The Medical Home: An Essential Competency for Pediatric Residents

Abstract

<div class="ftContainer"> <style> ol{ list-style-type:none; } </style> <div class="ftAuthorNotes"> <p>Aditee Pradhan Narayan, MD, MPH, is Assistant Professor, Duke University Department of Pediatrics, and Associate Program Director, Duke University Pediatric Residency Training Program. </p> <p>Dr. Narayan has disclosed no relevant financial relationships.</p> <p>Address correspondence to: Aditee Pradhan Narayan, MD, MPH; fax 919-681-5825; or e-mail naray001@mc.duke.edu.</p> </div> <div class="ftArticle"> <p>In recent years, the importance of the medical home model of healthcare delivery has gained widespread acceptance in the medical and family advocacy communities. 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 care” that is clearly central to provision of healthcare for both children and adults. <sup> <a href="#x00904481-20090820-08-bibr1">1</a> </sup> The Obama administration has highlighted the value of medical homes as essential to improved quality and cost-containment of health care. <sup> <a href="#x00904481-20090820-08-bibr2">2</a> </sup> Many family and community organizations, such as Family Voices and the National Partnership for Women and Families, have advocated for medical homes as a key component of a revitalized system of healthcare system redesign. </p> <p>In order to train both pediatric and adult physicians in this critical concept, resources are needed to guide and educate the practicing physician in the medical home. The AAP’s National Center for Medical Home Implementation has created interactive electronic modules that teach the four essential components of medical home, which include the following themes: family-centered partnerships, community-based systems, transition of care, and value of care. <sup> <a href="#x00904481-20090820-08-bibr3">3</a> </sup> These modules are a valuable resource, enabling practicing physicians to track their progress in meeting medical home goals. In addition, the American Board of Pediatrics (ABP) has identified the need for quality improvement training as part of the Maintenance of Certification (MOC). <sup> <a href="#x00904481-20090820-08-bibr4">4</a> </sup> This requirement may allow physicians to assess and improve their own practice of pediatrics, which is essential in medical home delivery. </p> <p>The next major step in ensuring the viability of the medical home model is to educate the future generation of physicians by focusing on residency training. Traditionally, residency programs have focused on training physicians in medical knowledge and patient care. This training provided physicians with clinical skills, but may not have trained them in working within and across systems of care. Through the medical home movement, it is now apparent that clinical skills alone are not sufficient for physicians in caring for their patients. Physicians must be able to assess their own practice and enact change, address systems issues within and across their practice, collaborate with families and other team members in delivering care, and practice medicine in a culturally competent manner. Although important for all children and adults to receive this type of care, it is especially important for children and youth with special healthcare needs, where navigating systems is a critical part of ensuring health care delivery. </p> <div class="ftSection"> <h3>ACGME Requirements</h3> <p>The Accreditation Council for Graduate Medical Education (AC-GME) has responded to this need by requiring all residents to be trained in quality improvement and systems-based practice. <sup> <a href="#x00904481-20090820-08-bibr5">5</a> </sup> This requirement is an important step towards skills development for residents. However, there remain other key elements of the medical home that need to be taught. Residency training represents a critical time for training physicians to launch their clinical skills in the context of family-centered principles. </p> <p>There are several challenges in how best to train residents in medical home competencies. First, in 2003, the ACGME implemented duty-hours rules restricting the time residents spend working in order to combat fatigue and related complications. <sup> <a href="#x00904481-20090820-08-bibr6">6</a> </sup> Additionally, residents and program directors are asked to submit far more tracking and documentation than in years past. Programs are challenged in providing the same high level and quality of clinical training for independent practice, but with less clinical and teaching time devoted to exclusively developing clinical skills. </p> <p>Second, there is a national crisis in primary care, with fewer medical students choosing primary care specialties for their training in both pediatrics and adult medicine (internal medicine and family medicine.) Coupled with this crisis, is the dichotomy of significant amount of time allocated to hospital-based training at a time when the healthcare system needs more community-based practitioners in primary care specialties. </p> <p>Finally, the current fiscal environment makes it difficult for programs to expand into new areas of training. Many programs may be faced with funding cuts in extracurricular or innovative programs. This may make it difficult to recruit additional staff in providing education to residents. </p> <p>Despite these challenges, it is paramount that residents must be trained in medical home concepts before they become independent practitioners. Doing so will enable these future graduates to implement medical home standards as they start their career in medicine and serve as role models to other practicing physicians. This may be particularly useful as their entry into the work-force coincides with the new MOC requirements from the ABP. </p> </div> <div class="ftSection"> <h3>Future Considerations</h3> <p>To address this need, it is both appropriate and timely that a core working group has initiated a collaborative project to create a national medical home curriculum and competencies for pediatric resident education. This curriculum is a joint venture between the AAP’s National Center for Medical Home Implementation, the Association of Pediatric Program Directors, Family Voices, and other key stakeholders. The goal of this project is to develop a focused, flexible, and sustainable medical home curriculum that is an adaptation of the National Center’s curriculum for practicing physicians. We hope to create a curriculum that is easy to implement across a variety of residency training programs, provides the basic structure of medical home concepts for residents from which they can continue to expand as independent learners and practitioners, and is cost-neutral for residency programs. We are also hopeful that the curriculum will not require significant amounts of time for residency program directors, and can be easily implemented within existing residency rotations and requirements. We expect this curriculum to provide the basic skills in medical home for both future generalists and subspecialists, providing a natural transition from residency to independent practice. We are hopeful that this curriculum could be easily adapted to medical student or adult primary care training — the opportunities for future collaborative efforts are numerous. </p> <p>There may be other excellent projects underway to address aspects of medical home in training for residents and other trainees. We hope our curriculum will supplement the existing training and inform future curricula that become available. Creating this curriculum will provide another step toward transforming the healthcare system, improving outcomes for families, medical providers, and the community. </p> </div> <div class="ftRefList"> <h3>References</h3> <ol> <a name="x00904481-20090820-08-bibr1"></a> <li> Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The medical home. American Academy of Pediatrics. <i>Pediatrics</i>. 2002;110(1 Pt 1):184-186. </li> <a name="x00904481-20090820-08-bibr2"></a> <li> News Staff. New White House Health Reform Director ties medical home to system overhaul efforts. AAFP News Now, April 22, 2009. </li> <a name="x00904481-20090820-08-bibr3"></a> <li> <a target="_blank" href="http://www.medicalhomeinfo.org">http://www.medicalhomeinfo.org</a>. Accessed August 19. 2009. </li> <a name="x00904481-20090820-08-bibr4"></a> <li> <a target="_blank" href="http://www.abp.org">http://www.abp.org</a>. Accessed August 19. 2009. </li> <a name="x00904481-20090820-08-bibr5"></a> <li> ACGME Program Requirements for Graduate Medical Education in Pediatrics. Effective July 1, 2007. <a target="_blank" href="http://www.acgme.org/acWebsite/RRC_320/320_prIndex.asp">http://www.acgme.org/acWebsite/RRC_320/320_prIndex.asp</a>. Accessed August 19. 2009. </li> <a name="x00904481-20090820-08-bibr6"></a> <li> ACGME Duty Hours Requirements. Effective July 1, 2007. <a target="_blank" href="http://www.acgme.org/acWebsite/RRC_320/320_prIndex.asp">http://www.acgme.org/acWebsite/RRC_320/320_prIndex.asp</a>. Accessed August 19. 2009. </li> </ol> </div> </div> </div>