Medical Homes for Children with Special Needs

Vol. 17 •Issue 21 • Page 35
Medical Homes for Children with Special Needs

Health care delivered close to home is vitally important, especially when the patient is a child. But how do community pediatric practices adapt to offer the best care when faced with a child who has complex and multiple health needs? Researchers at Dartmouth Medical School, in Hanover, NH, have outlined a process designed to help any practice become a state-of-the-art “medical home” for this population (Pediatrics, May 2004).

A model program was developed by W. Carl Cooley, MD, an adjunct associate professor in pediatrics, and Jeanne McAllister, RN, MS, MHA, a research associate in pediatrics. They founded and direct the Center for Medical Home Improvement (CMHI) within the Hood Center for Children at the Children’s Hospital at Dartmouth-Hitchcock Medical Center in Greenfield, NH. Dr. Cooley, a developmental pediatrician, is medical director of the Crotched Mountain Rehabilitation Center, also in Greenfield; and McAllister is a project director for medical home initiatives at CMHI.

Assessing the effectiveness of their model program, they reviewed the experience of four practices in Vermont and New Hampshire that used the program to identify and implement changes in order to improve the care they deliver to children with special health care needs.

Community-based medical homes are places where care is managed through the coordination of health care professionals, educators and caregivers. The concept has been advocated by national health policy-makers and the American Academy of Pediatrics as the best model for providing systematic yet individualized care to children with complex conditions and multiple needs.

However, the changes required for a practice to become an effective medical home can be difficult to make.

“Introducing change into a busy pediatric practice is like trying to repair a bicycle while riding it,” stated Dr. Cooley and McAllister. “Even the most motivated practice finds change difficult to implement. Many primary care providers believe that implementing the medical home concept is the right thing to do but question how they can do so and remain solvent.”

To make the process easier they developed a “medical home improvement tool kit” that allows practices to look at key functions of the medical home, assess their own operation, and identify the steps and strategies they will follow to become a medical home.

The four participating practices focused on improving different aspects of their medical home environment.

Exeter Pediatric Associates, in Exeter, NH, developed pre- and post-visit surveys to elicit parents’ chief concerns and then assessed whether or not these concerns were addressed in the visit. Dartmouth Hitchcock-Plymouth Pediatrics and Adolescent Medicine, in Plymouth, NH, created an educational series for children with attention deficit hyperactivity disorder (ADHD) that resulted in new partnerships with parents and schools.

Upper Valley Pediatrics, in Bradford, VT, began to schedule chronic condition management visits to provide regular, proactive care rather than only responding to problems after they arose. Gifford Pediatrics, in Randolph, VT, held a series of community forums aimed at facilitating the exchange of information between families and schools about children with acute care needs.

Each project has spurred new improvement projects in related areas. The participating practices also introduced the role of a practice-based care coordinator and discovered the value of systematic consumer input in the design and operation of a medical home.

The success of the model program in these practices and others across the country is encouraging on a number of fronts, stated Dr. Cooley and McAllister. Establishing medical homes improves access to care, potentially makes more treatments available to children, strengthens the relationship between families and caregivers, and ultimately provides the child with more comprehensive and effective care.

The concept has significant implications for the national health care system, they suggested. While only 20 percent of children have special health care needs, they account for 80 percent of pediatric health expenses.

The next step is to investigate the relationship between medical homes and outcomes for children with special needs. The CMHI directors are interested in whether effective medical homes lead to decreased utilization of the health care system, increased patient and family satisfaction, and better health outcomes.

For More Information

• Center for Medical Home Improvement, online: