Medical Home Becomes Headquarters for Care for Children With Chronic Conditions

Vol. 13 •Issue 10 • Page 33
Home Pathways

Medical Home Becomes Headquarters for Care for Children With Chronic Conditions

Eight-year-old Nick is wheezing again, this time with a fever. His asthma has been getting worse over the past year, resulting in three emergency room visits and two hospitalizations. In addition to his regular pediatrician, Nick also sees an allergist at a city hospital and a pediatric pulmonologist across town.

It’s Sunday evening, and Nick’s mother isn’t sure what to do. Nick’s pediatrician hasn’t been involved with his recent hospitalizations because she took Nick to the emergency room. Besides, the pediatrician only sees him for his camp physical. The allergist said Nick should be followed by his pulmonologist, but he didn’t say how often.

The Institute of Medicine in its 2003 report titled “Priority Areas for National Action — Transforming Healthcare Quality” identified care coordination as an overarching priority.1

Nick has excellent physicians, good health insurance and concerned parents, but he receives care for his asthma that’s unplanned, fragmented and inadequately monitored. Nick is one of the 12 million American children with special health care needs for whom the United States Maternal and Child Health Bureau (USMCHB), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) endorse a primary care medical home.2,3


Medical home isn’t a place so much as a process of care in which the word “home” connotes a headquarters or home base and communicates continuity, familiarity, reliability and accessibility. A medical home provides proactive chronic condition management based on care planning and coordination between specialists and primary care providers.

Under this model, families like Nick’s have chronic condition management visits with their primary care physician and with specialists. They know what to do and whom to call when a medical crisis arises. Information about their child’s health and treatments is communicated to those who need it in a timely fashion. And families are treated as expert partners in health care planning and decision making.

However, a gap exists between the ideal medical home model and the prevailing primary pediatric care model. The traditional model was designed primarily for the 85 percent of children without chronic conditions to afford them well-child care and acute illness management through primarily individual provider-patient encounters. Most primary pediatric care settings attempt to fit chronic condition care into this model.

As a result, follow-up of complex medical conditions is squeezed into the already full agenda of well-child visits or simply not addressed. Specialty consultations often become tacit, unstated transfers of care to disease- or systems-oriented specialists who may overlook the more holistic aspects addressed by primary care providers.


According to another Institute of Medicine report, “The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”4

But redesigning care in busy pediatric offices is like trying to change the tire on a bicycle while riding it. Changing the structure and process of office systems requires steady effort through a process of incremental improvement.

The Center for Medical Home Improvement (CMHI) at Crotched Mountain Rehabilitation Center in Greenfield, N.H., has refined a quality improvement methodology and developed tools for measuring “medical homeness” and patient outcomes that have successfully transformed primary care practices into medical homes in more than 15 states.

The CMHI approach helps practices support quality improvement teams consisting of a lead physician, another office staff member with the potential of becoming the office care coordinator, and two parents of children with chronic conditions. The teams are trained in quality improvement methods and begin implementing and testing small improvements in the “way things are done” in the office.

These small “tests of change” begin to aggregate into new processes of care such as the use of a registry of children with chronic conditions that stratifies by complexity; the completion of written care plans for the children with the most complex problems; the implementation of improved, timely communication with specialists; and the adoption of regular, reimbursed chronic condition management visits in addition to usual well-child visits.5

The CMHI Medical Home Index provides a numerical score of “medical homeness” to document the practice’s progress and to help identify other areas in need of improvement.6


CMHI recently partnered with the National Initiative for Children’s Healthcare Quality to direct a 15-month, USMCHB-funded national learning collaborative on the medical home. Thirty-one pediatric practices from 11 states participated in the process to improve their care of children with chronic conditions using the medical home model.

During the course of the collaborative, 80 percent of the practices developed a system for identifying and tracking children with chronic conditions, and 65 percent developed and sustained the role of a practice-based care coordinator. Participating practices saw a 30-percent increase in Medical Home Index scores and a reduction in emergency room visits by children with chronic conditions.7

The USMCHB and the National Center for Health Statistics surveyed nearly 39,000 families of children with special health care needs and found that only 53 percent received care resembling that provided by a medical home. However, those children receiving such care were only half as likely to forego needed medical care or have unmet health care needs.8

The USMCHB plans on repeating this national survey in 2005 and 2010 to assess success with the Healthy People 2010 objective that all children with special health care needs will receive comprehensive care in a medical home. As part of this policy agenda, every state and territory must have a plan in place for meeting this objective in order to continue to receive its share of federal maternal and child health block grant funding.

Find out what your state is doing and how you can become involved to ensure that Nick and other children like him benefit from systems of care designed to produce the best possible outcomes.

Dr. Cooley is co-director of the Center for Medical Home Improvement at Crotched Mountain Rehabilitation Center, Greenfield, N.H., where he’s the medical director.

For a list of references, please call Sharlene George at (610) 278-1400, ext. 1324, or visit