Posted on: February 19, 2009
Introduction to the Medical Home
Medical home, also called patient-centered care, is the model for 21st century primary care, with a goal of addressing and integrating high quality health promotion, acute care, and chronic condition management in a planned, coordinated and family-centered manner. The medical home model has the potential to resolve issues contributing to the primary care crisis and to improve the quality of care for patients facing a fragmented health system. The American Academy of Pediatrics (AAP) describes the medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.1 This model was developed to promote the implementation of evidenced based practices by the provision of family centered care, care coordination, and continuous quality improvement at the primary care practice. Universal medical home implementation is a key strategy to promote the health and well-being of all children and youth.
United States Child Health Statistics
The medical home model is designed to improve the quality of health promotion, acute care, and chronic condition management. Currently there is a need for increased access to medical homes for children and youth, particularly those with special needs. According to the 2004 National Survey of Children’s Health (NSCH) sponsored by the Maternal and Child Health Bureau of the Health Resources and Services Administration, only 46% of children/youth (ages 0-17) receive health care that meet the AAP’s definition of medical home. In addition, only 58.8% of children/youth (ages 0-17) reported receiving medical and dental preventative care visits over the past 12 months. Parents of children with special health care needs (CSHCN) aged 1-5 are particularly likely to report concerns about their children’s development. Of CSHCN in this age group, 43.7 percent are reported to be at moderate or high risk of developmental delay, compared to 21.8 percent of children without special health care needs; only 63.8% of children and youth with special needs were screened early and continuously for physical and developmental delays and other health concerns. Moreover, despite the widespread acknowledgement that care coordination is one of the cornerstones of a medical home, only 57.8% of respondents receive help from their personal doctor or nurse with follow-up after the child sees a specialist or gets specialized services/equipment, even though 83.3% of these respondents reported having a personal doctor or nurse. Furthermore, only 65.6% of families reported receiving enough time with their personal doctor and nurse and only 66.9% were always explained things in a way that the children and parents could understand.2
According to the National Survey of Children with Special Health Care Needs (CSHCN), only 57.4% of CSHCN whose families are partners in decision-making were satisfied with the services that they received, 47% reported receiving coordinated, comprehensive care within a medical home, and only 62% reported receiving family-centered care from health providers (National Survey of Children with Special Health Care Needs 2005/06).3 Nationally, while children and youth with special health care needs make up 13.9% of the child patient population, they account for 80% of child health care costs.
Illinois Child Health Statistics
In Illinois specifically, 451,000 or 14% of children ages 0 to 17 years have special health care needs. 3 These children and their families are vulnerable to the complexities of the health care system and the stresses of their child’s medical condition. According to the 2005/06 National Survey, families of only 60.3% of Illinois CYSHCN partnered in decision making at all levels and were satisfied with the services they received. In Illinois, only 45.1% of CYSHCN are estimated to have received coordinated, ongoing comprehensive care within a medical home, a 5% decrease from the 2001 National Survey. Other Illinois statistics of interest include:
• 45,096 children under 18 received Social Security Income (SSI) as of 12/06 (http://www.ssa.gov/policy/docs/statcomps/supplement/2007/7b.html)
• 23,019 children were served by the Division of Specialized Care for Children (DSCC) in 2007 (https://perfdata.hrsa.gov/mchb/mchreports/TVISReports/UI/Snapshot/snapshot.aspx?statecode=IL)
• 17,767 children with Individual Family Service Plans received Early Intervention services the end of October 2007. 59.7% of these children were insured by Medicaid/All Kids. 84.86% of 3 year olds leaving EI were referred to local education agencies Illinois Department of Human Services, Bureau of Early Intervention.
• 322,534 children had Individualized Educational Plans during the 2005-6 school year (http://nces.ed.gov/programs/stateprofiles/sresult.asp?mode=full&displaycat=1&s1=17)
• 1,349 children participated in child-specific Home and Community-Based 1915(c) Medicaid waivers; 574 were enrolled in the waiver for children who are medically fragile and technology dependent (Waiver year 2006) (http://www.hfs.illinois.gov/hcbswaivers/tdmfc.html)
• 600 children were enrolled in a new waiver program for children with developmental disabilities (waiver year 2008) (http://www.hfs.illinois.gov/hcbswaivers/supports_cyadd.html)
• 175 children participated in the Children’s Residential Waiver for children with DD (waiver year 2008) (http://www.hfs.illinois.gov/hcbswaivers/cyadd.html)
Equitable Health Care and Racial and Ethnic Disparities
The medical home model has the potential to promote equitable health care and address racial and ethnic disparities in access to care.4 According to the Commonwealth Fund 2006 Health Care Quality Survey, patients with medical homes were more likely to receive reminders to obtain preventative care, were more likely to receive preventative screenings, reported better managed chronic conditions and health outcomes, and experienced better coordination between primary and specialty care providers. Furthermore, racial and ethnic differences in receiving health care were reduced or eliminated when adults received care within a medical home.5
Primary Care Provider Shortages
The medical home model may ameliorate some of the driving forces behind the crisis in primary care. Over the past 10 years there has been a downward trend of physicians going into general primary care, of those who do, more are entering specialty tracks. There are fewer physicians staying in primary care practice, and a significant percentage of those are about to retire over the next couple of decades. The two most commonly sited reasons for the decline of primary care physicians are money and lifestyle. Student loans, lower salaries and low or no payment for services are major financial stressors for physicians in primary care practices.6 Another factor is the limited amount of time the primary care provider has with their patients even though most feel that more time would be an effective strategy to improve the quality of care. Furthermore, over half of these respondents felt that in order to improve quality, their income would be less because of the lack of payment for many services provided outside the visit.7 Nevertheless, acceptance of the medical home model, which is based on quality, adequate payment, specialization in the comprehensive care of the patient, and family professional partnerships, by payors and others may be one solution to this ever-growing crisis. Additionally, studies have shown that increased access to primary care compared to specialty care increases both quality and reduces cost of primary care both in the US and abroad.8
Addressing Unmet Needs
The Illinois Chapter of the American Academy of Pediatrics (ICAAP) is committed to advancing the development of medical homes by providing primary care providers with training and support to implement the model in their practices. Through expansion of the pilot Illinois Medical Home Project and implementation of the new Building Community-Based Medical Homes for Children Program, ICAAP and DSCC are providing practices and clinics with quality improvement team facilitation support to help organize their practices and guide their key clinical activities to build medical homes for all. These initiatives will not only support implementation to improve the quality of patient care but also have the potential to increase recognition and payment of services through the National Committee for Quality Assurance’s Physicians Practice Connection evaluation program on Patient Centered Medical Home.9 The ICAAP is also administering the Coordinating Care Between Early Intervention and the Primary Care Medical Home Project and the Integrated Systems of Services for Children and Youth with Special Health Care Needs three-year federally funded grant project. To learn more about ICAAP medical home activities, please click on the project links below.
1American Academy of Pediatrics. The Medical Home Pediatrics. 2004; 113(suppl):1471-1548.
2Child and Adolescent Health Measurement Initiative. 2005/2006 National Survey of Children with Special Health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved May 19, 2008
3Child and Adolescent Health Measurement Initiative. 2003 National Survey of Children’s Health, Data Resource Center for Child and Adolescent Health website. Retrieved May 19, 2008.
4Starfield B, Shi L. The Medical Home, Access to Care, and Insurance: A Review of the Evidence. Pediatrics. 2004; 113:1493-1497.
5Beal A, Doty M, Hernandez S, Shea K, Davis K. Closing the Divide: How Medical Homes Promote Equity in Health Care. The Commonwealth Fund. 2007: 1-40
6Reuben D. Saving Primary Care. The Association of Professors of Medicine. 2006: 99-102
7Audet AJ, Doty MM, Shamasdin J, Schoenbaum SC. Physician’s views on quality of care: findings from the Commonwealth Fund national survey of physicians and quality of care. Commonwealth Fund. 2005.
8Starfield B, Shi L, Macinko J. Contributions of Primary Care to Health Systems and Health. Milbank Quarterly. 2005; 457-502.
9National Committee for Quality Assurance. Physician Practice Connections Patient- Centered Medical Homes. National Committee for Quality Assurance website. Retrieved November 19, 2008.
For more information, please contact:
Kathy Sanabria, MBA, PMP
Senior Director, Medical Home Initiatives
1400 W. Hubbard, Suite 100
Chicago, IL 60642
Phone: 312/733-1026, ext 208