- The patient-centered medical home has become a popular and promising framework for improving care coordination, fostering preventative care, and generating better outcomes for patients, including children.
The patient-centered medical home’s emphasis on regular screenings, comprehensive services, caregiver involvement, and expanded access may be especially useful for pediatric patients as they reach anticipated milestones – and increasingly, require support and coordinated care for managing chronic diseases.
While PCMH certification requires an assessment of how well a provider adheres to a relatively detailed list of process and workflow measures, it also gives participants some freedom to tailor their activities to their unique patient populations.
For practices serving children, this may mean enhanced coordination with the local school district, a close partnership with child welfare organizations, or prioritizing health information exchange connections with the nearest pediatric medical center.
It may also mean engaging in slightly different population health management strategies than would be employed by a provider primarily serving Medicare patients.
While population health management tends to focus on reducing the burdens of chronic diseases for the highest utilizers of services – typically elderly patients with very complex needs – pediatric PCMHs need to shift their gaze to the other end of the age spectrum.
In a literature review published in the American Journal of Managed Care this month, researchers from Texas A&M University’s School of Public Health and Texas Children’s Pediatrics in Houston suggest that the first step for creating a successful pediatric patient-centered medical home relies on stratifying patients according to similarities in health status, special needs, and chronic disease burden.
They also outline six critical areas of care and service that may separate high-performing pediatric PCMHs from those which could benefit from more attention to the delivery of evidence-based, coordinated care.
Resources for patients with limited English proficiency
The patient-provider relationship requires both parties to have a clear and thorough understanding of each other’s needs, concerns, preferences, and instructions. For patients and their families with limited proficiency in English and unique cultural expectations, it is often difficult for providers to bridge the gap without an interpreter.
Providing a translator for non-English speaking patients and cultivating a sensitive and respectful approach to cultural barriers are key competencies for patient-centered medical homes, the study says.
“In an effective medical home, a family’s cultural background—including beliefs, rituals, and customs—are recognized, valued, respected, and incorporated into the care plan,” write the authors. “Pediatric primary care physicians should make an effort to improve their knowledge, skills, and attitudes in working and communicating with diverse children and families.”
Emergency care for pediatric patients
While reducing emergency department utilization is a goal for many healthcare providers looking to cut expenses and redirect care to the proper setting, parents may actually be putting their children at risk when they bring them to their primary care provider for an emergency situation.
Primary care organizations are not designed to deliver emergency care for pediatric patients with seizures, dehydration, and certain infections, yet caregivers do not always see these situations as requiring a visit to the ED.
The study suggests that pediatric PCMHs should develop a plan for treating emergency-level patients who do enter the primary care setting.
“It is recommended that an office-based self-assessment should be done to analyze what types of patients and emergencies have already been experienced, or may be seen in the future,” the researchers said.
“Reviewing answers from a standardized office-based self-assessment can help inform primary care practices in making knowledgeable decisions, identifying gaps, and optimizing office readiness.”
PCPs may wish to invest in basic equipment and training to cope with medical emergencies, but should also educate caregivers about the appropriate steps to take when their child experiences a crisis event.
Integrating home visitation through the Building Healthy Children collaborative
Home visitation may not be appropriate for every family, but enhanced community involvement can have a significant impact on the welfare of children born to younger mothers with lower incomes.
Through the Building Healthy Children model, developed by the American Academy of Pediatrics, patient-centered medical homes may be able to get vulnerable children off to a healthy start by addressing issues in the home such as domestic violence or housing insecurity.
Social workers and outreach workers, assigned to families based on their familiarity with relevant cultural and socioeconomic factors, have produced high retention rates and an important understanding of the complex needs of many patients, the study notes.
Bimonthly meetings with families can help providers create tailored service plans, deliver services like immunizations, and educate caregivers about healthy behaviors and lifestyle choices.
Addressing mental and behavioral healthcare needs
Both pediatric patients and their caregivers can benefit from mental and behavioral health assessments that may help to connect patients with care. Pediatric PCMH providers should learn how to integrate mental healthcare screenings and assessments into routine visits, and should connect with behavioral health providers to coordinate referrals and treatment plans.
Developing a multi-disciplinary care team that includes behavioral health specialists can help reduce fragmentation in care, make it easier for patients to access services, and even cut costs and improve outcomes, the authors said.
Managing obesity to prevent additional burdens of chronic disease
Obesity in childhood may lead to a host of other chronic diseases over the patient’s lifetime, including early-onset diabetes, heart disease, arthritis, and high cholesterol. Addressing the issue of overweight or obese pediatric patients as soon as possible may help children avoid complications later in life, and reduce future costs for the healthcare system.
The study points out the success of the Envision New Mexico’s Pediatric Overweight Quality Improvement Initiative, which educated providers about pediatric obesity and highlighted clinical guidelines to manage the condition.
“The model also emphasized the importance of early screening and prevention in the pediatric primary care setting, opening telehealth clinics with a focus on instructive education, patient consultation for overweight medical management, coaching calls to go over improvement plans, and counseling with a nutritionist or dietician,” the study said.
The initiative was able to improve body mass index percentile assessments and provide counseling and education around physical activity and dietary choices for patients.
Tailoring care for developmentally disabled children
Highly complex pediatric patients often experience developmental issues related to genetic conditions, many of which are not identified as early as would be ideal for intervention and treatment.
Pediatric patient-centered medical homes should pay close attention to screening children for developmental milestones in order to deliver a speedy diagnosis of any delays, and should understand how to create individualized care plans for children who do experience developmental issues.
“Tailoring care to this developmental disability population and providing collaborative, preventative, and family-centered healthcare can lead to optimum patient outcomes and patient and family satisfaction,” the authors stressed. “Thus, this is a substantial sub-segment that should be given more attention in order to provide the best care possible.”
Complex patients with chronic conditions, including those caused by developmental issues, may be able to benefit significantly from a combination of these six pillars of quality patient-centered care. Pediatric PCMHs may wish to integrate these recommendations into their existing workflows in order to boost the impact of the high quality care they already deliver to their populations.