Designing Systems of Care that Work for Children with Special Health Care Needs

Access to Medical Home

The Medical Home Model

According to the American Academy of Pediatrics, a "medical home" provides care that is accessible, family-centered, comprehensive, continuous, coordinated, compassionate and culturally effective, and for which the primary care physician shares responsibility.

A critical element of the medical home is its role in care coordination, the process of developing and implementing specific care plans by a team of multiple service providers accessing resources in an organized fashion (American Academy of Pediatrics, 1999). Time, staff limitations, and reimbursement issues have traditionally been the main barriers to the provision of comprehensive care coordination.

A study conducted by Nashaway Pediatrics set out to determine the nature and cost of care coordination through a prospective time study measuring all staff members' engagement in non-reimbursable care coordination activities. This study concluded that:

• To provide medical home services, care coordination costs are appreciable but not prohibitive.
• It is essential to standardize care coordination practices enabling performance by qualified and most cost-effective staff.
• Care coordination activities must be made amenable to quality improvement initiatives.
• Mechanisms to finance office-based care coordination must be developed.
• Care coordination by trained non-provider staff may enhance productivity of provider staff.
• Further studies are needed to examine the nature of care coordination across provider types and settings.

These findings have significant implications for policy and practice, as they require that the traditional, office-based, medically-focused interaction be re-examined and that financing systems support connecting families of children with special health care needs (CSHCN) with community-based resources.

Measures and Widespread Implementation Strategies

Because of the critical nature of the medical home in a system of care for CSHCN, the Center for Medical Home Improvement (CMHI) was founded to help in building, strengthening, and promoting medical homes for this population. A fully developed medical home implies an expansion of services beyond strictly medical care to include care coordination, advocacy, and family education. Thus, a medical home should be able to form partnerships with families, identify and monitor CSHCN, coordinate care in a systematic manner, and communicate with other community resources. In order to do this, CMHI suggests that existing pediatric primary care services be redesigned.

The CMHI model for Medical Home emphasizes:

• Partnerships with parents.
• Primary care-based care coordination.
• Continuous improvement process.
• Linkages to community resources.
• Improved office systems that:
  • Identify CSHCN.
  • Track and monitor progress.
  • Evaluate outcomes.

To monitor the implementation of medical homes with these characteristics, CMHI has developed the Medical Home Index (MHI). The MHI has six domains, including:

• Organizational capacity.
• Chronic condition management.
• Care coordination.
• Community outreach.
• Data management.
• Quality improvement and change.

Practices can measure the level of "medical homeness" using indicators in each of these domains.

To date, seven States have implemented the CMHI model for monitoring and improving the quality of medical homes for CSHCN, and a National Learning Collaborative on the Medical Home is being established in ten States.

Another model for improving the quality of primary care and care coordination for CSHCN, especially in a managed care environment, is that established by Partnerships for Enhanced Managed Care (PEMaC), a pilot project implemented by Anthem Blue Cross Blue Shield, Cigna of New Hampshire, and the Hood Center for Children and Families at Dartmouth Medical School. PEMaC has developed The Enhanced Care Coordination (ECC) model, which provides a structured team approach to care coordination for CSHCN. The components of the ECC Model include:

• Identification of children with complex health problems based on complexity and need, rather than on the cost of care.
• Determination of family needs, priorities, and medical issues.
• In-office ECC team meeting with the primary care provider, office care coordinator, MCO case manager, and any other key players.
• Follow-up care coordination support to ensure that the plan is implemented and new issues solved.
• Ongoing dialogue between the office-based care coordinator and the MCO case manager.

The ECC is designed to establish a partnership between managed care and primary care offices to provided a family-centered team approach to coordinate care. For CSHCN and their families, this partnership improves primary care practices' ability to meet their patients' ongoing care coordination needs, address families' concerns and priority issues, develop a care plan that gives attention to preventive care and anticipates potential crises, and decrease the overall cost of care. On the system level, the ECC model has demonstrated:

• Improved outcomes for enrolled children.
• A reduction in the use of inpatient services and an increase in the use of outpatient specialty services and primary care.
• Reduced total expenditures.

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