From the Presidents

The Medical Home: Where We’ve Been, Where We Are, Where are We Going

By Phyllis J. Sloyer, RN, PhD, FAHM, FAAP 

No single concept evokes such a powerful calling in me for a national response that moves individuals, communities, and states to get it right for children as does the term medical home. The values that medical home embodies: family-centered care, trusting relationship, continuity of care, comprehensiveness of care are so pivotal to quality child health care and a child’s future that I consider it to be one of the central themes of child health policy.  

I have been asked to speak about where we have been, what’s happening now, and where we are going. I know that this issue will be full of interesting information from national experts in medical home with past, present and future perspectives, so I will touch on some personal and professional experiences about medical homes.  

As a child growing up in rural northern Indiana, my physician made home visits, an idea that shocks most people today. As a young pediatric nurse in Pensacola, Florida, I was quite used to interacting with primary care pediatricians who managed a great deal of chronic illness. It was typical for me to see the primary care provider look at all the specialists’ recommendations and give a very thorough overview of the child’s care and treatment to the families. I also watched families turn to the pediatrician for more than just the care and treatment of their children. Several young adults who were “chronic visitors” to Sacred Heart Children’s Hospital returned to their pediatricians because there wasn’t an adult provider who felt comfortable with the children I knew who had cystic fibrosis, rare bleeding disorders, spina bifida, congenital anomalies, etc. So, in essence, my childhood experiences and my professional career exposed me to physicians who provided medical homes before the term was in vogue. How grateful I was to have had those experiences because my professional foundation was based on the principles we use to frame medical homes of today and tomorrow.  

It is not surprising to me that the American Academy of Pediatrics coined the term medical home in 1967, decades before the adult world promoted patient-centered primary care. The focus was on a central medical record or complete information about the child; something we strive for today and promote technology as a potential solution to the centralization of medical information and the exchange of information to enhance continuity and coordination of care. 

But the concept of medical home would not reappear for a couple of decades. During the 1970s and 80s, we witnessed the development and organization of highly specialized services into multidisciplinary programs, regional programs, or “centers of excellence.” Children with chronic or complex problems were surviving past childhood and the need for on-going specialized services grew. If you follow the evolution of crippled children’s programs into children with special health care needs programs, you can easily understand why communities and states focused on the development of specialty programs. However, it was not the norm to talk about the coordination of all of these services with a medical home until the late 1980’s and into the 1990s. 

Others will address the evolution of the Title V Programs and the shifting focus from specialty care to medical homes, including the shift to coordinated systems of care in this issue; however, I want to recognize Dr. Cal Sia, who first implemented the medical home concept in Hawaii. I am not sure he had any idea at the time that these early programs would grow into a national movement focusing on adults and children. Dr. Merle McPherson and families joined forces to establish the charge for Title V Children with Special Health Care Needs Programs. They created many firsts; including a set of six national performance measures around comprehensive systems of care and the promotion of medical homes for children with special health care needs that would spread to all children. 

I have said many times that we must break down the silos between public health and health care. There is no better example of the need for a strong linkage between public health and health care than the development and implementation of medical homes. Look at the work in Illinois between the Title V Children with Special Health Care Needs Program, the Illinois Chapter of the American Academy of Pediatrics in developing medical home criteria and quality improvement initiatives. The states of Colorado and Minnesota have strong partnerships between their Title V agencies and their Medicaid agencies in the development of medical homes. You can look at Washington and many of the northeastern states and see similar progress. The New York Title V Program works with the private sector and health care purchasers to develop quality measures. 

Each of us work in different organizational structures, face different political and policy environments, live in challenging economic times, have varying degrees of capacity to perform certain functions, are required to meet certain state mandates, and have varying skill sets. However, each of us are charged with promoting comprehensive and coordinated systems of care and if we truly believe that the quality of children’s health care is significantly affected by the current chaos in our delivery systems, then we have our future charter in front of us. 

Take a look at where we are: According to the national children’s health and children with special health care needs surveys, in 2007, approximately 58 percent of all children have a medical home as compared to 47 percent of children with special health care needs (2005 data). We live in a nation with children who are not insured or whose families don’t have the means to provide those services not covered by insurance. We are creating electronic health records, however, some of these systems operate in silos and the much needed specialty note hasn’t made its way to the medical home. We are just beginning to look at the quality of care from a population or provider perspective using a common set of measures. 

We have witnessed the development and evolution of the term medical home. We know that it is much more than a usual source of care and it can be provided by physicians and other qualified health providers. States are moving forward with implementation of the concept of “medical home” although the actual definition and implementation activities vary from state to state. Commercial insurers know it is the right way to deliver care and are beginning to promote medical homes through a variety of incentives. The term medical home has evolved to patient-centered primary care and it has blazoned new paths in the adult community, including the maternal health field.  

The concept of medical home will not disappear. The National Committee on Quality Assurance has developed criteria for the patient-centered medical home and I suspect it will not be long before it becomes a measurable and institutionalized concept with most payers. A word of caution: While insurance is important, insurance is not a provider of care and it is the relationship between the provider and the patient that creates the necessary environment for quality and cost-effective care.  

Some of you may wonder if you have any role to play in the development and implementation of medical homes. Remember a successful medical home relies on the multitude of supports we bring to the service delivery system that surrounds the family and community. We certainly will have varying roles in each of our states and communities, but I believe we have 75 years of experience as a maternal and child health profession that successfully forges partnerships between public and private practice on behalf of women, children and families.  

Enjoy this issue of Pulse and I hope that it fuels the passion inside of you to be a part of making medical homes a success in your state and communities. 

 

Medical Home Getting Long-Deserved Recognition

By Judith S. Palfrey, M.D., FAAP
President, American Academy of Pediatrics 

As I begin drafting this article with the knowledge of the passing of the Patient Protection and Affordable Care Act endorsed by the American Academy of Pediatrics (Academy) — I cannot help but reflect on what an exciting time in history this is!  

In 2010 — even beyond the health care reform discussions — it seems that everybody is talking about the medical home. And for good reason. The medical home is the system best suited to meet the health care concerns of all our citizens. 

The origins of the medical home go back to the 1960s when pediatricians in the Academy wanted to develop a single repository for all health information on their patients. The medical home was really the forerunner of a personal heath record and included information on a child’s history, physical findings, immunizations, consultations, medications, therapies and anything pertinent to the patient’s health status. 

Over time, largely as a result of a partnership between visionary Calvin C.J. Sia, M.D., FAAP, and leaders at the Maternal and Child Health Bureau, the medical home grew into a system of care that is accessible, continuous, comprehensive, coordinated, compassionate and culturally effective (see the Academy’s desirable characteristics of a medical home here).  

Families can trust that there is one place where their child is seen as a whole, where all aspects of physical, mental and emotional health are addressed over the long haul of the child’s life. Not a building or a designated space, the medical home is a 24/7 system of care that is well-resourced with primary care, subspecialty care, emergency department and hospital-based care to which the child has ready access. 

The doctors, nurses and staff of the medical home know the child and family well. They do not need to go back to the beginning every time they see a child because health information, including recent consultations, medication changes and lab values, is at hand. Getting appointments for tests and consultations is handled in a coordinated fashion. When the consultations are completed, the information comes back to the primary care physician and the family in real time so that timely interventions can take place. Importantly in the medical home, children with special health care needs have access to community-based care coordination. 

Today, the medical home is the gold standard for medical care and includes the entire framework of practical elements necessary to assure patients experience optimal outcomes. The AAP is the home for the National Center for Medical Home Implementation — through a cooperative agreement funded by the federal Maternal and Child Health Bureau, Health Resources and Services Administration. The National Center has developed outstanding materials to help practices implement each of the medical home components. 

The most recent accomplishment is the Building Your Medical Home toolkit, which was designed to assist pediatricians in meeting the National Committee for Quality Assurance (NCQA) Physician Practice Connections® Patient-Centered Medical Home™ (PPC-PCMH) recognition program requirements. It includes the specific components each practice needs to incorporate to meet the gold standard the Academy has set. Check it out!

If pediatricians and others want to provide medical home services, they need the flexibility and discretion to dictate how their practices are run, to decide what the priorities are for the children and families in the local area, and to adapt their practice patterns to take advantage of local resources and to overcome local barriers. Appropriate payment for creating and managing medical homes that improve the child health outcomes in their communities also needs to be provided. 

The Academy is committed to working with its partners, like AMCHP, on the implementation of many of the health care reform law’s provisions. As we know, some of this will take place piece by piece, with some child health components of the law taking effect immediately and others over the next several years.  

We hope to see enhanced and ongoing emphasis on medical home at the national and state levels because we know that the systems and programs embedded in the Title V framework will play a vital role in health reform implementation in the coming years. We need to be strategic — together — in our efforts to meet the needs of children. We must continue to make the life success of every child our highest national priority.

Excerpts taken from February 2010 AAP News.