Medical Home Teams Research Articles

Delegation of Work Within a Patient-Centered Medical Home.

The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work. Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams. This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey. Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants. Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation.

Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study.

The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity. We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding. Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork. Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.

Factors Associated With Patient-Centered Medical Home Teams' Use of Resources for Identifying and Approaches for Managing Patients With Complex Needs.

Using data from a Veterans Health Administration national primary care survey, this study identified the most highly rated tools and care approaches for patients with complex needs and how preferences varied by professional role, staffing, and training. Nurses were significantly more likely to rate most tools as very important as compared with primary care providers. Having a fully staffed team was also significantly associated with a very important rating on all tools. Nurses and fully staffed teams reported a greater likeliness to use most care approaches, and those with perceived need for training reporting a lower likeliness to use.

Patient Vs. Soldier-Centered Medical Home: Comparing Access, Continuity, and Communication in the U.S. Army.

Over the last 40 years, patient-centered medical home (PCMH) has evolved as the leading primary care practice model, replacing traditional primary care models in the United States and internationally. The goal of PCMH is to improve chronic condition management. In the U.S. Army, the scope of the medical home, which encompasses various care delivery platforms, including PCMH and soldier-centered medical home (SCMH), extends beyond the management of chronic illnesses. These medical home platforms are designed to support the unique health care needs of the U.S. Army's most vital asset-the soldier. The PCMHs and SCMHs within the U.S. Army employ patient-centered care principles while incorporating nationally recognized structural attributes and care processes that work together in a complex adaptive system to improve organizational and patient outcomes. However, U.S. Army policies dictate differences in the structures of PCMHs and SCMHs. Researchers suggest that differences in medical home structures can impact how organizations operationalize care processes, leading to unwanted variance in organizational and patient outcomes. This study aimed to compare 3 care processes (access to care, primary care manager continuity, and patient-centered communication) between PCMHs and SCMHs. This was a retrospective, cross-sectional, and correlational study. We used a subset of data from the Military Data Repository collected between January 1, 2018, and December 31, 2018. The sample included 266 medical home teams providing care for active duty soldiers. Only active duty soldiers were included in the sample. We reviewed current U.S. Army Medical Department policies to describe the structures and operational functioning of PCMHs and SCMHs. General linear mixed regressions were used to evaluate the associations between medical home type and outcome measures. The U.S. Army Medical Department Center and School Institutional Review Board approved this study. There was no significant difference in access to 24-hour and future appointments or soldiers' perception of access between PCMHs and SCMHs. There was no significant difference in primary care manager continuity. There was a significant difference in medical home team continuity (P < .001), with SCMHs performing better. There was no significant difference in patient-centered communication scores. Our analysis showed that while the PCMH and SCMH models were designed to improve primary care manager continuity, access to care, and communication, medical home teams within the U.S. Army are not consistently meeting the Military Health System standard of care benchmarks for these care processes. Our findings comparing 3 critical medical home care processes suggest that structural differences may impact continuity but not access to care or communication. There is an opportunity to further explore and improve access to appointments within 24 hours, primary care manager and medical home team continuity, perception of access to care, and the quality of patient-centered communication among soldiers. Knowledge gained from this study is essential to soldier medical readiness.

Caring for Caregivers: Implications for Providing Authentic Family-Centered Care

In this issue of Pediatrics, Fuller et al1 provide compelling evidence that both the fathers and mothers of children born with major congenital anomalies have a higher risk of premature mortality. The increased paternal mortality is the new revelation. The authors looked at time to death and cause of death after the birth of an infant with major congenital anomalies. Data were harvested from multiple national registries in Denmark by using a robust methodologic approach.The authors found an increased risk of both paternal and maternal mortality due to cardiovascular, endocrine, and metabolic causes. Behavioral health needs, including for substance and alcohol abuse, were higher. Distressingly, mothers of affected infants had an increased risk of death from unintentional injuries, violence, and other trauma. Notably, these are largely preventable causes of morbidity and mortality.The authors’ analytic approach does not support drawing causal inferences related to circumstances arising beyond the newborn period, limiting the ability to generalize the conclusion that parenting an infant with complex medical needs can lead to increased premature mortality. However, it is generally known that family caregivers of children with complex needs experience significant stress. The authors appropriately cite evidence that increased stressors borne by family caregivers of children and youth with special health care needs (CYSHCN) are associated with increased risk of poor health as well as negative social and economic outcomes. Self-reported outcomes in the US National Survey of Children’s Health (2018–2019) reveal that 53% of mothers of CYSHCN with more complex needs who are the primary caregiver in the household and 45% of fathers who are the primary caregiver in the home report that their physical and/or mental health is not “excellent or very good.”2The recommendation to include assessment of the health risks and wellness of fathers, in addition to the mother, is of vital importance and represents an important contribution to the evidence in support of advancing comprehensive, family-centered care. We are now confronted with important questions regarding the most reliable, equitable, and sustainable approach by which this recommendation might be implemented. For example, who should be accountable for thorough, longitudinal screening of both parents? How do those doing the screening get trained, and what instrument might be employed? Should this screening be linked with ongoing screening of the CYSHCN by team members of the patient- and family-centered medical home?3,4 How will the results of these screens be interpreted, and who will be responsible for following-up? Should the care plan of the CYSHCN include referrals for assessment of the health and wellness of the parents? What are implications for integrating care across providers of different family members? For care models in which the medical home team follows the entire family, such as family medicine or medicine-pediatrics, operationalizing this may be more straightforward. In care models that are limited to children and adolescents, this may be more challenging. To inform this more holistic approach, we must draw on frameworks that support person- and family-centered care coordination and integration.5,6 Performance measurement will be essential.7The limitations of this study need to be acknowledged. First, Denmark is a small country with a predominantly white population with access to universal health care. In fact, associated parental mortality may be more significant in countries with diverse populations, poorer economies, and/or reduced access to health care. Second, the study period spans 30 years (1986–2015), a period that has seen significant improvements in health care and management for individuals with congenital anomalies and rare genetic conditions.Although this study is primarily focused on children with congenital anomalies, one wonders about its implications for a broader spectrum of conditions, including neurodevelopmental disorders, autism,8 Down syndrome,9 and disorders identified through newborn screening, in which long-term parental anxiety plays a significant role, even in conditions with excellent outcomes.10The results of the study support a holistic, family-oriented approach to the management and care of patients with congenital anomalies and potentially other rare genetic conditions that is long overdue and must inform current standards of care. It is reasonable to advocate for screening the health and wellness of the caregivers of CYSHCN, irrespective of the etiology of those special health care needs. In addition, we must note the impact of disparities based on race, ethnicity, and language for some CYSHCN and their families who are at an increased risk of receiving insufficient care coordination and of consequent poor outcomes.11,12 To ensure achievement of equitable outcomes, we must implement robust measurement, enabling stratification, if not risk adjustment, of performance metrics. If we are committed to optimizing the health outcomes of all persons, the family-centered care model must include assessment of the needs and strengths of all caregivers in the family. If this is not done, are we truly providing care that is family centered?

What Do Patient-Centered Medical Home (PCMH) Teams Need to Improve Care for Primary Care Patients with Complex Needs?

Intensive primary care (IPC) programs for patients with complex needs do not generate cost savings in most settings. Strengthening existing patient-centered medical homes (PCMH) to address the needs of these patients in primary care is a potential high-value alternative. Explore PCMH team functioning and characteristics that may impact their ability to perform IPC tasks; identify the IPC components that could be incorporated into PCMH teams' workflow; and identify additional resources, trainings, and staff needed to better manage patients with complex needs in primary care. We interviewed 44 primary care leaders, PCMH team members (providers, nurses, social workers), and IPC program leaders at 5 VA IPC sites and analyzed a priori themes using a matrix analysis approach. Higher-functioning PCMH teams were described as already performing most IPC tasks, including panel management and care coordination. All sites reported that PCMH teams had the knowledge and skills to perform IPC tasks, but not with the same intensity as specialized IPC teams. Home visits/assessments and co-attending appointments were perceived as not feasible to perform. Key stakeholders identified 6 categories of supports and capabilities that PCMH teams would need to better manage complex patients, with care coordination/management and fully staffed teams as the most frequently mentioned. Many thought that PCMH teams could make better use of existing VA and non-VA resources, but might need training in identifying and using those resources. PCMH teams can potentially offer certain clinic-based services associated with IPC programs, but tasks that are time intensive or require physical absence from clinic might require collaboration with community service providers and better use of internal and external healthcare system resources. Future studies should explore the feasibility of PCMH adoption of IPC tasks and the impact on patient outcomes.

Patient Centered Medical Home Cooking: Community Culinary Workshops for Multidisciplinary Teams.

Ideal management of chronic disease includes team based primary care, however primary care medical staff face a lack of training when addressing nutritional counseling and lifestyle prevention. Interactive culinary medicine education has shown to improve knowledge and confidence among medical students. The aim of this study was to determine whether a culinary medicine curriculum delivered to a multidisciplinary team of primary care medical staff and medical students in a community setting would improve self-reported efficacy in nutritional counseling and whether efficacy differed between participant roles. A 4-h interactive workshop that took place within the neighborhood of a primary care medical home was delivered to medical staff and students. Participants completed a voluntary questionnaire before and after the workshop that addressed participants’ attitudes and confidence in providing nutritional counseling to patients. Chi-square tests were run to determine statistically significant associations between role of participant and survey question responses. Sign Rank tests were run to determine if pre-workshop responses differed significantly from post-workshop responses. Thirteen of seventeen responses related to attitudes and efficacy demonstrated significant improvement after the workshop compared with prior to the workshop. Significant differences noted between roles prior to the workshop disappear when asking the same questions after the workshop. Delivery of culinary medicine curricula to a primary care medical home team in a community setting is an innovative opportunity to collaboratively improve nutritional education and counseling in chronic disease prevention.

Using the PACT Resources Framework to Understand the Needs of Geriatric Primary Care Teams.

To identify the perceived organizational resources required by healthcare workers to deliver geriatric primary care in a geriatric patient aligned care team (GeriPACT). Cross-sectional observational study using deductive analyses of qualitative interviews conducted with GeriPACT team members. GeriPACTs practicing at eight geographically dispersed Department of Veterans Affairs (VA) healthcare systems. GeriPACT clinicians, nurses, clerical associates, clinical pharmacists, and social workers (n = 67). Semistructured qualitative interviews conducted in person, transcribed, and then analyzed using the PACT Resources Framework. Using the PACT Resources Framework, we identified facility-, clinic-, and team-level resources critical for GeriPACT implementation. Resources within each level reflect how the needs of older adults with complex comorbidity intersect with general population primary care medical home practice. GeriPACT implementation is facilitated by attention to patient characteristics such as cognitive impairment, ambulatory limitations, or social support services in staffing and resourcing teams. Models of geriatric primary care such as GeriPACT must be implemented with an eye toward the most effective use of our most limited resource-trained geriatricians. In contrast to much of the literature on medical home teams serving a general adult population, interviews with GeriPACT members emphasize how patient needs inform all aspects of practice design including universal accessibility, near real-time response to patient needs, and ongoing interdisciplinary care coordination. Examination of GeriPACT implementation resources through the lens of traditional primary care teams illustrates the importance of tailoring primary care design to the needs of older adults with complex comorbidity.

Understanding impact of family construct on childrenrsquo;s psycho ndash;social health and wellness

Children and youth with special health care needs (CYSHCN) and their families may experience a variety of internal (ie, emotional and behavioral) and external (ie, interpersonal, financial, housing, and educational) psychosocial factors that can influence their health and wellness. Many CYSHCN and their families are resilient and thrive. Medical home teams can partner with CYSHCN and their families to screen for, evaluate, and promote psychosocial health to increase protective factors and ameliorate risk factors. Medical home teams can promote protective psychosocial factors as part of coordinated, comprehensive chronic care for CYSHCN and their families. A team-based care approach may entail collaboration across the care spectrum, including youth, families, behavioral health providers, specialists, child care providers, schools, social services, and other community agencies.

STAKEHOLDER PERSPECTIVES ON DESIGN, IMPLEMENTATION, AND SUSTAINMENT OF SERVICES FOR OLDER VETERANS

A majority of United States Veterans are older adults, compelling healthcare systems such as Veterans Health Administration to attend to their unique needs when designing and implementing programs for workforce development and service delivery. In this symposium authors will present findings from four studies examining how older Veterans’ needs and preferences affect implementation and sustainment in a variety of settings. Presenters demonstrate how: 1) understanding Veterans’ perspectives and preferences for measuring functional status may inform the improvement of care coordination in the primary care setting; 2) the role of population characteristics in implementation of geriatric patient centered medical home teams (i.e., GeriPACTs); 3) the interaction of patient, provider, and delivery system information needs in limiting sustainment of diverse initiatives to improve osteoporosis screening and management for Veterans; and 4) the factors affecting transferability and sustainment of rural and geriatrics-focused quality improvement initiatives beyond local settings. Beyond their focus on how older adults’ needs are reflected or shape implementation, the studies illustrate the application of qualitative data to clinical practice and workforce development.

Physicians as Advisors Not Leaders of Multidisciplinary Teams: A Qualitative Study of an Innovative Practice

Abstract Background and Aims As various models of team-based chronic disease management have proliferated, physicians have assumed the leadership role in most of them. However, physician time is costly, and regular attendance of team meetings adds another task to a long list of responsibilities. This is the first study to explore the role of physicians as advisors rather than leaders of a multidisciplinary team. Methods We conducted an exploratory qualitative research study of a subspecialty medical home located within a tertiary academic medical center that cares for highly complex pediatric and adult patients with inflammatory bowel diseases. The medical home team consists of a psychologist, dieticians, social workers, a clinical pharmacist, and nurses. No physicians regularly attend team meetings. We conducted semi-structured interviews with nonphysician team members (N = 11) and gastroenterologists (N = 6). Two authors coded interview transcripts in NVivo 11 for themes related to “physician role” using an inductive qualitative analysis approach. Results Nonphysician participant believed gastroenterologists did not need to attend weekly meetings. Having only nonphysician personnel in the room made them feel more empowered to openly express their views. Gastroenterologists expressed interest in attending one or more, but not all meetings, in order to better understand the process of the team and desired a more formal feedback loop for staying informed about their patients’ progress. Conclusions Our findings suggest that gastroenterologist participation may not require regular attendance of team meetings. Team meeting consisting of nonphysician providers would result in cost savings and may empower nonphysician providers.

Psychosocial Factors in Children and Youth With Special Health Care Needs and Their Families.

Children and youth with special health care needs (CYSHCN) and their families may experience a variety of internal (ie, emotional and behavioral) and external (ie, interpersonal, financial, housing, and educational) psychosocial factors that can influence their health and wellness. Many CYSHCN and their families are resilient and thrive. Medical home teams can partner with CYSHCN and their families to screen for, evaluate, and promote psychosocial health to increase protective factors and ameliorate risk factors. Medical home teams can promote protective psychosocial factors as part of coordinated, comprehensive chronic care for CYSHCN and their families. A team-based care approach may entail collaboration across the care spectrum, including youth, families, behavioral health providers, specialists, child care providers, schools, social services, and other community agencies. The purpose of this clinical report is to raise awareness of the impact of psychosocial factors on the health and wellness of CYSHCN and their families. This clinical report provides guidance for pediatric providers to facilitate and coordinate care that can have a positive influence on the overall health, wellness, and quality of life of CYSHCN and their families.

Pharmacist-Delivered Comprehensive Medication Management Within Family Medicine Practices An Evaluation of the SCRIPT Project.

Pharmacist inclusion in patient-centered medical home (PCMH) teams has been shown to benefit both patients and practices. However, pharmacists' inclusion on these teams is not widespread, partly because the work they do is not well known. The Successful Collaborative Relationships to Improve PatienT care (SCRIPT) project was started in August 2009 to understand the clinical and economic impact of pharmacists providing direct patient care. The objective of this study was to describe the work of pharmacists practicing as integrated members of the patient care team within PCMHs through retrospective analysis of their patient care documentation over a 4-year time frame. Two pharmacists were placed into four suburban medical home practices in Pittsburgh, Pennsylvania to perform comprehensive medication management (CMM). These pharmacists documented their CMM encounters in an electronic health record and a database for reporting purposes. This study is a retrospective, descriptive analysis of pharmacist-documented CMM encounters from February 2010 through February 2014. Pharmacists' work-including patient demographics, disease states, and medication therapy problems-was recorded in a Microsoft Access database and tabulated. The pharmacists conducted 11,206 CMM encounters with 3,777 unique patients during the study period. The pharmacists identified 9,375 medication therapy problems (MTPs) and performed 14,092 interventions. Pharmacists most commonly worked with patients with diabetes, hypertension, pain, and hyperlipidemia. Physician and patient acceptance of the pharmacists' work was high. Pharmacists working in family medicine offices contribute to patient care through identification and resolution of MTPs and also by collaborating with PCMH teams.

Long-term impact of evidence-based quality improvement for facilitating medical home implementation on primary care health professional morale

BackgroundPoor morale among primary care providers (PCPs) and staff can undermine the success of patient-centered care models such as the patient-centered medical home that rely on highly coordinated inter-professional care teams. Medical home literature hypothesizes that participation in quality improvement can ease medical home transformation. No studies, however, have assessed the impact of quality improvement participation on morale (e.g., burnout or dissatisfaction) during transformation. The objective of this study is to examine whether primary care practices participating in evidence-based quality improvement (EBQI) during medical home transformation reduced burnout and increased satisfaction over time compared to non-participating practices.MethodsWe used a longitudinal quasi-experimental design to examine the impact of EBQI (vs. no EBQI), a multi-level, interdisciplinary approach for engaging frontline primary care practices in developing evidence-based improvement innovations and tools for spread on PCP and staff morale following the 2010 national implementation of the medical home model in the Veterans Health Administration. The sample included 356 primary care employees (107 primary care providers and 249 staff) from 23 primary care practices (6 intervention and 17 comparison) within one Veterans Health Administration region. Three intervention practices began EBQI in 2011 (early) and three more began EBQI in 2012 (late). Three waves of surveys were administered across 42 months beginning in November 2011 and ending in January 2016 approximately 2 years 18 months apart. We used repeated measures analysis of the survey data on medical home teams. Main outcome measures were the emotional exhaustion subscale from the Maslach Burnout Inventory, and job satisfaction.ResultsSix of 26 approved EBQI innovations directly addressed provider and staff morale; all 26 addressed medical home implementation challenges. Survey rates were 63% for baseline and 48% for both follow-up waves. Age was associated with lower burnout among PCPs (p = .039) and male PCPs had higher satisfaction (p = .037). Controlling for practice and PCP/staff characteristics, burnout increased by 5 points for PCPs in comparison practices (p = .024) and decreased by 1.4 points for early and 6.8 points (p = .039) for the late EBQI practices.ConclusionsEngaging PCPs and staff in EBQI reduced burnout over time during medical home transformation.

Care team perspectives on community pharmacy enhanced services

ObjectivesTo determine the awareness, collaboration, and perceived values and barriers of enhanced pharmacy services from care managers and primary care practice responders. MethodsAn electronic questionnaire was sent to 1648 primary care practices and 600 care managers that work in 76 North Carolina counties containing an enhanced-service community pharmacy. Questionnaires were distributed in January 2017 and responses collected for 7 weeks. The questionnaire collected data on the awareness and perceived value of enhanced pharmacy services, preferred method and level of communication for referral, and barriers to using enhanced services. Data were gathered with the use of Likert-type, rank-order, dichotomous, and multiple-choice questions. Data were analyzed with the use of descriptive statistics, and group mean responses were compared by means of t tests. ResultsData analysis was performed in March 2017. Response rates were 5.4% (n = 89) from practice responders and 45% (n = 270) from care managers. In the responses received, 35% of practice responders and 88% of care managers were familiar with enhanced services offered by community pharmacies. A majority of respondents thought that enhanced pharmacy services are valuable, with more than 85% of practice responders agreeing that partnering with an enhanced-service pharmacy can help to improve patient health outcomes. Lack of knowledge of enhanced-service pharmacies, services offered, and the referral process were identified as significant barriers for practice responders. ConclusionCommunity-based pharmacies have an opportunity to collaborate with patient-centered medical home teams to provide enhanced pharmacy services, but provider outreach and education on enhanced services offered and the referral process are necessary to maximize this collaboration.

The complexity, diversity, and science of primary care teams.

This article examines the past, present and future of primary care and teamwork. It begins with a definition and description of primary care-its uniqueness, diversity and complexity, including the historical role of teams within primary care. The article then reviews the emergence of innovative primary care teams, including those grounded in new processes such as the Patient-Centered Medical Home and interprofessional teams that include new types of health professionals, particularly psychologists and other integrated behavioral health clinicians. The article describes key factors that support or hinder primary care teamwork, as well as evidence of the impact of these team-based models on patient outcomes, costs, and team members. It also discusses the role of primary care teams within multiteam systems (or 'teams of teams'), which are organized around the needs of patients and families, and the unique challenges these systems pose to coordinating care. The article concludes with recommendations for advancing teams in primary care, including changes in payment, descriptions of team competencies, models for primary care team training, and research necessary to inform the gaps in scientific knowledge. (PsycINFO Database Record

Challenges with Implementing a Patient-Centered Medical Home Model for Women Veterans

BackgroundThe Veterans Health Administration (VA) Patient Aligned Care Team (PACT) initiative aims to ensure that all patients receive care consistent with medical home principles. Women veterans’ unique care needs and minority status within the VA pose challenges to delivery of equitable, comprehensive primary care for this population. Currently, little is known about whether and/or how PACT should be tailored to better meet women veterans' needs. MethodsIn 2014, we conducted semistructured interviews with 73 primary care providers and staff to examine facilitators and barriers encountered in providing PACT-principled care to women veterans. Respondents were located in eight VA medical centers in eight different states across the United States. ResultsRespondents perceived PACT as improving continuity of care for patients and as increasing ability of nursing staff to practice at the top of their license. However, the implementation of core medical home features and team huddles was inconsistent and varied both within and across medical centers. Short staffing, inclusion of part-time providers on teams, balancing performance requirements for continuity and same-day access, and space constraints were identified as ongoing barriers to PACT implementation. Challenges unique to care of women veterans included a higher prevalence of psychosocial needs, the need for specialized training of primary care personnel, and short staffing owing to additional sharing of primary care support staff with specialist providers. ConclusionProviders and staff face unique challenges in delivering comprehensive primary care to women veterans that may require special policy, practice, and management action if benefits of PACT are to be fully realized for this population.

Care coordination over time in medical homes for children with special health care needs.

To explore how care coordination changes conceptually and practically in primary care practices when implementing the medical home and to identify reasons for different types of changes. Six years after a 2003-2004 national learning collaborative to implement the medical home model for children with special health care needs, we examined care coordination in 12 pediatric practices with the highest postintervention Medical Home Index scores, indicating high level of adoption of the model. Data included interviews of 48 clinicians, care coordinators, and parents and medical record reviews of 60 patients with special health care needs receiving care in these practices. Initially, care coordination activities were prompted by patients' acute problems, and over time activities, tools, and policies were implemented to avert many such problems and expand the scope of services offered to patients. Example activities were making previsit calls with families, writing care plans, developing relationships with community agencies, and tracking referrals. Although some activities were common across practices, the persons involved and efforts toward different activities varied with practice context. Drivers included motivation and creativity of medical home teams, organizational changes, funding to expand care coordinator positions, protected time for such activities, and adoption of electronic record systems. In high-performing medical homes, care coordination activities changed from being mostly reactive to patients' episodic needs to being more systematically proactive and comprehensive. This shift was promoted by factors external and internal to the practice. Ensuring these factors in medical home implementation may accelerate adoption of proactive care coordination activities.

Rethinking primary care visits: how much can be eliminated, delegated or performed outside of the face-to-face visit?

Office visits represent the core component of primary care practice, but little is known about what percentage of primary care provider (PCP) visit time could be suitable for reassignment to another medical home team member or to a non-face-to-face modality (e.g. secure messaging) in order to optimize face-to-face PCP visit time. We videotaped 121 PCP office visits at four Veterans Health Administration Medical Centers and divided visits into discrete activity segments. Two physicians reviewed each visit recording and provided independent clinical judgments regarding which segments might be suitable for reassignment. We examined the activity category distribution of visit time rated as needing face-to-face time with a PCP. Reviewers judged 53% of the 5398 minutes of rated visit time as suitable for reassignment to another team member or modality. The percentage of time rated as needing face-to-face PCP care varied greatly by activity category, from a high of 73.9% (for examining patients) to a low of 16.2% (for medication review). Rater agreement regarding tasks' suitability for reassignment varied across activity categories. These data offer an example of how face-to-face PCP visit time might be optimized as practices seek to shift components of patient care to other team members and other modalities. Given variations in provider preferences and judgments, successful redesign efforts will need to involve stakeholders in decisions about how to best utilize medical home resources.

Recognizing the importance of the social determinates of health.

All adults once were children. Who we are, how we function, how we think and perform, and many other traits have their beginnings in our earliest years. Although the foundation of the United States is embedded in the concept of equality, it is certainly true that not all children have similar advantages as they move through their first several years of life. Many of the inequalities that affect health in general, and brain health in particular, may be evident to astute pediatricians and their medical home team partners while they are providing primary care visits with families. In their article, “Addressing Social Determinants of Health at Well-Child Care Visits: A Cluster RCT,” Garg, Toy, and colleagues address the utility of systematically screening for unmet basic needs at well-child visits and providing “simple” referrals and follow-up. They present their data from a … Address correspondence to Robert W. Block, MD, FAAP, 256 E 27th St, Tulsa, OK 74114. E-mail: rblock{at}aap.net