Imagine you’re a primary care pediatrician meeting a new family who recently moved to your city or town. The family has two children – Dion, a 6-month old who was born 28 weeks prematurely with feeding difficulties, chronic lung disease and developmental delays; and Shawna, a 12-year-old with moderate persistent asthma, anxiety and depression. The mother, a 32-year old with a history of depression, is unemployed and lives with friends.
So, how do you as that pediatrician manage these children and this family?
Such cases, pediatrician Barry Solomon explained at a recent Hopkins Children’s Grand Rounds, illustrate the need for a family-centered medical home model in pediatric practice, especially for patients with special healthcare needs. Those children, who are at increased risk for chronic conditions – physical, emotional or developmental – and require health and related services beyond that required by children in general, need a medical home with a healthcare team that can manage all aspects of care.
“We can’t just think about the patient in the context of the office or the clinic,” Solomon said. “We have to think about what’s going on in their homes, neighborhoods and schools.”
What is the medical home? [WATCH Barry Solomon, M.D., M.P.H., discuss the concept of a medical home]
Solomon explained that the concept dates back to 1967 when the American Academy of Pediatrics (AAP) first established practice standards for children with special needs. A decade later the AAP cited the need for a “repository for medical records” for children with multiple-care needs to ensure continuity of care.
“The concern at the time,” Solomon said, “was that these children would see their primary care pediatricians and their pediatric specialists, but there was a lack of communication among providers.”
The model further evolved through physicians like Hawaiian pediatrician Calvin Sia, who incorporated concepts like family-centered and community-based care, and who developed training programs that tapped into neighborhood resources and focused on the emotional as well as medical aspects of care. Such contributions led to a 2002 AAP definition of medical home care as “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. It should be delivered or directed by well-trained physicians who provide primary care and help to manage and facilitate essentially all aspects of pediatric care. The physician should be known to the child and family, and should be able to develop a partnership of mutual responsibility and trust with them” (Pediatrics 2002;110:184-186).
How big is the need for such care models today? How prevalent are medical home practices and do they improve outcomes?
Today, there are more than 10 million children in this country with special healthcare needs, Solomon noted. In a 2005-06 telephone survey, 47 percent of families of such children said they had a medical home (National Survey of Children with Special Health Care Needs, Pediatrics 2009). In another survey of some 83,000 families of children with and without special healthcare needs, 56.9 percent of the families reported having a medical home (Pediatrics 2011;127:604-611). Of those families with a medical home, 1.6 percent said they had unmet medical needs, while 6.4 percent of those with no medical home reported unmet medical needs.
Also, in a retrospective review of 30 studies from 1986 to 2006 looking at medical home activities like care coordination, care planning and cultural competence, researchers found some positive short-term outcomes regarding effectiveness, efficiency, timeliness and family centeredness of care. Long term positive outcomes included health and functional status and family function (Pediatrics 2008;122:3922-e937).
“So children in a medical home do have fewer unmet medical needs,” Solomon said. “We think the medical home improves patient care, but we need more research to prove it.”
Hopkins Children’s Harriet Lane Clinic (HLC), which Solomon directs, may provide much of the evidence. Of the 8,500 patients this primary care clinic serves, about 30 percent are medically complicated with one or more chronic conditions, and approximately 90 percent receive medical assistance. In addition to assigning each patient a primary care provider, the HLC offers patients and their families the services of case managers, Child Life specialists, health educators, outreach workers, mental health providers, and social workers. The HLC also participates in a number of nationally recognized family-centered programs, including Health Leads, which helps pediatricians and the medical home team connect and collaborate with community partners.
“Employing a medical home model, we’re seeing benefits for our patients and families every day, like improved access to specialty care, better coordination of care with community-based organizations, and improved child-health outcomes,” Solomon said. “For our providers we’re seeing increased communication with other providers, and increased knowledge in addressing issues outside the scope of normal pediatric practice.”
Learn how to implement a medical home model in your practice.
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