American academy of pediatrics

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AMERICAN ACADEMY OF PEDIATRICS

POLICY STATEMENT

Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children

Medical Home Initiatives for Children With Special Needs Project Advisory Committee

The Medical Home

ABSTRACT. The American Academy of Pediatrics proposed a definition of the medical home in a 1992 policy statement. Efforts to establish medical homes for all children have encountered many challenges, including the existence of multiple interpretations of the "medical home" concept and the lack of adequate reimbursement for services provided by physicians caring for children in a medical home. This new policy statement contains an expanded and more comprehensive interpretation of the concept and an operational definition of the medical home.

ABBREVIATION. AAP, American Academy of Pediatrics.

The American Academy of Pediatrics (AAP) believes that the medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family centered, coordinated,1 compassionate, and culturally effective.2 It should be delivered or directed by well-trained physicians who provide primary care3 and help to manage and facilitate essentially all aspects of pediatric care. The physician should be known to the child and family and should be able to develop a partnership of mutual responsibility and trust with them. These characteristics define the "medical home." In contrast to care provided in a medical home, care provided through emergency departments, walk-in clinics, and other urgent-care facilities, though sometimes necessary, is more costly and often less effective. Although inadequate reimbursement for services offered in the medical home remains a very significant barrier to full implementation of this concept,4,5 reimbursement is not the subject of this statement. It deserves coverage in other AAP forums.

Physicians should seek to improve the effectiveness and efficiency of health care for all children and strive to attain a medical home for every child in their community.6 Although barriers such as geography, personnel constraints, practice patterns, and economic and social forces create challenges, the AAP believes that comprehensive health care for infants, children, and adolescents should encompass the following services:

PEDIATRICS (ISSN 0031 4005). Copyright ? 2002 by the American Academy of Pediatrics.

1. Provision of family-centered care through developing a trusting partnership with families, respecting their diversity, and recognizing that they are the constant in a child's life.

2. Sharing clear and unbiased information with the family about the child's medical care and management and about the specialty and community services and organizations they can access.

3. Provision of primary care, including but not restricted to acute and chronic care and preventive services, including breastfeeding promotion and management,7 immunizations, growth and developmental assessments, appropriate screenings, health care supervision, and patient and parent counseling about health, nutrition, safety, parenting, and psychosocial issues.

4. Assurance that ambulatory and inpatient care for acute illnesses will be continuously available (24 hours a day, 7 days a week, 52 weeks a year).

5. Provision of care over an extended period of time to ensure continuity. Transitions, including those to other pediatric providers or into the adult health care system, should be planned and organized with the child and family.

6. Identification of the need for consultation and appropriate referral to pediatric medical subspecialists and surgical specialists. (In instances in which the child enters the medical system through a specialty clinic, identification of the need for primary pediatric consultation and referral is appropriate.) Primary, pediatric medical subspecialty, and surgical specialty care providers should collaborate to establish shared management plans in partnership with the child and family and to formulate a clear articulation of each other's role.

7. Interaction with early intervention programs, schools, early childhood education and child care programs, and other public and private community agencies to be certain that the special needs of the child and family are addressed.

8. Provision of care coordination services in which the family, the physician, and other service providers work to implement a specific care plan as an organized team.

9. Maintenance of an accessible, comprehensive, central record that contains all pertinent information about the child, preserving confidentiality.

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TABLE 1. Desirable Characteristics of a Medical Home

Accessible Care is provided in the child's or youth's community. All insurance, including Medicaid, is accepted. Changes in insurance are accommodated. Practice is accessible by public transportation, where available. Families or youth are able to speak directly to the physician when needed. The practice is physically accessible and meets Americans With Disabilities Act10 requirements.

Family centered The medical home physician is known to the child or youth and family. Mutual responsibility and trust exists between the patient and family and the medical home physician. The family is recognized as the principal caregiver and center of strength and support for child. Clear, unbiased, and complete information and options are shared on an ongoing basis with the family. Families and youth are supported to play a central role in care coordination. Families, youth, and physicians share responsibility in decision making. The family is recognized as the expert in their child's care, and youth are recognized as the experts in their own care.

Continuous The same primary pediatric health care professionals are available from infancy through adolescence and young adulthood. Assistance with transitions, in the form of developmentally appropriate health assessments and counseling, is available to the child or youth and family. The medical home physician participates to the fullest extent allowed in care and discharge planning when the child is hospitalized or care is provided at another facility or by another provider.

Comprehensive Care is delivered or directed by a well-trained physician who is able to manage and facilitate essentially all aspects of care. Ambulatory and inpatient care for ongoing and acute illnesses is ensured, 24 hours a day, 7 days a week, 52 weeks a year. Preventive care is provided that includes immunizations, growth and development assessments, appropriate screenings, health care supervision, and patient and parent counseling about health, safety, nutrition, parenting, and psychosocial issues. Preventive, primary, and tertiary care needs are addressed. The physician advocates for the child, youth, and family in obtaining comprehensive care and shares responsibility for the care that is provided. The child's or youth's and family's medical, educational, developmental, psychosocial, and other service needs are identified and addressed. Information is made available about private insurance and public resources, including Supplemental Security Income, Medicaid, the State Children's Health Insurance Program, waivers, early intervention programs, and Title V State Programs for Children With Special Health Care Needs. Extra time for an office visit is scheduled for children with special health care needs, when indicated.

Coordinated A plan of care is developed by the physician, child or youth, and family and is shared with other providers, agencies, and organizations involved with the care of the patient. Care among multiple providers is coordinated through the medical home. A central record or database containing all pertinent medical information, including hospitalizations and specialty care, is maintained at the practice. The record is accessible, but confidentiality is preserved. The medical home physician shares information among the child or youth, family, and consultant and provides specific reason for referral to appropriate pediatric medical subspecialists, surgical specialists, and mental health/developmental professionals. Families are linked to family support groups, parent-to-parent groups, and other family resources. When a child or youth is referred for a consultation or additional care, the medical home physician assists the child, youth, and family in communicating clinical issues. The medical home physician evaluates and interprets the consultant's recommendations for the child or youth and family and, in consultation with them and subspecialists, implements recommendations that are indicated and appropriate. The plan of care is coordinated with educational and other community organizations to ensure that special health needs of the individual child are addressed.

Compassionate Concern for the well-being of the child or youth and family is expressed and demonstrated in verbal and nonverbal interactions. Efforts are made to understand and empathize with the feelings and perspectives of the family as well as the child or youth.

Culturally effective The child's or youth's and family's cultural background, including beliefs, rituals, and customs, are recognized, valued, respected, and incorporated into the care plan. All efforts are made to ensure that the child or youth and family understand the results of the medical encounter and the care plan, including the provision of (para)professional translators or interpreters, as needed. Written materials are provided in the family's primary language.

Physicians should strive to provide these services and incorporate these values into the way they deliver care to all children. (Note: pediatricians, pediatric medical subspecialists, pediatric surgical specialists, and family practitioners are included in the definition of "physician.")

10. Provision of developmentally appropriate and culturally competent health assessments and counseling to ensure successful transition to adult-oriented health care, work, and independence in a deliberate, coordinated way.

Medical care may be provided in various locations, such as physicians' offices, hospital outpatient clinics, school-based and school-linked clinics, community health centers, and health department clinics.

Regardless of the venue in which the medical care is provided, to meet the definition of medical home, a designated physician must ensure that the aforementioned services are provided (see Table 1 for more details).

The need for an ongoing source of health care-- ideally a medical home--for all children has been identified as a priority for child health policy reform at the national and local level. The US Department of

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Health and Human Services' Healthy People 2010 goals and objectives state that "all children with special health care needs will receive regular ongoing comprehensive care within a medical home"8 and multiple federal programs require that all children have access to an ongoing source of health care. In addition, the Future of Pediatric Education II goals and objectives state: "Pediatric medical education at all levels must be based on the health needs of children in the context of the family and community" and "all children should receive primary care services through a consistent `medical home.' "9 Over the next decade, with the collaboration of families, insurers, employers, government, medical educators, and other components of the health care system, the quality of life can be improved for all children through the care provided in a medical home.

Medical Home Initiatives for Children With Special Needs Project Advisory Committee, 2000 ?2001

Calvin J. Sia, MD, Chairperson Richard Antonelli, MD Vidya Bhushan Gupta, MD Gilbert Buchanan, MD David Hirsch, MD John Nackashi, MD Jill Rinehart, MD

Consultants Antoinnette Parisi Eaton, MD Merle McPherson, MD, MPH Maureen Mitchell Bonnie Strickland, PhD Trish Thomas

Staff Thomas F. Tonniges, MD

REFERENCES

1. American Academy of Pediatrics, Committee on Children With Disabilities. Care coordination: integrating health and related systems of care for children with special health care needs. Pediatrics. 1999;104:978 ?981

2. American Academy of Pediatrics, Committee on Pediatric Workforce. Culturally effective pediatric care: education and training issues. Pediatrics. 1999;103:167?170

3. American Academy of Pediatrics, Committee on Pediatric Workforce. Pediatric primary health care. AAP News. November 1993;11:7. Reaffirmed June 2001

4. American Academy of Pediatrics, Committee on Child Health Financing. Guiding principles for managed care arrangements for the health care of newborns, infants, children, adolescents, and young adults. Pediatrics. 2000;105:132?135

5. American Academy of Pediatrics, Committee on Children With Disabilities. Managed care and children with special health care needs: a subject review. Pediatrics. 1998;102:657? 660

6. American Academy of Pediatrics, Committee on Community Health Services. The pediatrician's role in community pediatrics. Pediatrics. 1999;103:1304 ?1306

7. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 1997;100:1035?1039

8. US Department of Health and Human Services, Health Resources and Services Administration. Measuring Success for Healthy People 2010: National Agenda for Children with Special Health Care Needs. Washington, DC: US Department of Health and Human Services; 1999. http:// mchb.hrsa. gov/html/achievingmeasuringsuccess. html. Accessed September 19, 2001

9. American Academy of Pediatrics, Task Force on the Future of Pediatric Education. The Future of Pediatric Education II. Organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. Pediatrics. 2000;105:157?212

10. Americans With Disabilities Act. Pub L No. 101?336 (1990)

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

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The Medical Home Medical Home Initiatives for Children With Special Needs Project Advisory

Committee Pediatrics 2002;110;184 DOI: 10.1542/peds.110.1.184

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The Medical Home Medical Home Initiatives for Children With Special Needs Project Advisory

Committee Pediatrics 2002;110;184 DOI: 10.1542/peds.110.1.184

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ? 2002 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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