the most?
We liked the ethnography models.
What would you have us do with that?
For me it was helpful in keeping the eye on the prize. The families are at the center and what ever you do should impact that process.
If you know what the stages families are going to go through you can put services in place to anticipate their needs. It gives you a model to work with.
It isn't just about getting the kid along the trajectory and getting them back into the community.
There is nothing in there that we haven't thought about but it's put together in a way that's different.
It's anticipatory guidance for the special needs family.
It helps with the issue of training.
One thing we are going to do with this is use this to educate the members of the Board of the Foundation.
There is the physician piece but you want to go beyond them to the nurses, social workers and the other care providers.
You have to figure out what you mean by the medical home.
In our group we talked about the blended funding thing. You can bring the system to a place where you don't look at a kid based on diagnosis but based on need. Over here you have to fit into a qualifying condition to get care. Having a blended model might loosen things. That will downsize the payer system. The cost of that is currently obscene. It takes away the ability to pay for care.
The other two places we talked about was in the ethnography report as well - helping people to understand what's happening. It would be great to plan for these things so they don't fall apart along the way.
The care principles of the medical home and the holistic approach is important. Medical home is broader then just medical care. If you have the blended funding model you can make something like this happen.
A couple of areas where there were different thoughts was this issue of eligibility. How do you do that on a functional basis? The school system does that on a functional basis.
All of the effort we have put in to the medical system about eligibiity on a functional level has been too difficult.
Where are the limits on this program? There are three things you have to include: reimbursement, eligibility and a care package. Eligibility will be challenging because people who are in will be happy and those that aren't won't be happy.
In our current system the PCPs are not in the middle. The PCP is further out than the specialist.
Doesn't there need to be some redefinition of primary care? Don't we have to think about how PCPs will be deployed to get them where they belong?
Well Child Check is 90% of some practices and others have mostly cancer patients.
One of the aha's is how out of the loop the PCP is.
There is an evolving thing called chronic care co-management that we should be aware of.
The right model for a PCP and a specialist to work together in a city is different from one in rural areas. How do we make sure the family gets those services they need no matter where they are?
Regarding qualifying conditions - how do you decide who is included and who isn't? Is it a diagnosis? Is it a functional level criteria? Or a combination of both?
Structure follows the funding. The major reason we don't have PCPs functioning the way you envisioned is because of funding. The other problem is communication. If you don't have both of those in place they won't be successful. The third is training.
The same problem exists with the specialists. Because of our funding cardiologists get paid to perform procedures.
You need someone that can think about these things and get paid for that.
Not only do PCPs need to be trained but the specialists need to be trained on how to work with PCPs.
Are we trying to define a separate system for children with special needs or are we trying to define parts of the health care system that can meet the needs of children with special needs?
The answer is yes and no. If you can figure out a system that works for these children it should work for everyone. As we are currently envisioning it it should be a separate system.
We're defining a system for the kids with the highest needs and that would take care of everyone else.
Will it be public and privately funded? The idea is to make it a blend.
The payment to the provider would be from a single source. 66% of the kids are privately funded right now. It's not quite as slanted with kids with complicated conditions.
Some data on that - hospitals are filled with 40% to 80% state supported patients.
A lot of this would have to be done in a step wise fashion.
Maybe advocacy will happen where funding happens? There is a leverage point at the intersection of where providers control and where funders control.
Families are in the hospitals for 30 days and after that hospitals try to get paid for that 30 days. But then after that the family is concerned about paying for the rest of their lives.
One of the things is data - where do we get data on outcomes? What are the quality and outcome measures we want?
We've been looking at distribution of services for kids with chronic illnesses in the state.
How do I manage and know that my program has managed children and my outcomes are better?
There are no unified systems that look at this. We've been looking at the system and how the system manages this population of kids.
How do we improve quality?
Are kids getting to the right places? There are data sets that are sometimes available that would allow us to look at these types of things. There are some successes that need to be protected. The more seriously ill kids have some good care.
The development of new data sets could be valuable.
One of the big unanswered questions is, 'is there political will now to do something there wasn't will to do some years ago?' Are we saying we need this? Are we at a different time now?
For the purpose of today I might ask you to set that aside as we're going to think about how to implement as if the political will is there.
What is the role of academic centers? We teach them how to take care of trauma and shock but we need to start teaching a whole new body of knowledge.
Research around evidence based practices is important.
My concern is quite basic. The issue with a process like this is looking at an ideal model. It's not moored in the current system and it ignores the current reality. There are so many existing county structures throughout the state that need to be taken into consideration.
My concern is about the model. This leads to a passionate group looking at developing a new system that overlays on the current system so that it fragments things even more.
The question of eligibiity is at the core of this. Lack of accountability will still be an issue.
Is accountability missing from the model? It's hard to build a model with full accountability. What you have now could be exascerbated by that new model.
What is it? Are we talking about the healthcare of the child between the hospital and the home or are we talking about the child that has a healthcare issue for the rest of their lives?
As daunting as this is you might have to think about this as, if you are a kid you are part of this. Age is easy but the rest of it is more challenging. When you think about putting all children into a system like this we can't afford it.
Langdon
We're having the conversations that we hoped you would have. We'll be in four teams in this next activity. We'll give you quite a long time to address some detailed questions. One set of questions are about designing the strategy and one set of questions are about stress testing the ideal model and improving it. There are a couple of steps in each activity. When you finish each step you will get the next step. Lunch will be included.
We have some team lists here.
The actual assignments will be in the break out areas.
If you are in a group with one focus of questions you will have an opportunity to give input into the other set in a little while.
As soon as lunch is available we will invite you to eat.
Please pass in your notes from the previous conversation.