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Breakout Session Discussion Summary: All CSHCN will receive ongoing comprehensive care within a medical home in a managed care setting.

Paul Newacheck, DrPH, Institute for Health Policy Studies, University of California, San Francisco - Group Facilitator

The grantees shared their perspectives on the concept of the "medical home." The group focused on the following aspects: accessible, comprehensive, coordinated, continuous, culturally competent, compassionate, and family partnerships. It was generally agreed that, first and foremost, a medical home infers a specific place -- located in or very near a child's community of residence -- where care is provided. Some, however, proposed that "place" can be represented by teams of professions from different institutions who work in concert to ensure that the attributes of medical home are implemented. Finally, group members concurred that a "medical home" for CSHCN requires some level of professional expertise related to the needs of children with chronic illness or disability and their families.

Because implementing the medical home concept can be challenging in some practices or localities given capacity requirements, MCHB is promoting priority focus on the following four aspects:

• access to primary care,
• coordination of primary and specialty care,
• coordination of medical care with needed education, social, and other services and,
• support for the child and family within the community.

A primary finding of the group discussion was that more attention is needed to promoting a shared understanding of the concept/definition of medical home. With more widespread awareness and agreement on the elements, a wide range of appropriate community- and practice-specific models can evolve. The American Academy of Pediatrics (AAP) Medical Home Project is about to finalize an operational definition of medical home.

1. Contributions of the Grantees

• Through the Hood Center in New Hampshire, a new model of team-based medical management has been designed and tested. In this model, case managers with expertise in CSHCN are assigned to function within a large managed care organization (MCO). At the Hood Center, pre-post data collection (no data on controls available) found lower costs for MCOs implementing the medical home model implemented there.

• Through the Providence Health Systems project in Washington and Oregon, medical home leadership teams have been established in communities. These teams assist local pediatricians in thinking about CSHCN population management.

• The Institute for Child Health Policy at the University of Florida has used adapted survey instruments designed to assess the concept of medical home (the Primary Care Assessment Tool -- PCAT) to document the relationship between care provided in a medical home and quality of care.

• Demonstrating the direct relationship between family stress and hospitalization of children with severe emotional disturbance, Tennessee's Family Voices project has been able to promote respite care prevention strategies. In addition project staff negotiated arrangements for payment to pediatricians caring for CSHCN for up to six mental health visits so that time/compensation could be given by primary care provider for supportive communication/time with families caring for SED children.

• At the Children’s Hospital and Regional Medical Center in Seattle, the project illustrated how administrative data sets can be used to identify the target group of CSHCN within MCOs.

2. Collaborators

• All of the grantees noted extensive partnerships in implementing their projects. Partnerships were established with Title V CSHCN programs, Medicaid (Title XIX), the S-CHIP program (Title XXI), Families, and Family Voices. In addition, one project specifically was pleased with their partnership with family practice physicians (SAFE at Home project, in Minnesota).

3. Challenges

• Adequate compensation to pediatricians/practices for the time, effort, and expertise necessary to implement a medical home for CSHCN is not currently built into insurance schemes.

• Given the shifts in corporate arrangements between medical care clinicians, facilities, plans, and payers, as well as the frequent need for families to change insurance (due to changes in employer plan options offered in their benefit practices), continuity of care (a key component of the medical home concept) is a major challenge. Working group members noted that this is an area where there is evidence of the association between continuity of care and improved health outcomes. Such research findings should be used to further press for systems improvements related to continuity of care.

• It was suggested that a significant future challenge will evolve from anticipated changes in structuring of employee benefits packages to a defined contribution approach.

• Some discussion centered on the underlying "tensions" between generalist and sub-specialist pediatricians. While progress in this regard can be observed, at times issues surface related to which clinician "owns" responsibility for management of the child's care, and who is due the additional reimbursement for such care management. The question that needs to be addressed is, "what is the 'specialty' function of primary care pediatricians that complements the ' specialty care' provided under the auspices of the sub-specialists?" It will be important to, where possible, convince primary care pediatricians and sub-specialists to see themselves as members of a team.

4. Lessons Learned

• The process of "buy-in" to the medical home concept takes time; each provider needs to have his/her own "ah-ha" experience. Moreover, especially in the managed care setting, there needs to be a champion of the medical home concept in order for implementation to occur and be sustained. Implementation does not occur without a systematic approach, specific attention needs to be given to addressing the logistic and capacity requirements of implementing the medical home concept in practices and in managed care organizations. A Continuous Quality Improvement (CQI) approach and a long-term investment in mentoring for problem-solving with pediatricians committed to implementing the medical home concept are needed. In addition, there is a need to test "thined down" versions of the more comprehensive models implemented (e.g., through the Hood Center) to see what is absolutely required/effective, and institutionalize that.

• Capacity/resources need to be provided to individual pediatricians and pediatric practices to assist them in implementing the medical home concept. This means not only adequate reimbursement, but training and technical assistance as well. Of note also, there are large differences in the challenges to assuring a medical home in rural versus urban practice settings. In some cases, limited practice management consultation can be sufficient for this purpose. For example, "call books" that practice partners can hand off to one another can be used to improve continuity of care for CSHCN w/in a practice. In other situations, re-organization of the practice and/or addition of personnel capacity (for example, in the form of adding case managers) are necessary. Parent expectations of their child's provider that the components of medical home will be provided also can be a powerful incentive for a pediatrician to make the necessary changes in his/her practice: pediatricians are committed to serving their families well. Reaching physicians takes a multi-pronged approach -- "early and often" should be the motto. Managed care plans have less latitude to change practice patterns of pediatricians than was thought to be the case. There was general consensus among the workgroup participants that "real progress" will occur only when pediatric training (e.g., during residency) incorporates the concepts and skills necessary for implementing the CSHCN medical home concept. The Anne E. Dyson Initiative holds promise in this regard.

• Environments need to be created in pediatric practices where families can feel supported in communicating their needs and priorities related to planning care for their child/family. The traditional office visit routine often does not promote this environment. In addition, MCOs need to have processes in place where families can bring non-medical grievances to light; most MCOs do not have such processes.

• The Medical Home in Managed Care initiative offers the opportunity for Title V Programs to reach the population of CSHCN with commercial insurance. Grantees can encourage Title V programs to partner with managed care.

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