Nursing

Care Coordination in a Medical Home in Post-Katrina New Orleans: Lessons Learned

Susan Berry • Eleanor Soltau • Nicole E. Richmond •

R. Lyn Kieltyka • Tri Tran • Arleen Williams

Published online: 14 July 2010

� Springer Science+Business Media, LLC 2010

Abstract This is a prospective study to evaluate ability of a

nurse care coordinator to: (1) improve ability of a pediatric

clinic to meet medical home (MH) objectives and (2)

improve receipt of services for families of children with

special health care needs (CSHCN). A nurse was hired to

provide care coordination for CSHCN in an urban, largely

Medicaid pediatric academic practice. CSHCN were iden-

tified using a CSHCN Screener. Ability to meet MH criteria

was determined using the MH Index (MHI). Receipt of MH

services was measured using the MH Family Index (MHFI).

After baseline surveys were completed, Hurricane Katrina

destroyed the clinic. Care coordination was implemented for

the post-disaster population. Surveys were repeated in the

rebuilt clinic after at least 3 months of care coordination. The

distribution of demographics, diagnoses and percent

CSHCN did not significantly change pre and post Katrina.

Psychosocial needs such as food, housing, mental health and

education were markedly increased. Essential strategies

included developing a new tool for determining complexity

of needs and involvement of the entire practice in care

coordination activities. MHFI showed improvement in

receipt of services post care coordination and post-Katrina

with P \ 0.05 for 13 of 16 questions. MHI demonstrated improvement in care coordination and community outreach

domains. Average cost was $36.88 per CSHCN per year.

There was significant improvement in the ability of the clinic

to meet care coordination and community outreach MH cri-

teria and in family receipt of services after care coordination,

despite great increase in psychosocial needs. This study pro-

vides practical strategies for implementing care coordination

for families of high risk CSHCN in underserved populations.

Keywords Care coordination � Medical home � Children with special healthcare needs (CSHCN) � Title V CSHCN � Hurricane Katrina

Eleanor Soltau has relocated to Atlanta, Georgia, after her

involvement with this research.

S. Berry (&) � N. E. Richmond � A. Williams Department of Pediatrics, Louisiana State University

Health Sciences Center, 1010 Common Street Suite #610,

New Orleans, LA 70112, USA

e-mail: sberry@lsuhsc.edu

N. E. Richmond

e-mail: Nicole.richmond@la.gov

A. Williams

e-mail: Arleen.williams@la.gov

E. Soltau

Children’s Hospital Medical Practice Corporation,

New Orleans, LA, USA

e-mail: esoltau@gmail.com

S. Berry � N. E. Richmond � A. Williams Louisiana Office of Public Health, Children’s Special Health

Services, New Orleans, LA, USA

R. L. Kieltyka � T. Tran Department of Pediatrics, Louisiana State University Health

Sciences Center, 1010 Common Street Suite #2710,

New Orleans, LA 70112, USA

R. L. Kieltyka

e-mail: lyn.kieltyka@la.gov

T. Tran

e-mail: tri.tran@la.gov

R. L. Kieltyka � T. Tran Louisiana Office of Public Health, Maternal and Child Health

Services, New Orleans, LA, USA

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Matern Child Health J (2011) 15:782–793

DOI 10.1007/s10995-010-0641-4

 

 

Introduction

Primary care in a medical home (MH) has many advanta-

ges for Children with Special Healthcare Needs (CSHCN)

[1, 2]. According to the Maternal and Child Health Bureau

and the American Academy of Pediatrics (AAP), a medical

home provides healthcare that is ‘‘accessible, continuous,

comprehensive, family-centered, coordinated, compas-

sionate, and culturally effective’’ [3]. CSHCN according to

the Maternal and Child Health Bureau are children who

‘‘have or are at increased risk for chronic physical, devel-

opmental, behavioral, or emotional conditions that require

health and related services of a type or amount beyond that

required by children generally [4]. This broad definition

includes not only children with more severe disabling

conditions, but children with common conditions such as

asthma and attention deficit disorder. CSHCN that meet

these criteria constitute approximately 13–20% of the

population [5], but consume a disproportionate share of

healthcare dollars [6–8]. Studies have demonstrated cost

savings when primary care for CSHCN is implemented in a

MH, primarily through decreased emergency room visits

and hospitalizations [7, 9–12].

In February 2007 the American Academy of Pediatrics

(AAP), American Academy of Family Practice, American

College of Physicians and American Osteopathic Associa-

tion developed the ‘‘Joint Principles of the Patient-Centered

Medical Home (PCMH)’’ [13] and adopted the National

Center for Quality Assurance (NCQA)—PCMH criteria as

standards for practices [14]. As of February 2009, at least 30

states, including Louisiana, had proposed legislation to

encourage the development of MHs for children [15]. Yet

while care coordination is a key component of MHs for

CSHCN, in traditional pediatric practices, time, staff limi-

tations and reimbursement issues have posed significant

barriers for its implementation [10, 16–19]. Research doc-

umenting successful models of care coordination in differ-

ent populations is lacking [11, 20]. Such models are

essential to assist pediatricians in providing MH’s that meet

the needs of CSHCN. One method of providing care coor-

dination in a practice is through the addition of a care

coordinator. A care coordinator works with the physician

and practice staff to link families to medical, public health,

and community resources and advocate for their needs [17,

21–24]. Several studies have demonstrated the ability of a

care coordinator to improve family satisfaction [4, 20] and a

few have analyzed cost [11, 12, 19, 25], but none in a

population with such high risk.

In Louisiana, 54% of CSHCN live in households below

the federal poverty level, vs. 46.9% nationally [26]. Loui-

siana’s Medicaid eligible CSHCN have twice the unmet

need for care coordination as those with private insurance

(22.4 vs. 11.0%) [27]. Compared to the national average,

Louisiana CSHCN families spend more hours each week

coordinating their child’s care (5–10 h/week, 8.9% US vs.

12.9%; P \ .05). This study evaluates the ability of a nurse care coordinator to improve MH criteria in an urban, pre-

dominantly Medicaid pediatric practice in post-Katrina

New Orleans, and to meet the needs of families of CSHCN

when resources were disrupted, families displaced, and

much of the healthcare infrastructure destroyed. Lessons

learned in implementing care coordination for this high risk

population are discussed.

Methods

In March 2005, after obtaining Institutional Review Board

approval from Louisiana State University (LSU) Health

Sciences Center and Children’s Hospital of New Orleans,

Louisiana’s Title V Children’s Special Health Services

(CSHS) Program hired a nurse to coordinate care for an

urban, academic pediatric practice. The practice is located

in downtown New Orleans on the city’s major bus route,

next to a key Medicaid office, with the goal of providing

comprehensive care to an underserved, largely Medicaid

population. The clinic is the primary outpatient teaching

practice, or ‘‘continuity clinic’’, for 27 LSU pediatric res-

idents, and is staffed by 5 general pediatric faculty and one

developmental pediatrician.

Baseline surveys were completed and care coordination

begun just before Hurricane Katrina struck in August 2005.

The clinic received four feet of water. All computers, most

medical records, study data, and the backup flash drive

were destroyed. Only initial baseline aggregate results

presented on a poster survived. When the rebuilt clinic

opened in March 2006, care coordination resumed in the

post-disaster environment.

MH Rating

The Medical Home Index (MHI) [28] is a validated, self-

rating tool for quality improvement within the practice. It

consists of 25 items or themes divided into six domains of

practice activity that are critical to the quality of care in a

medical home: 1. Organizational capacity; 2.Chronic con-

dition management; 3. Care coordination; 4. Community

outreach; 5. Data management; 6. Quality improvement.

Questions are scored across four levels of achievement

corresponding to a continuum of quality: 1. Good basic

pediatric care; 2. Responsive care; 3. Proactive care; 4.

Comprehensive care. Achievement can be partial or com-

plete within each level, depending on the rater’s evaluation

of activity within the practice compared to the description

provided for each theme and level. Six pediatric faculty,

the office manager, and the clinic nurse completed separate

Matern Child Health J (2011) 15:782–793 783

123

 

 

baseline MHI’s in March 2005 before Katrina and care

coordination, and follow-up MHI’s post care coordination

in March 2007, 1 year after the clinic reopened.

Faculty Training

Following the baseline MHI survey, a 2-h workshop on

MH concepts was held for clinic faculty and staff using

training materials from the AAP Website. The slide set,

‘‘Common Elements’’, was presented with a case presen-

tation of the care coordinator’s own child with Down

syndrome, whose doctor was ‘‘an excellent pediatrician,

but whose practice was not a MH.’’ AAP policies on MH

and care coordination, Louisiana data on CSHCN, and a

review of state and national MH initiatives were presented.

The importance of teaching MH concepts to pediatric

residents in continuity clinics as embraced in the Future of

Pediatric Education II guidelines was emphasized [23, 29,

30]. MHI baseline results were presented.

Family Inclusion Criteria

A CSHCN Screener [5, 31] modified for literacy level

(Table 1) was used to identify CSHCN in the practice. At

baseline, a convenience sample of families of CSHCN

identified by the screener who had been receiving primary

care services in the clinic for at least 3 months were sur-

veyed. After the flood, baseline families could no longer be

identified. Therefore, new CSHCN families were identi-

fied, followed at least 3 months, and surveyed.

Case Complexity

The HOMES Complexity Index [32] was completed by

parents of CSHCN identified by the screener at baseline to

determine CSHCN case complexity and to appropriately

target care coordination services. Since the HOMES failed

to distinguish degree of complexity within the clinic pop-

ulation, the care coordinator developed a new tool to

determine intensity of care coordination needed for the

post-disaster population (Appendix 1). Using this tool,

CSHCN were considered Level 1 if they required simple

referrals that could be managed by office staff and Level 2

if they had more complex needs requiring the care coor-

dinator. For example, a child with asthma who had minimal

emergency room visits or missed school days was Level 1.

The same child with many missed school days or multiple

emergency room visits in the past year was Level 2. An

autistic child with an appropriate Individual Educational

Plan (IEP) for special education receiving family support

services, such as respite care, was Level 1; the same child

receiving inadequate school services or with frequent

school expulsions was Level 2. CSHCN frequently chan-

ged levels as their needs changed, indicated by the color

sticker on the chart. Care coordinator caseload was there-

fore fluid, depending on families’ ever-changing needs.

Care Coordination Activities

After CSHCN were identified by the CSHCN Screener, the

care coordinator met with the family in the exam room

while waiting for the physician. After a brief assessment,

level of care coordination complexity was determined

using the tool in Appendix 1. If the child met criteria for

Level 2 complexity, an effort was made to identify

immediate needs that could be met during the clinic visit.

Further assessment was done after consultation with the

physician, and a care plan developed. Because the clinic

had no electronic medical record (EMR), a separate care

coordination chart was created and kept in the coordina-

tor’s office. Children who did not meet criteria for Level 2

complexity had care coordination needs handled by the

physician and front desk staff. To encourage physicians to

make Level 1 referrals, information and forms for routine

referrals were wall-mounted for ease of use. The coordi-

nator held quarterly MH meetings to develop clinic pro-

cedures and to discuss community resources. She also

arranged for Families Helping Families to hold ‘‘IEP

Table 1 CSHCN Screener (Modified from CAHMI http://www.cahami.org)

1. Does your child need or use medicine prescribed by a doctor?

List prescription medicines your child takes on a regular basis:

2. Does your child need or use more medical care than other children the same age?

3. Does your child have trouble doing things most children the same age can do?

4. Does your child need or get special therapy, such as physical therapy, occupational, or speech therapy?