Medical Homes for Children With Special Health Care Needs: Primary Care or Subspecialty Service?

doi:10.1016/j.acap.2015.10.009

Academic Pediatrics

Volume 16, Issue 4, May–June 2016, Pages 366-372

https://doi.org/10.1016/j.acap.2015.10.009 Get rights and content

Abstract

Objective

To examine primary care pediatricians' (PCPs) beliefs about whether the family-centered medical home (FCMH) should be in primary or subspecialty care for children with different degrees of complexity; and to examine practice characteristics associated with these beliefs.

Methods

Data from the American Academy of Pediatrics Periodic Survey (PS 79) conducted in 2012 were analyzed. Outcomes were agreement/strong agreement that 1) primary care should be the FCMH locus for most children with special health care needs (CSHCN) and 2) subspecialty care is the best FCMH locus for children with rare or complex conditions. In multivariate models, we tested associations between outcomes and practice barriers (eg, work culture, time, cost) and facilitators (eg, having a care coordinator) to FCMH implementation.

Results

Among 572 PCPs, 65% agreed/strongly agreed primary care is the best FCMH setting for most CSHCN, and 43% agreed/strongly agreed subspecialty care is the best setting for children with complexity. Cost and time as barriers to FCMH implementation were oppositely associated with the belief that primary care was best for most CSHCN (cost: adjusted odds ratio [AOR] 2.31, 1.36–3.90; time: AOR 0.48, 0.29–0.81). Lack of skills to communicate and coordinate care was associated with the belief that specialty care was the best FCMH for children with complexity (AOR 1.99, 1.05–3.79).

Conclusions

A substantial minority endorsed specialty care as the best FCMH locus for children with medical complexity. Several barriers were associated with believing primary care to be the best FCMH for most CSHCN. Addressing medical complexity in FCMH implementation may enhance perceived value by pediatricians.

Section snippets

Data Set Description

This is an analysis of the American Academy of Pediatrics Periodic Survey of Fellows 79 (PS 79). Periodic Surveys of Fellows are conducted by the AAP's Division of Health Services Research 3 or 4 times a year on topics of importance to pediatricians and are national, random-sample surveys of nonretired, US-based AAP members. PS 79 was an 8-page self-administered questionnaire mailed to 1618 postresidency members from September 2011 to February 2012. The focus of the survey was practices'

Results

A total of 957 surveys were received, for a response rate of 59%; responses comprised 874 paper surveys (54%) and 83 online surveys (5%). Sixty percent reported providing primary care in an office- or clinic-based ambulatory care setting (n = 572). Respondents were compared to the target sample on variables available from the AAP membership file and did not differ for gender and US region; respondents were slightly older (47.9 vs 46.7 years, P < .001).

Discussion

In this analysis of the AAP PS 79, we examined perceptions of PCPs regarding the locus of medical home services for CSHCN and children with rare or complex conditions. We found that pediatricians varied in their beliefs about where the medical home should be in relation to medical complexity. For patients with rare and complex conditions, 43% of pediatricians believed that specialty care centers are better suited to serve as medical homes, but when considering most CSHCN, 65% of PCPs believed

Conclusions

PCPs report the ideal locus of care for a child's medical home depends on medical complexity. Both settings have their strengths: specialty-based programs can draw on a hospital's broad resources, receive philanthropic support, and serve as a base for condition-specific research. They can also offer family-centered support, education and disease management related to a specific condition (eg, connecting families of children with similar conditions, or managing sickle cell with a

Acknowledgments

Presented in part at the Pediatric Academic Societies annual meeting, May 6, 2014, Vancouver, BC, Canada. The survey was supported by the AAP and the National Center for Medical Home Implementation, Medical Home Capacity Building for CSHCN Cooperative Agreement, Health Resources and Services Administration, Maternal and Child Health Bureau (grant U43MC09134). Part of JVC's effort was supported by the National Institute of Mental Health (grant K23MH083885).

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For some patients, a condition-specific complex clinic, such as those specializing in Down syndrome, can be beneficial. Condition-specific philanthropy, research, and resources are sometimes easier to champion and access [10]. Clear and consistent communication between the PCP and complex team in this consultative model is key to avoiding unclear patient ownership and overlooked medical issues [9].
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Pediatría de AP y unidad de patología crónica compleja (UPCC) del Hospital Universitario La Paz (HULP).
Pacientes y familiares de la UPCC y sus médicos de AP de la Comunidad de Madrid (CAM).
Realización de encuestas validadas presenciales y online.
Grado de satisfacción en la formación, capacitación y manejo específico del NPCC según escalas tipo Likert.
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Patients and relatives of the UPCC and their PC physicians of the Community of Madrid (CAM).
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Degree of satisfaction in the training, education and specific management of the CMC according to Likert-type scales.
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View all citing articles on Scopus

: The authors declare that they have no conflict of interest.

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Medical HomeMedical Homes for Children With Special Health Care Needs: Primary Care or Subspecialty Service?

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Data Set Description

Results

Discussion

Conclusions

Acknowledgments

Ambul Pediatr

Genet Med

The medical home

Pediatrics

A review of the evidence for the medical home for children with special health care needs

Pediatrics

Effect of an enhanced medical home on serious illness and cost of care among high-risk children with chronic illness: a randomized clinical trial

JAMA

How the Affordable Care Act will strengthen the nation's primary care foundation

J Gen Intern Med

About half of the states are implementing patient-centered medical homes for their Medicaid populations

Health Aff

Contrasting trajectories of change in primary care clinics: lessons from New Orleans safety net

Ann Fam Med

Readiness of primary care practices for medical home certification

Pediatrics

Children with medical complexity: an emerging population for clinical and research initiatives

Pediatrics

The rise in chronic conditions among infants, children, and youth can be met with continued health system innovations

Health Aff (Millwood)

Hospital-based comprehensive care programs for children with special health care needs: a systematic review

Arch Pediatr Adolesc Med

Physician practices and readiness for medical home reforms: policy, pitfalls, and possibilities

Health Serv Res

Implementation of the patient-centered medical home in the Veterans Health Administration

JAMA Intern Med

Medical home transformation in pediatric primary care—what drives change?

Ann Fam Med

Medical Home
Medical Homes for Children With Special Health Care Needs: Primary Care or Subspecialty Service?