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Funded Projects

Grant Status: Completed

Grant Title: The Achievable Innovative Medical Home Initiative (AIM HI)

Web Site: The Achievable Foundation Project Exit Disclaimer

Project Director(s):

Carmen Ibarra
The Achievable Foundation
Culver City, CA
Phone: (424)266-7476
Email: cibarra@achievable.org

Problem:

Children with or at risk for developmental disabilities are more likely to live in poverty, rely on Medicaid, have poor health, have lower quality of life and lack access to quality healthcare. Achievable Innovative Medical Home Initiative (AIM HI) addresses vital healthcare needs of these children.

Goals and Objectives:

Goal 1: To create an innovative, developmentally- and family-centered medical home for children with or at risk for developmental disabilities (DD). Objective 1: In 2 years, 150 families will consider AIM HI to be their medical home of choice and will report satisfaction with services. In 5 years, this number will rise to 350. Objective 2: By year 5, AIM HI will become a certified Patient-Centered Medical Home (PCMH) through the National Committee for Quality Assurance (NCQA). Objective 3: By year 5, AIM HI's model of care will be disseminated for potential replication nationwide. Goal 2: To improve the quality of care and access to primary and speciality health care services for children with or at risk for DD and their families through AIM HI. Objective 1: In 5 years, the percentage of children with or at risk for DD receiving appropriate preventive services (including vaccinations) and developmental screenings in accordance with national standards will increase to at least 70% and 80% respectively. Objective 2: In 5 years, the proportion of patients with developmental red flags or concerning screenings/ evaluations who are referred to specialty care providers will increase to at least 80%; and 70% of referred families will utilize those services. Goal 3: To improve the health status of children with or at risk for DD who receive care through AIM HI. Objective 1: In 5 years, at least 70% of participating families will report an improved quality of life for their child(ren). Objective 2: In 5 years, as a result of improved screening, access, and coordination, there will be a 30% increase in appropriate provision of hearing aids, glasses and other similar adaptive equipment and health technologies. Objective 3: In 5 years, there will be a 20% reduction in obesity rates among children who are patients at AIM HI.

Methodology:

Key programs and activities planned to attain the goals and objectives include: 1. The Achievable Clinic will become a state-licensed, Federally Qualified Health Center offering a range of primary care services to underserved pediatric patients with or at risk for DD. AIM HI is an initiative of the Achievable Clinic. Services include enhanced developmentally-centered well-child visits; vision, hearing, and other preventive screenings; immunizations; pharmaceutical, diagnostic and radiological services. 2. Patients will receive extended visits to allow for the extra time needed to assess and treat a child with or at risk for DD. Family-centered primary care visits will be structured using the Bright Futures guidelines. 3. Patients and families will receive individual and/or group health education which is modified based on the developmental level of the patient and family values. 4. Specialty care will be available and initially includes pediatric neurology and mental health services, which are frequently needed by children with or at risk for DD but extremely difficult to access. In addition, a referral network will be developed to include physical therapy, cardiology, endocrinology, and other needed specialties. 5. Care coordination services will be provided in conjunction with the clinical care team to ensure timely access to care and coordination of services. 6. The Achievable Clinic will implement a comprehensive practice management and electronic health records system.

Coordination:

The Achievable Clinic and its AIM HI will collaborate with the local regional center (Westside Regional Center), school districts, service providers, health plans and community-based advocacy organizations such as the Westside Family Resource and Empowerment Center (WFREC). WFREC is a local nonprofit dedicated to providing information, resources, and support to parents, families, professionals, and members of the developmental disabilities community.

Evaluation:

The evaluation plan outlines a direct and systematic approach to routinely assessing and improving administrative and clinical processes and outcomes. Evaluation methods and tools may include electronic health records, peer review, clinical outcomes review, quality review, variance analysis, benchmarking, performance appraisals, patient surveys, workflow modifications and other appropriate quality improvement techniques using the Plan-Do-Study Act cycle principles.

Experience to Date:

Past year activities: 1) Revision of project goals/objectives to make them more realistic and measurable, based on TA team suggestions. 2) Hired a new Outreach and Enrollment Specialist who is a parent of a child with DD and has over 15 years of experience working with this special population. 3) Recruiting new Advisory Board members, to include patients, family, leaders, providers and community health workers. The first meeting is expected in August 2016. 4) Working with our EHR and CAIR to ensure that immunization data is received and recorded properly. 5) Working towards switching to the online version of the PEDS. 6) Collaborations formed with The Children's Dental Center of Greater Los Angeles, Venice Family Clinic (prenatal services) and Westside Family Health Center (emergency vaccine storage). 7) Continuously fine tuning our EHR and data collection to ensure we are effectively serving the intended target population. 8) Continuing to align our practice with PCMH standards. 9) A new Pediatrician, Dr. Lauren Wu, will begin seeing patients August 2016. Dr. Wu will serve to ensure high quality care and access for AIM HI participants. 10) In January 2016, we began participating in Cedars-Sinai's Los Angeles Quality and Process Improvement Learning Community. As part of this process we aim to improve team-based care, patient access (decreasing time to third next available), referral cycle, and patient action plans. 11) Engaging policymakers to increase awareness and garner support.

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