Medical Home Meeting: November 13, 2013

Our November meeting began with Denise Guilbeault, LICSW explaining the Medical Review Team.  In Massachusetts, the admission of a child into any of the three pediatric nursing facilities needs to be reviewed.  The Medical Review Team is composed of medical and human service agency representatives.  In order to qualify for long term placement, the child must have two discrete daily nursing care needs and developmental function scores of less than 12 months.  Short term respite care is available for families.  The nursing requirements are the same as long term placement, but the developmental profile is slightly higher, under 24 months.  Approval for respite care allows for up to 90 days at the facility.  As expected, summers and  holidays are the busiest time for respite requests.  MassHealth is the primary payor of respite services.

There is a real gap of services in Western MA; these pediatric nursing facilities are located in Billerica, Groton and Plymouth, MA.  Right now, there are about 25 beds available for respite care.  Without respite, families do suffer.

The initial application is very difficult, due to paperwork requirements.  Once the child is approved, the annual review is quite a bit easier.   The Medical Review Team offers a list of alternate community-based programs to families whose child does not qualify for admission to a pediatric nursing facility.  Many children will qualify for temporary placement after discharge from a hospital stay.  Hospitals develop the discharge plans, but the pediatric nursing facilities make the final decision on whether to admit a child or not.  Again, these services are located in Eastern MA.  For children having surgery in Boston, this is a viable option.

Next up:  Charles DiFazio, attorney with Sam’s food stores in Connecticut, spoke about Sam’s Children, Inc.

Sam’s Children is a small charity seeking to help families facing the chronic illness of a child.  This charity provides funding for diverse expenses associated with caring for children with medical conditions.  Sam’s Children tries to provide support within one week of the family’s request.  One example of support was the purchase of a generator for a family after the tornado in 2011.  The grant is given to the vendor, not the family.  This is a one-time opportunity to help families, and should not be seen as a source of on-going support.

Sam’s Children also donates food to the Ronald McDonald House.  Shriner’s Hospital and other area hospitals send referrals for funding to Sam’s Children.  Referrals come from doctors, nurses, social workers and other health care professionals.  The referral must explain the need to the charity board and give justification for funding.  The service area for Sam’s Children is Connecticut, Massachusetts and Rhode Island.  The charity is looking into providing services for New York families.

Several attendees at the Medical Home Work Group meeting spoke enthusiastically and warmly about the work done by Sam’s Children.


Medical Home Meeting: October 9, 2013

Our October meeting began with a presentation by Diane Tillman, manager of the Springfield and Berkshire branches of Caregiver Homes of Massachusetts. They are located at 35 Center Street, Suite 203, Chicopee, MA 01013 and can be contacted at 866-797-2333. Caregiver Homes is an adult foster care program supporting structured family care. They operate in MA, RI, and several other states and serve about 2000 people across MA.

The individual needing care must be 16 years of age or older, have a disability or chronic illness (including physical or mental illness, or developmental disability. The individual must need a 24-hour live-in caregiver. Said caregiver is credentialed by Caregiver Homes, including a background and CORI check. CH must also inspect the home for safety standards. The caregiver may not be the parent of the individual who is a minor, the individual’s spouse, or the individual’s legal guardian. The caregiver receives a stipend of $20-50/day, tax-free.

Caregiver Homes provides support to the individual needing care and the caregiver using a team model that includes monthly home visits. A nurse provides training to the caregiver to meet the needs of the individual needing care. Continuity of care is conducted thorough daily laptop-based communication with the CH team. The individuals receiving care can and do graduate from the program, as increasing independence is a goal. The individual receiving care may not have both a caregiver through the Adult Foster Care program and a Personal Care Attendant, however the individual may use caregiver services along with an adult day care program.


Our next presenter was Jennifer Amadon, director of admissions at Seven Hills Pediatric Center at 22 Hillside Ave Groton, MA. She can be contacted at (978) 732-5311 or a Seven Hills provides short-term respite care and long term residential care for eligible medically complex children who are 0-22 years of age. The child must have a cognitive level at 24 months or less and two skilled nursing needs. For example, many of the children have a seizure disorder and use medical technology such as a tracheostomy tube, a feeding tube, or a Baclofen pump.

The pediatric medical director is Dr. Julie Hauer of Boston Children’s Hospital. There are two nurse practitioners and two medical fellows on-site five days/week and on-call on weekends. Weekends are staffed with RNs and LPNs. There are 83 pediatric beds including both respite and long-term residents.

Before either type of stay, the Medical Review Team convened by the MA Department of Public Health must approve the child. Families are encouraged to visit Seven Hills before or during the application and before a child’s first stay. Families are welcome during a child’s stay. One parent may stay with the child overnight and families often stay near by. During the application process, Jennifer usually makes a home visit to the family for assessment and screening. The Medical Review Team’s application must be renewed yearly.

Respite care provides families who can take care of their children at home, times to rest, attend to other medical and personal needs, or travel. There is often a waiting list for respite stays, although some times are busier than others. Respite stays are limited to 90 days per year and do not need to be consecutive, although Seven Hills prefers a child’s first respite stay to be at least seven days to allow the staff to get to know the child and their needs. Respite stays can provide an opportunity for other care, like dental cleanings and care. Seven Hills has a dental clinic on site that is affiliated with Tufts University Dental School.


The meeting continued with discussion of the Holiday Party at Shriners on December 12th from 5-7 pm. We are looking for volunteers, entertainment (with the help of Karen Cassidy), donations, gifts for kids and giveaways, and food donations. Suggestions included: having Shriners clowns and inviting inpatients.


We wrapped up the meeting with a presentation on MassStart by Carrie Somppi. This is a free nursing consultation service to collaboratively help families and schools to develop a child’s school health plan, including planning for emergencies so a child can safely attend school. This is especially for children who utilize medical technology, but includes children with other complex medical needs. She covers all four counties of Western Massachusetts and is based at Baystate.

Medical Home Meeting: September 11, 2013

Our first meeting of the fall began with a presentation by AmeriCare, a part of Epic Health Services, specifically their “At Home” portion of their services. Their contacts are Jill Chaban and Martha Rankins. AmeriCare can be reached through 1-800-601-3562. AmeriCare At Home offers medical home care with a specialty in clients that have a mental health component. Their current target population is ages sixteen and over, but there is a pediatric division opening in the next few months that will expand the age range. They offer home visits, medication management, and reinforcement of behavioral plans, but do not have prescribing capabilitites.

Our next speaker was Dr. Matthew Sadof, who is developing a care plan project this fall. He would like to form a family and community based focus group to help develop universal care plans that can be cloud based, paper based, and tied in the health information exchange and possibly patient portals. The group discussed the importance of a flagging system for frequent flyers in the pediatric system. A possible link to cell phone applications was also emphasized.

Next, Community Resources for People with Autism’s Carla Doyle-Florence spoke. She can be contacted at (413)529-2428 ext. 119. Their office is located in Easthampton and multilingual services are available. CRPA serves individuals ages zero to twenty-two in the four counties of Western Massachusetts.

She shared the following: The Department of Developmental Services Autism Waiver Program is accepting application for children under nine years of age for three-year intensive care plans between October 7th and October 18th. There are only two-hundred slots available statewide. The application is available here in eleven languages or by phone at 1-888-367-4435.

To continue, Karen Cassidy from Thom Western Regional Consultation Program, spoke in regards to the Thom Holiday Party coming up at Shriners this December. If interested in sponsoring or volunteering, contact Karen Cassidy at (413) 783-5500 ext. 25 or Dr. Jane O’Brien of the Franciscan Hospital for Children.

Nancy Bazanchuk of the CHD announced new classes starting for both adults and children including dance and sled hockey. Their activities calendar can be found here.