Medical Homes in Illinois

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Medical Home Initiatives
This section provides information on state medical home initiatives/programs. States that are a part of the mentorship network will have a "Promise to the State" which outlines how they will achieve ensuring that all children have a medical home by 2010. This is based on the Healthy People 2010 goals which is a 10 year action plan to achieve and measure success for all CSHCN.

Illinois Medical Home Contact:

Name: Charles Onufer, MD, FAAP
Contact: Phone: 217-793-2340 |Fax: 217-793-0773 | Email: cnonufer@uic.edu
State Team: Roster

Announcements:

Updates from the Illinois Medical Home Team

• Phase I Results and Project Update, June 2008 - Report
  
• Summary Progress Report for Year 4, July 2007 to June 2008 -PowerPoint
  
  
• When It Comes to Special-needs Kids, There’s No Place Like “Home”: Pilot Program Takes a New Approach to Pediatric Care - Article
  
  
• IMHP ANNUAL NEWSLETTER: "Medical Homes: Spreading Innovative Practices"
  March 2007
  September 2005 (first edition)
  
  
• Medical Home Project Learning Session II, March 10, 2007: Presentations (video-taped)
  *Windows Media Player is necessary to view the presentations at the following link: http://video.google.com/videosearch?q=%22medical+home%22
  
  
• Medical Home Project Learning Session III, December 8, 2007: 
  Summary Article and Presentations (video-taped)

  Patience White, MD, MA, provided an inspirational presentation on transitioning adolescents with special needs to the adult healthcare system and preparing them to be productive and ready for work.  Dr. White is the Chief Public Health Officer of the Arthritis Foundation – the nation’s largest national, nonprofit health agency working on behalf of the 66 million Americans with arthritis and related diseases. In addition to her work at the national office of the Arthritis Foundation, she is a professor of medicine and pediatrics at the George Washington University School of Medicine and Health Sciences.  In addition to Dr. White’s academic accomplishment she has also authored numerous books and articles.  Much of her published work deals with the long-term outcome of youth with disabilities as they move into the world of work and adult medical care.
  
  Maureen Lowry-Fritz, a licensed attorney who operates a special education law consulting practice in Naperville, IL, provided a high-powered talk on advocacy for special education services in schools. Dr. White’s and Ms. Lowry-Fritz’s presentations were videotaped and are available for viewing at the following google site.                     

  *Windows Media Player is necessary to view the presentations at the following links:

  Dr. Patience White: http://video.google.com/videoplay?docid=-3769689362710186321&hl=en

  Ms. Maureen Lowry-Fritz:  http://video.google.com/videoplay?docid=-1236708449502996117&hl=en

   

MCHB Medical Home Grant: Illinois Medical Home Project Abstract
Contact: Kathy Sanabria, MBA, PMP Phone: 312-733-2850 | Email: ksanabria@illinoisaap.net
Project Period: 4 years from July 1, 2004 to June 30, 2008
Purpose: The IMHP supports development of community-based medical homes for CYSHCN by informing primary care providers about the medical home model; providing access to quality improvement (QI) processes involving partnerships with parents, linkages to community resources, and reimbursement; facilitating QI Teams at practices; and sponsoring Leadership Forums to develop statewide action plans. For more information on the Illinois Medical Home Project please visit their website at www.illinoisaap.org/medicalhome.htm.



Primer on the Illinois Medical Home Model for Physicians
(Click on the Medical Home logo in the upper left hand corner of the Providers Section to link to the Primer.)

The first two components of the Illinois Medical Home Model define what it means when families say they have a Medical Home and and what it means when physicians say they provide a Medical Home. The third component describes the activities occurring in Illinois to promote the Medical Home Model. The primer includes references, video clips, PowerPoint presentations and many handouts that are downloadable. Also included is the 2nd edition of the UIC-DSCC Medical Home CME Monograph for community pediatricians and family physicians that was published on May 1, 2004. The entire 70 page document is downloadable as a PDF file.

Primer on the Illinois Medical Home Model for Families
" What Families Need to Know about a Medical Home" has been developed to explain the Medical Home Model for families and children with special health care needs. It explains the family-professional partnership and how it relates to accessing quality health care. The primer goes on to explain how families can become proactively involved in Quality Improvement Teams in their primary care provider's practice. There are links to the AAP web site describing what others states are doing to promote Medical Home, a downloadable Parent-Partner Guide, Power Point presentations, and information about the Illinois Title V CSHCN Program.

Medical Home Physician Reimbursement Brochure
DSCC recognizes that serving children with special health needs is often more complex and time consuming. Medical Home Physicians will be reimbursed when the level of decision-making or planning complexity requires more physician time. Reimbursable services may include telephone consultations with specialists and certain care coordination activities not otherwise covered by third party payers. More specific information is available in the DSCC Fee Schedule for Medical Home Services brochure. If you have any questions or would like more information about becoming a Medical Home Physician, please contact DSCC.

Pediatric Specialists Available for Consultation to Assist Primary Care Physicians Managing Care for CSHCN
A statewide network of pediatric specialists who will provide telephone consultation to community primary care physicians is in the process of being finalized. For physicians with limited experience in treatment planning for medically complex children, the consultants will be available to provide consultation in the development and management of care for CSHCN. Reimbursement for consultation services with these specialists will be available for DSCC approved medical home providers. More information about this new consultation service will be available from this site in the near future. Contact DSCC for more information about becoming a DSCC approved medical home provider.

Governor Ryan proclaims 2002 The Year of the Medical Home in Illinois
On January 31, 2002 Governor George Ryan issued a proclamation announcing 2002 as the year of the medical home in Illinois. The proclamation recognizes the collaborative work of the Illinois Chapter of the American Academy of Pediatrics, the Illinois Academy of Family Physicians, and the University of Illinois Division of Specialized Care for Children to ensure that every child and family is guaranteed quality, comprehensive health services through a medical home.

Illinois Statewide Medical Home Implementation Plan: Promise to the State
Read about the Illinois Statewide Medical Home Implementation Plan. This document is available in PDF and requires the Adobe Reader to view and print the brochure. The Reader is available free from the Adobe web site.

Families Assisting in the Development of the Medical Home Implementation Plan
Members of the DSCC Family Advisory Council, which is comprised of families representing each of the agency's thirteen service regions throughout Illinois, have been engaged in the development of the medical home concept. Members participated in the development of medical home informational brochures for distribution to families and physicians.

Related Grant Initiatives
This section provides information on current state grants that are working on medical home initiatives. This includes the grant abstract as well as key contacts for the grant.

The Region 4 Collaborative (IL, IN, KY, MI, MN, OH, & WI)) was awarded a Medical Home Visting Professorship

The state of Illinois was awarded a Genetics Visiting Professorship (2008)

Medical Home/Genetics Visiting Professorship Pilot Program

The American Academy of Pediatrics National Center for Medical Home Initiatives for Children with Special Needs and the American College of Medical Genetics' National Coordinating Center for the Regional Genetics and Newborn Screening Service Collaboratives (NCC) in partnership with the ACMG and MCHB recently developed a pilot visiting professorship program. This program focuses on the specific topic areas of genetics and medical home and also establishing linkages between Regional Genetics and Newborn Screening Services Collaboratives (RCs) and AAP Chapters.

Educational Initiatives
This section provides information on training initiatives on the medical home. Some states will discuss their outreach projects in relation to physicians, families, and the community.

Educational Outreach Includes Medical Grand Rounds and CATCH Meetings
Efforts to provide primary care providers with information on the medical home model and the tools needed to introduce the process within their medical practices are underway. DSCC has begun providing presentations on the medical home model at local CATCH (Community Access to Child Health) meetings and at medical grand rounds. These opportunities provide physicians and other interested health care providers with information about the state Title V program (DSCC), introduction to the medical home model, and a brief introduction to the Medical Home Index and Medical Home Family Index.

• Campaign for Better Health Care
• Coach House
• Illinois Academy of Family Physicians
• Illinois Chapter of the American Academy of Pediatrics
• Illinois Maternal Child Health Coalition
• Miles Square Family Health Center
• National Center for Education in Maternal Child Health
• Shriners Hospitals for Children, Chicago
• University of Illinois at Chicago Craniofacial & Cleft Lip/Cleft Palate Center
• University of Illinois - Division of Specialized Care for Children
• Voices for Illinois Children

UIC-Division of Specialized Care for Children
Administered by the University of Illinois at Chicago, the Division of Specialized Care for Children (DSCC) is the Illinois Title V agency that provides care coordination for families and children with special health care needs. DSCC has been one of Illinois' lead agencies in developing and implementing the medical home model in Illinois. To find out more information, visit the DSCC website.

Title V Block Grant to States
Title V of the Social Security Act is one of the largest Federal block grant programs. It leads the nation in ensuring the health of all mothers, infants, children, adolescents, and children with special health care needs (CSHCN). Title V is administered by the Maternal and Child Health Bureau (MCHB) as part of the Health Resources and Services Administration, U.S. Department of Health and Human Services.

Title V and Children with Special Health Care Needs
MCHB Objective: Support development and implementation of comprehensive, culturally competent, coordinated systems of care for the estimated 18 million U.S. children who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.

MCH Contact:
Dr. Myrtis Sullivan, M.D., M.P.H.
Associate Director for Family Health
Address: 1112 S. Wabash - 3rd Floor
Chicago, IL 60605
Phone: 312-793-4605 | Fax: 312-793-4666
Email: Myrtis.Sullivan@illinois.gov
Internet site: www.dhs.state.il.us/chp/

Early Hearing Detection & Intervention (EHDI) Contact(s):
State EHDI programs promote universal newborn hearing screening, develop effective tracking and follow-up as a part of the public health system, promote appropriate and timely diagnosis of the hearing loss, prompt enrollment in appropriate Early Intervention, link newborns to a medical home and strive to eliminate geographic and financial barriers to service access.

Name: Gail Tanner, MS CCC-A
Contact: Phone: 217 782-4733 - Fax: 217-557-5324
Email: gtanner@idph.state.il.us

Early Intervention/Part C Coordinator:
The Program for Infants and Toddlers with Disabilities (Part C of IDEA) is a federal grant program that assists states in operating a comprehensive statewide program of early intervention services for infants and toddlers with disabilities, ages birth through age 2 years, and their families.

Name: Janet Gully, Chief
Contact: Phone: (217) 782-1981 | Fax: (217) 524-6248
Email: dhsvr50@dhs.state.il.us
Website: www.state.il.us/agency/dhs/eisnp.html

Section 619/ Preschool Grants Program of the Individuals with Disabilities Education Act (IDEA). This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities:

Name: Pam Reising-Rechner, Principal Consultant
Contact: Phone: (217) 524-4835 | Fax: (217) 785-7849
Email: preising@isbe.net
Website: www.isbe.net/earlychi/Default.htm

State Interagency Coordinating Council (ICC) Chairs:
The ICC advises appropriate agencies on the unmet needs in early childhood special education and early intervention programs for children with disabilities, assists in the development and implementation of policies that constitute a statewide system, and assists all appropriate agencies in achieving full participation, coordination, and cooperation for implementation of statewide system.

Name: Anne Shannon, ICC Chair
Contact: Phone: (708) 547-3550 x3597 | Fax: (708) 547-4067
Email: parcassn@aol.com

Screening Initiatives
This section provides information on surveillance and screening initiatives in the state.

Developmental Surveillance and Screening Policy Implementation Project (D-PIP)
North Arlington Pediatrics from Arlington Hts., IL is participating in the Developmental Surveillance and Screening Policy Implementation Project (D-PIP). The D-PIP has selected 17 practices from across the United States to implement the AAP policy statement (scheduled for publication in July 2006) “Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening” to 1) determine if the algorithm is efficiently and effectively implemented into pediatric practice; 2) recognize strategies for implementing the algorithm; and 3) examine outcomes of implementation. Following the project, information and outcomes will be shared with pediatric clinicians and other health care professionals who are seeking to improve the delivery of developmental surveillance and screening.

Click here for additional information on the D-PIP.

State Newborn Screening & Genetics Programs: genes-r-us.uthscsa.edu/resources.htm

• State Newborn Screening Program Links
• State Genetics Program Links
• Regional Genetics and Newborn Screening Collaborative Links
• Newborn Screening State Contact Fact Sheet

Illinois Early Autism Detection and Referral Program Honored with National Award of Excellence
The Illinois Chapter of the American Academy of Pediatrics (ICAAP) has won the Award of Excellence in the 2005 Associations Advance America (AAA) Awards programs, a national competition sponsored by the American Society of Association Executives (ASAE), Washington, DC.

ICAAP received the award for its physician education program titled, Screening Tools and Education for Pediatric Providers 2 (STEPPs 2): Early Autism Detection and Referral, which was developed by Illinois pediatricians. Autism has gained a great deal of national attention in recent years. The Centers for Disease Control estimates that as many as 1 in 166 children may be affected by an autism spectrum disorder (ASD). Early detection and referral by physicians is crucial to helping children get the best start they can.

STEPPs 2 is now in the running to receive a Summit Award, ASAE’s top recognition for association programs, to be presented in ceremonies at ASAE’s 6th Annual Summit Awards Dinner in September 2005 in Washington, DC. STEPPs 2 is funded by The Autism Project (TAP) of the Illinois Department of Human Services. TAP’s goal is to promote an overall systems change in Illinois for those with ASD. One of the ways in which they do this is to raise awareness of autism among primary care medical professionals, in order to help children with autism get the early diagnosis and intervention services they need. The STEPPs 2 program has made possible by offering providers an overview of ASD, including definitions and information about recognizing early signs of autism. The educational program also discusses common misconceptions about the causes and stereotypes of autism, as well as how to refer children who show signs of autism to the Early Intervention system, the Special Education system, and to specialists. ICAAP also strives to help the office staff become familiar with the team approach to diagnosis and the importance of evidence-based treatment of autistic spectrum disorders. Practicing pediatricians and experts in the field serve as speakers for the program, which will have been presented nearly 60 times in private practices, clinics, and hospitals by June 2005. For more information on the STEPPs 2 program, contact Sarah Baur, project director, at sbaur@illinoisaap.net or 312-733-1929.

Assuring Better Health and Child Development (ABCD) Program:
http://12.109.133.213/_docdisp_page.cfm?LID=BB138571-949F-4AFB-8AD4813752870C0D
The ABCD II Initiative, launched in 2003, is designed to assist states in building the capacity of Medicaid programs to deliver care that supports children’s healthy mental development.

Illinois was chosen as one of five states to join the National Academy for State Healthy Policy’s (NASHP’s) Assuring Better Child Heath and Development II (ABCD II) initiative. Other states involved in the initiative are California, Iowa, Minnesota and Utah. In Illinois, the project is called “Healthy Beginnings.” The Illinois Department of Healthcare and Family Services (IDHFS, formerly the Illinois Department of Public Aid) is the lead agency for Healthy Beginnings and is working in partnership with many organizations which are focused on improving child health and development, including the Illinois Chapter of the American Academy of Pediatrics (ICAAP), the Illinois Academy of Family Physicians (IAFP), and the Ounce of Prevention Fund.

Healthy Beginnings has identified the following three overarching goals:
1. increase Illinois primary care providers’ ability to provide more comprehensive care to Medicaid-eligible families with young children, including identification of social/emotional health issues;
2. improve the provision of mental health-related intervention services to Medicaid-eligible women and their children under age three identified by primary health care providers;
3. provide lessons learned to inform future efforts that will lead to changes in statewide policy and practice in Illinois and in Medicaid programs in other states.

These goals will be achieved, in part, through educational programs for pediatricians and family physicians in topic areas such as:

• Social/Emotional Screening and Referral, including using the Ages and Stages Questionnaire: Social/Emotional (ASQ: SE)
• Perinatal Maternal Depression Screening and Referral, including using the Edinburgh Post-Natal Depression Scale

Trainings will be offered both on-site, as well as through teleconferences. Both models of training will offer CME credit.

Enhancing Developmentally Oriented Primary Care: www.edopc.org
The Illinois Chapter of the American Academy of Pediatrics (ICAAP), the Advocate Health Care Healthy Steps Program, the Illinois Academy of Family Physicians (IAFP), and the Ounce of Prevention Fund have partnered on an initiative to define developmentally-oriented primary care and identify needs for Illinois pediatric care providers in terms of training, technical assistance, and community support. The partnership focuses on using the Healthy Steps model and other programs to develop a range of strategies that practices can implement to most effectively provide developmentally-oriented primary care. Not every medical site will be able to implement all the recommended Healthy Steps components, and each practice faces unique challenges in terms of its patient population, staff strengths, and other factors. One goal of the project is to develop a training and technical assistance program that meets the needs of the diverse group of health professionals providing care to the children of Illinois. An advocacy component will work with state systems and legislation to create the supports necessary for providers to better address child development issues.

Issues that are being incorporated into this initiative include:

• Support for all providers and office staff on incorporating developmentally-oriented primary care into their practice
• On-site educational programs/training (with CME credit available)* offered in topic areas such as:
  
  1. Developmental Screening and Referral, including using the Ages and Stages Questionnaire
  2. Social/Emotional Screening and Referral, including using the Ages and Stages Questionnaire: Social/Emotional (ASQ: SE)
  3. Perinatal Maternal Depression Screening and Referral, including using the Edinburgh Post-Natal Depression Scale
  4. Autism
  *Training will also be available through periodically-scheduled teleconference. Contact the project staff for dates/times.

• anticipatory guidance beginning prenatally
• parent education on childbirth, infant care and other topics
• literacy promotion
• developmentally-focused interventions on feeding, sleeping, discipline, toilet training
• screening for gross and fine motor development
• interventions for language and cognitive development
• improvement in linkages and referrals to developmental diagnostic evaluation services, parent education and support services, early intervention services, early childhood education and child care programs, child and family mental health services, and adult literacy and education services

The project will also work with Illinois’ 9 pediatric and 30 family practice residency programs, as well as the 4 physician assistant and 8 nurse practitioner programs, to engage faculty in biannual learning experiences meant to enhance their ability to teach child development. The first of these meetings was held on 9/23/05. In addition, training will be available to residency and training programs, similar that which is being offered to providers in their offices/clinics.

In addition, the project team is working in-depth with selected Federally Qualified Health Centers (FQHCs), in other on-site training that will assist in developing programming for the larger number of practices that will be reached through 2007. The model for the FQHCs is that they will receive 32 hours of large group training on developmental care and onsite programming, as well as technical assistance weekly for smaller groups. A Best Practice Meeting was held in May 2005, with six out of the seven participating FQHCs attending. Sites presented what they viewed as their successes and shared insights and experiences. Additional meeting such as this, allowing for networking among the FQHCs, will be planned again in the future.

For more information, please contact: info@edopc.org, 1-888-270-0558, or
Sarah Baur, ICAAP Developmental Projects Director: sbaur@illinoisaap.net

Autism Task Force Report
Illinois has undertaken several initiatives in the last eight years to address the impact of ASD. The Illinois General Assembly commissioned The Autism Program (TAP) which addresses the needs of ASD-challenged children in the areas of screening, identification, diagnosis, programs and services, workforce development, and research. Equally important has been the Illinois State Board of Education’s (ISBE) sponsorship of the Illinois Autism Technical Assistance and Training program, which provides professional development and training to local school districts and special education cooperatives. ISBE has also sponsored Giant Steps, a school with a professional best practices curriculum for ASD challenged children. Additionally, DHS has sponsored the Early Intervention Program (EI), which provides services to children birth to three
years of age. http://www.dhs.state.il.us/AutismTaskForceReport.pdf

State Resources on the Internet

Note: The information provided on the state pages was submitted by the state medical home teams.As this is not an exhaustive list, please let us know if you have additions for your state resource page. You can contact us at: medical home@aap.org.

Last Updated August 26, 2008