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The Pediatric Medical Home: What Do Evidence-Based Models Look Like?
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The Pediatric Medical Home: What Do Evidence-Based Models Look Like?

Bita Kash, PhD, MBA, FACHE; Debra Tan, MPH; Katherine Tittle, MS, RN, FACHE; and Lesley Tomaszewski, PhD, MS
This study presents practice relevant information and actionable results that can help to operationalize evidence-based patient-centered medical home models in pediatric clinics.
ABSTRACT

Objectives: To identify characteristics of effective, evidence-based pediatric medical home models using a primary care patient segmentation approach.

Study DesignA systematic literature review of literature using the Medline database focusing on improving pediatric primary care and original studies of the pediatric medical home model was conducted. The primary care patient segmentation approach to organizing original studies resulted in 5 patient population segments used to further categorize and present findings.

Methods: We searched the MEDLINE Ovid database with the keywords [“pediatric primary care”] and [“pediatric medical home”]. Inclusion criteria included data specific to pediatric primary care and data specific to the pediatric medical home. We excluded nonempirical data, non–peer-reviewed articles, medical case studies, articles not in the English language, and published abstracts.

Results: We identified 94 studies that met all inclusion criteria. Of these studies, 6 were identified and described as evidence-based models that targeted 5 patient population segments. We found that studies that report statistically significant results are directed toward even more targeted sub-segments than the original primary care patient segmentation framework used for this study and so used specialized care teams targeted toward these segments.

Conclusions: The developed pediatric primary care patient segmentation framework developed in this study can be applied to improve implementation and operationalization of pediatric medical homes. This study demonstrates the importance of specialized sub-segments within pediatric population segments beyond the original primary care patient segmentation framework.
A pediatric medical home is comprised of a coordinated system of care encompassing a team of health and social providers who are focused on supporting the medical and nonmedical needs of the child and its family.1 In light of the 2010 Affordable Care Act (ACA), medical homes have been implemented as a method to improve health outcomes, as well as reduce rising healthcare expenditures.2

The American Academy of Pediatrics (AAP) developed the medical home model with the aim of delivering better primary care to children and adolescents with special health needs in the late 1960s.3 It is purposed to facilitate an integrated healthcare system with an interdisciplinary team of patients and families, primary care physicians, specialists, subspecialists, hospitals and healthcare facilities, public health officials and the community.4 Interest in the patient-centered medical home (PCMH) model has grown exponentially across many spectrums of the healthcare system since 2010.4 It is important to note that the literature on PCMH has supplied primary care providers and policy makers with limited evidence and mixed results about the effectiveness of this patient care model, which calls for a systematic review of PCMH outcomes and effectiveness using a patient segmentation framework approach that can shed some light on the mixed messages in today’s literature. In using a primary care patient segmentation framework approach for this study, we were able to identify evidence-based models of PCMH practice and refine the patient segmentation model for pediatric primary care.

The Primary Care Patient Segmentation Framework

As a way to better individualize and reduce discontinuity in healthcare delivery, Porter and colleagues propose in their study that improving primary care should be approached through organizing subgroups of patients with similar needs as a way to better individualize and reduce discontinuity in healthcare delivery.5-8 They note that value is often improved by multidisciplinary teams of clinicians that act as integrated provider units and collaborate to meet the major needs of the patients.8

Moreover, Porter et al recommend that patients’ outcomes and true costs should be measured by subgroups, and payment should be customized to bundle reimbursement for each subgroup to successively reward any improvement in care.8,9 By dividing the population into subgroups of patients with similar needs and conditions, progress can be made toward measuring outcomes and costs in regard to integrating primary care with specialty care.8,9 Additionally, collaboration and integration of care has the potential to improve and to increase by integrating primary care patient subgroup teams with relevant specialty care teams.8

In this current study, we propose that for pediatric practices, children can be segmented similarly into analogous groups. By grouping children according to similarities in chronic diseases, special needs, and health status, many pediatric practices have developed multiple “needs-based” delivery systems explicitly designed to measure and improve value for specific segments of pediatric patients and families.

METHODS

Literature Search

An exhaustive computer-assisted search was conducted in the Ovid interface to MEDLINE databases to identify relevant published articles. The search terms: [“pediatric primary care”] and [“pediatric medical home”] were used in the MEDLINE Ovid database. An additional search was also conducted in Google Scholar to identify any missing literature. Manual searches of references from relevant articles were performed to identify studies that were missed by the computer-assisted search. This study was approved by the Texas A&M University Institutional Review Board.

Study Selection

Two investigators (DT and BK) reviewed all publication titles of citations identified by the search strategy and confirmed the selected articles presented in this study. Study populations were then organized into the primary care patient segmentation framework by the second investigator (BK) and further reviewed and confirmed by both investigators (DT and BK). Potentially relevant studies were retrieved and articles were independently checked for inclusion. Inclusion criteria included data specific to pediatric primary care and data specific to the pediatric medical home. We excluded nonempirical data, non–peer-reviewed articles, medical case studies, articles not in the English language, and published abstracts.

Data Extraction

One investigator (DT) independently extracted required information from eligible studies using a standardized form adapted from Porter et al.8 The second investigator (BK) reviewed and confirmed all data extracted. Data was also collected on study design, date of the study, outcomes and impact of the study, and information related to the respective pediatric patient segmentation. These population segmentation groups were separated into 5 ordinal health categories: 1) Healthy, 2) Healthy With A Complex Acute Illness, 3) At Risk, 4) Chronically Ill, and 5) Complex; modeled after Porter and colleagues’ framework.8,9 Frequencies of emergent themes in relation to pediatric primary care were also recorded.

This patient segmentation model served as the framework of analysis; the primary care patient segmentation strategy is therefore applied to pediatric primary care. This conceptual model is presented in Table 1.10-14

RESULTS

The computer-assisted search yielded 200 potentially relevant citations. After the initial review, 174 titles were considered appropriate, and these abstracts were reviewed. Of these articles, 31 did not meet inclusion criteria, and, subsequently, 143 articles underwent full-text review. Of these articles, 49 were excluded, as they did not have relevant information or evidence-based data specific to pediatric primary care or the pediatric primary care home. This left a total of 94 studies that met all inclusion criteria.

Of the remaining 94 studies, 6 were chosen and those evidence- based models were categorized into the framework of the aforementioned 5 population segments (Healthy, Healthy With a Complex Acute Illness, At Risk, Chronically Ill, and Complex). We found that a more sub-segmented approach was needed to serve pediatric populations with special needs because the primary care patient segmentation framework was too general for these populations. Sub-segments for various socioeconomic statuses, geography, and payer mix should also be considered when developing evidence- based programs of pediatric primary care. A summary table of the evidence-based pediatric primary home results is presented (Table 29-14), and includes selected studies that also provided guidance and information on how to operationalize the evidence-based model of care.

Applying this primary care patient segmentation framework to the results of the systematic literature review, we find that studies that report statistically significant results are directed toward very targeted sub-segments. A detailed analysis of these evidence-based pediatric primary care models and correlated segment populations and subsequent sub-segments are presented next.

1. Limited English Proficiency

The medical home model has the potential to foster high-quality care and reduce disparities in treatment, especially among vulnerable populations.9,15 In an effective medical home, a family’s cultural background—including beliefs, rituals, and customs—are recognized, valued, respected, and incorporated into the care plan. Pediatric primary care physicians should make an effort to improve their knowledge, skills, and attitudes in working and communicating with diverse children and families.9,16

A qualitative study by DeCamp and colleagues assessed the views and experiences of Latina mothers with regard to expectations for pediatric primary care to inform medical home implementation in practices serving large limited English proficiency (LEP) populations.9 DeCamp and colleagues found that children with mothers with limited English proficiency were not receiving high-quality pediatric care.9 These mothers suggested methods to improve this, which included a composition of certain members of the patient care team.9 This team composition is analyzed in further detail below:

Pediatric primary care providers. The quality of the parent– provider relationship was central to the mothers’ satisfaction with care.9 Latina mothers described an excellent provider as someone who had a warm, friendly manner, and could relate to and engage the child.9 Mothers also expressed that they valued providers who engaged them by asking how they were doing and taking time to provide a thorough examination, as well as evoke and answer all parent questions.9

Nursing and office staff. Mothers expressed that they anticipate nursing and clinic staff to be friendly and caring. Many mothers expected and appreciated nursing and office staff that could calm and comfort the child during blood draws or immunizations.9

Language services. Language services were often limited for specialty and emergency care, causing both misinformation and difficulty. 9 Clinics without a Spanish-speaking provider usually had clinic nurses who provided interpretation to the mothers; however, the nurses were not constantly present in the exam room, resulting in impeded communication.9

Health system navigator. There was observed frustration in obtaining and maintaining public health insurance coverage for their children.9 Central barriers included lack of forms in Spanish and limited availability of interpreters at social services offices.9 Families who experienced much difficulty obtaining and maintaining public health insurance delayed care when their child lacked coverage.9 Further, families encountered challenges regarding finding providers that accepted their child’s Medicaid managed care plan.9

2. Pediatric Emergency Care

The pediatric emergency care study applies to the Healthy population segment, which outlines pediatric emergency care. A significant number of pediatric emergencies are seen in pediatric primary care practices10 and numerous studies have found that children are continuously taken to primary care offices by their parents or caregivers at the time of an emergency.10,17-20 The most common types of emergencies include seizures, infections in young infants, and dehydration.10 Upon these urgent situations, pediatricians and primary care providers may be required to provide emergent care in their offices for children with these conditions as they await the arrival of emergency medical services personnel.10 This suggests an opportunity to prepare pediatric primary care providers for these emergent situations in a pediatric medical home setting.

 
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