Relationship-focused vs. Structural Activities in Medical Home Measurement in Pediatrics.

Objectives The Family-Centered Medical Home (FCMH) has become a model of effective and efficient primary care. However, efforts to measure the FCMH may ignore its complexity. We sought to determine whether U.S. primary care pediatricians view structure-focused and relationship-focused practice activities of the FCMH as distinct constructs and how these constructs are associated with practice functions. Methods We analyzed data from the 2012 American Academy of Pediatrics Periodic Survey of Fellows #79 (n = 572) addressing opinions and practice activities related to the FCMH. Through a modified Delphi expert process, we selected items believed to be primarily structure-focused and items that were relationship-focused. Confirmatory factor analysis was used to test whether these constructs were distinct. Separate structural equation models assessed whether structure-focused and relationship-focused activities predicted three broader survey items: (1) interest in FCMH; (2) application for FCMH recognition; and (3) whether a team meets to discuss FCMH improvements. Results The initial two-factor model did not fit well, but improved with movement of two items from the structure to the relationship-focused group. The two factors correlated at r = 0.70. Respondents with increased relationship-focused activities had statistically higher odds of having medium/high interest in FCMH, and having a team meet to discuss FCMH improvements. Respondents with increased structure-focused activities also had higher odds of having team meetings to discuss FCMH improvements, but lower odds of applying for FCMH recognition. Conclusions for Practice The FCMH is multi-dimensional, with relationship- and structure-focused activities differentially linked to pediatrician reports of broader FCMH functions.

Pediatric Medical Subspecialist Use in Outpatient Settings.

Importance: A first step toward understanding whether pediatric medical subspecialists are meeting the needs of the nation's children is describing rates of use and trends over time. Objectives: To quantify rates of outpatient pediatric medical subspecialty use. Design, Setting, and Participants: This repeated cross-sectional study of annual subspecialist use examined 3 complementary data sources: electronic health records from PEDSnet (8 large academic medical centers [January 1, 2010, to December 31, 2021]); administrative data from the Healthcare Integrated Research Database (HIRD) (14 commercial health plans [January 1, 2011, to December 31, 2021]); and administrative data from the Transformed Medicaid Statistical Information System (T-MSIS) (44 state Medicaid programs [January 1, 2016, to December 31, 2019]). Annual denominators included 493 628 to 858 551 patients younger than 21 years with a general pediatric visit in PEDSnet; 5 million beneficiaries younger than 21 years enrolled for at least 6 months in HIRD; and 35 million Medicaid or Children's Health Insurance Program beneficiaries younger than 19 years enrolled for any amount of time in T-MSIS. Exposure: Calendar year and type of medical subspecialty. Main Outcomes and Measures: Annual number of children with at least 1 completed visit to any pediatric medical subspecialist in an outpatient setting per population. Use rates excluded visits in emergency department or inpatient settings. Results: Among the study population, the proportion of girls was 51.0% for PEDSnet, 51.1% for HIRD, and 49.3% for T-MSIS; the proportion of boys was 49.0% for PEDSnet, 48.9% for HIRD, and 50.7% for T-MSIS. The proportion of visits among children younger than 5 years was 37.4% for PEDSnet, 20.9% for HIRD, and 26.2% for T-MSIS; most patients were non-Hispanic Black (29.7% for PEDSnet and 26.1% for T-MSIS) or non-Hispanic White (44.9% for PEDSnet and 43.2% for T-MSIS). Annual rates for PEDSnet ranged from 18.0% to 21.3%, which were higher than rates for HIRD (range, 7.9%-10.4%) and T-MSIS (range, 7.6%-8.6%). Subspecialist use increased in the HIRD commercial health plans (annual relative increase of 2.4% [95% CI, 1.6%-3.1%]), but rates were essentially flat in the other data sources (PEDSnet, -0.2% [95% CI, -1.1% to 0.7%]; T-MSIS, -0.7% [95% CI, -6.5% to 5.5%]). The flat PEDSnet growth reflects a balance between annual use increases among those with commercial insurance (1.2% [95% CI, 0.3%-2.1%]) and decreases in use among those with Medicaid (-0.9% [95% CI, -1.6% to -0.2%]). Conclusions and Relevance: The findings of this cross-sectional study suggest that among children, 8.6% of Medicaid beneficiaries, 10.4% of those with commercial insurance, and 21.3% of those whose primary care is received in academic health systems use pediatric medical subspecialty care each year. There was a small increase in rates of subspecialty use among children with commercial but not Medicaid insurance. These data may help launch innovations in the primary-specialty care interface.

National Research Agenda on Health Systems for Children and Youth With Special Health Care Needs.

Children and youth with special health care needs (CYSHCN) "have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions and also require health and related services of a type or amount beyond that required by children generally." CYSHCN rely on health systems, which extend beyond traditional health care entities, to optimize their health and well-being. The current US health system is not fully equipped and functioning to meet the needs of CYSHCN. Recognizing this, the Maternal and Child Health Bureau and the US Health Resources and Services Administration established the Research Network on Health Systems for CYSHCN (CYSHCNet, http://www.cyshcnet.org). With input from >800 US stakeholders, CYSHCNet developed a national research agenda on health systems for CYSHCN designed to: 1) highlight important health system challenges faced by key stakeholders (ie, patients and families, health care providers, insurers, administrators, etc.); 2) organize research topics and goals to identify opportunities for improvement, to address challenges and to promote progress toward the ideal health system; and 3) provide a blueprint for health systems research ideas and studies that will guide CYSHCN investigators and other stakeholders going forward. We introduce the 6 research topics currently included in the research agenda-transition to adulthood, caregiving, family health, child health care, principles of care, and financing-to inform and guide investigators as they embark on a trajectory of health systems research on CYSHCN.

Moving From Spending to Investment: A Research Agenda for Improving Health Care Financing for Children and Youth With Special Health Care Needs.

Children and youth with special health care needs (CYSHCN) use disproportionately more health care resources than non-CYSHCN, and their unique needs merit additional consideration. Spending on health care in the United States is heavily concentrated on acute illnesses through fee-for-service (FFS). Payment reform frameworks have focused on shifting away from FFS, addressing health outcomes and the experience of care while lowering costs, particularly for high resource utilizers. The focus of payment reform efforts to date has been on adults with chronic illnesses, with less priority given to investment in children's health and life course. Spending for children's health is also considered an investment in their growth and development with long-term outcomes at stake, so research questions should focus on where and how such spending should be targeted. This paper discusses high-priority research topics in the area of health care financing for CYSHCN in the context of what is currently known and important knowledge gaps related to investment for CYSHCN. It proceeds to describe 3 potential research projects that can address these topics, following a framework informed by the priority questions identified in a previous multistakeholder research agenda development process. We focus on 3 areas: benefits, payment models, and quality measures. Specific aims and hypotheses are offered, as well as suggestions for approaches and thoughts on potential implications.

Health System Research Priorities for Children and Youth With Special Health Care Needs.

OBJECTIVES: In this study, we sought to establish priorities for a national research agenda for children and youth with special health care needs (CYSHCN) through a structured, multistakeholder, mixed-methods approach. METHODS: Using surveys, we solicited responses from >800 members of expert-nominated stakeholder organizations, including CYSHCN families, health care providers, researchers, and policymakers, to identify what research with or about CYSHCN they would like to see in a national research agenda. From 2835 individual free-text responses, 96 research topics were synthesized and combined. Using an adapted RAND/UCLA Appropriateness Method (a modified Delphi approach), an expert panel rated research topics across 3 domains: need and urgency, research impact, and family centeredness. Domains were rated on 9-point Likert scales. Panelist ratings were used to sort research topics into 4 relative-priority ranks. Rank 1 (highest priority) research topics had a median of ≥7 in all domains. RESULTS: The RAND/UCLA Appropriateness Method was used to prioritize CYSHCN research topics and depict their varying levels of stakeholder-perceived need and urgency, research impact, and family centeredness. In the 15 topics that achieved rank 1, social determinants of health (disparities and rurality), caregiving (family resilience and care at home), clinical-model refinement (effective model elements, labor divisions, telemedicine, and system integration), value (stakeholder-centered value outcomes, return on investment, and alternative payment models), and youth-adult transitions (planning, insurance, and community supports) were emphasized. CONCLUSIONS: High-priority research topics identified by CYSHCN experts and family leaders underscore CYSHCN research trends and guide important directions. This study is the first step toward an efficient and cohesive research blueprint to achieve highly-effective CYSHCN health systems.

Building communication between professionals at children's specialty hospitals and the medical home.

OBJECTIVE: Build a quality improvement (QI) intervention to improve communication between a children's specialty hospital and referring primary care providers (PCPs). METHODS: A network of charitable children's hospitals identified improving communication as a systemwide goal. At one model hospital, we used qualitative telephone interviewing of hospital specialists and staff, and referring PCPs, to characterize the communication system and identify potential improvements. We identified potential high-impact areas through content analysis and developed a QI change package with hospital leadership. RESULTS: Participants described inconsistent communication, with no systematic identification of PCPs. Families were the typical means of inter-physician communication. Multiple non-PCP referral sources were a major contributor to communication breakdowns. Respondents identified a system for identification and communication with PCPs as an essential first step. CONCLUSIONS: Systems for communication with PCPs are underdeveloped at a children's charitable specialty hospital. Straightforward changes could build an effective system that is generalizable to other hospitals.

Physician responses to a community-level trial promoting judicious antibiotic use.

PURPOSE: In an environment of multiple campaigns promoting judicious antibiotic use in children, identification of effective strategies is important. We assessed physician responses to a community-level intervention with respect to antibiotic prescribing, related practices, and perceived effectiveness. METHODS: This study was a mixed qualitative and quantitative evaluation of a randomized controlled community-wide educational intervention in 16 Massachusetts communities. Physicians in intervention communities received locally endorsed guidelines, group educational sessions, and biweekly newsletters. Parents simultaneously received materials in physicians' offices and by mail. After the intervention, we conducted a mailed physician survey and individual interviews to assess the impact of the intervention. We compared survey responses for intervention and control physicians, and we analyzed interview transcripts to provide in-depth information about selected topics. RESULTS: Among survey respondents (n = 168), 91% of intervention and 4% of control physicians reported receiving intervention materials. Physicians received information from multiple other sources. More intervention than control physicians reported decreased antibiotic prescribing from 2000-2003 (75% vs 58%, P = .03), but there were no differences between groups in knowledge, attitudes, or behaviors favoring judicious antibiotic use. Both groups were concerned about antibiotic resistance and reported room to reduce their own prescribing. Interviewed physicians suggested frequent repetition of messages, brief written materials on specific topics for themselves and patients, and promotion in the mass media as the most effective strategies to reduce prescribing. CONCLUSIONS: In multiple communities an intervention in physician offices to promote judicious antibiotic prescribing reached its intended audience, but physicians' self-reported attitudes and practices were similar in intervention and control communities. Campaigns that repeat brief, consistent reminders to multiple stakeholder groups may be most effective at assuring judicious antibiotic use.

Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?

Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models.

Health-care spending and utilization for children discharged from a neonatal intensive care unit.

OBJECTIVES: To describe health-care spending and utilization for infants discharged from the neonatal intensive care unit (NICU). STUDY DESIGN: Retrospective cohort analysis of 4973 NICU graduates in the Truven MarketScan Medicaid database, with follow-up to the third birthday. Health-care spending and utilization after NICU discharge were assessed. Using logistic regression, we assessed clinical characteristics associated with hospitalization and emergency department (ED) visits. RESULTS: Most (69.5%) post-NICU spending occurred within the first year [$33,276 per member per year]. Inpatient care accounted for most (71.6%) of the 3-year spending. The percentages of infants with a 1-year readmission or ED visit were 36.8% and 63.7%, respectively. Medical technology was associated with the highest likelihoods of hospital [aOR 17.8 (95%CI 12.2-26.0)] and ED use [aOR 2.3 (95%CI 1.8-3.0)]. CONCLUSIONS: Hospital care accounts for the majority of spending for NICU graduates. Infants with medical technology have the highest risk of hospital and ED use.

Care System Redesign for Preterm Children After Discharge From the NICU.

Approximately 1 in 8 children in the United States are born preterm. Existing guidelines and research examine the cost of prematurity from the NICU stay and developmental surveillance and outcomes after discharge from the NICU. Preterm children are at greater risk for excess hospitalizations, outpatient visits, and societal costs after NICU discharge. Improved delivery of care and health promotion from the community setting, particularly from the patient-centered medical home, may result in improved growth, health, and development, with accompanying reduction of post-NICU discharge costs and encounters. There has been comparatively little focus on how to promote health and wellness for children born preterm, particularly for community-based providers and payers. Accordingly, health care delivery for NICU graduates is often fragmented, with little guidance on medical management beyond tertiary care follow-up. In this article, we use what is known about chronic care and practice transformation models to present a framework for health care system redesign for children born preterm. We discuss the rationale for NICU graduates as a priority population for health system redesign. Promotion of health and wellness for children born preterm who are discharged to the community setting entails population health management from the patient-centered medical home; comanagement, clinical care protocols, and clinical support from the tertiary care-based tertiary care-based center; and a favorable payer strategy that emphasizes support for chronic care management. Practical suggestions are provided for the practicing physician for the child born preterm as health care systems are redesigned.

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

Coordinated care is a defining principle of primary care, but it is becoming increasingly difficult to provide as the health care delivery system in the United States becomes more complex. To guide recommendations for research and practice, the evidence about implementation of coordinated care and its benefits must be considered. On the basis of review of the published literature this article makes recommendations concerning needs for a better-developed evidence base to substantiate the value of care coordination, generalist practices to be the hub of care coordination for most patients, improved communication among clinicians, a team approach to achieve coordination, integration of patients and families as partners, and incorporation of medical informatics. Although coordination of care is central to generalist practice, it requires far more effort than physicians alone can deliver. To make policy recommendations, further work is needed to identify essential elements of care coordination and prove its effectiveness at improving health outcomes.

Targeted child psychiatric services: a new model of pediatric primary clinician--child psychiatry collaborative care.

Between 15% and 25% of children and adolescents seen in pediatric primary care have a behavioral health disorder with significant psychopathology, high functional impairment, and frequent psychiatric diagnostic comorbidity. Because child psychiatry services are frequently unavailable, primary care clinicians are frequently left managing these children without access to child psychiatry consultation. We describe Targeted Child Psychiatric Services (TCPS), a new model of pediatric primary clinician-child psychiatry collaborative care, and describe program utilization and characteristics of children referred over the first 18 months of the program using a retrospective chart review. The TCPS model can serve a large number of pediatric primary care practices and provide collaborative help with the evaluation and treatment of complex attention deficit hyperactivity disorder, depression, anxiety disorders, and pediatric psychopharmacology.

Barriers to Care Coordination and Medical Home Implementation.

BACKGROUND: Pediatricians are central in leading the family-centered medical home (FCMH), yet little is known about how provider-perceived barriers to and attitudes toward the FCMH affect implementation. This study aims to assess the relationship between pediatrician-perceived barriers to and attitudes toward FCMH and reported care coordination. METHODS: Pediatricians working in ambulatory care responded to the American Academy of Pediatrics Periodic Survey of Fellows #79 (N = 572, response rate, 59%). Our primary care coordination outcomes were whether pediatricians were: (1) leading a multidisciplinary team; (2) developing care plans; and (3) connecting with support services. Independent variables included barriers to FCMH implementation (lack of communication skills, support services, and time). Associations between outcomes and barriers were assessed by multivariate logistic regression, controlling for pediatrician and practice characteristics. RESULTS: Lack of sufficient personnel was significantly associated with fewer care coordination activities: leading a multidisciplinary team (odds ratio [OR], 0.53), developing care plans (OR, 0.51), and connecting with support services (OR, 0.42). Lacking communication skills was significantly associated with lower odds of development of care plans (OR, 0.56) and assistance with support services (OR, 0.64). Lack of time was significantly associated with lower odds of leading a multidisciplinary team (OR, 0.53). A pediatrician's belief that the FCMH encourages the use of preventive services was significantly associated with increased support services (OR, 2.06). CONCLUSIONS: Pediatricians report a need for sufficient personnel and communication skills to provide care coordination, a core component of the FCMH. Interventions to boost FCMH implementation should focus on providing resources to develop these characteristics.

Adapting practice-based intervention research to electronic environments: opportunities and complexities at two institutions.

BACKGROUND AND PURPOSE: Primary care practice-based research has become more complex with increased use of electronic health records (EHRs). Little has been reported about changes in study planning and execution that are required as practices change from paper-based to electronic-based environments. We describe the evolution of a pediatric practice-based intervention study as it was adapted for use in the electronic environment, to enable other practice-based researchers to plan efficient, effective studies. METHODS: We adapted a paper-based pediatric office-level intervention to enhance parent-provider communication about subspecialty referrals for use in two practice-based research networks (PBRNs) with partially and fully electronic environments. We documented the process of adaptation and its effect on study feasibility and efficiency, resource use, and administrative and regulatory complexities, as the study was implemented in the two networks. RESULTS: Considerable time and money was required to adapt the paper-based study to the electronic environment, requiring extra meetings with institutional EHR-, regulatory-, and administrative teams, and increased practice training. Institutional unfamiliarity with using EHRs in practice-based research, and the consequent need to develop new policies, were major contributors to delays. Adapting intervention tools to the EHR and minimizing practice disruptions was challenging, but resulted in several efficiencies as compared with a paper-based project. In particular, recruitment and tracking of subjects and data collection were easier and more efficient. CONCLUSIONS: Practice-based intervention research in an electronic environment adds considerable cost and time at the outset of a study, especially for centers unfamiliar with such research. Efficiencies generated have the potential of easing the work of study enrollment, subject tracking, and data collection.

The medical home and integrated behavioral health: advancing the policy agenda.

There has been a considerable expansion of the patient-centered medical home model of primary care delivery, in an effort to reduce health care costs and to improve patient experience and population health. To attain these goals, it is essential to integrate behavioral health services into the patient-centered medical home, because behavioral health problems often first present in the primary care setting, and they significantly affect physical health. At the 2013 Patient-Centered Medical Home Research Conference, an expert workgroup convened to determine policy recommendations to promote the integration of primary care and behavioral health. In this article we present these recommendations: Build demonstration projects to test existing approaches of integration, develop interdisciplinary training programs to support members of the integrated care team, implement population-based strategies to improve behavioral health, eliminate behavioral health carve-outs and test innovative payment models, and develop population-based measures to evaluate integration.

Summary of STARNet: Seamless Transitions and (Re)admissions Network.

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Generalist-subspecialist communication about children with chronic conditions: an analysis of physician focus groups.

OBJECTIVE: To describe barriers and facilitators to effective generalist-subspecialist communication in the care of children with chronic conditions. METHODS: We conducted 5 focus groups with 14 general pediatricians and 10 pediatric specialty providers to discuss factors that facilitate or obstruct effective communication. The specialty groups included 2 nurse practitioners; the rest were pediatricians from an academic medical center and the surrounding community. We performed a content analysis to generate groups of themes and classify them as barriers or facilitators, and we returned to the participants to solicit their feedback. RESULTS: We identified 201 themes in 6 domains: the method, content, and timing of communication; system factors; provider education; and interpersonal issues. Barriers to communication mostly involved the method of communication and system factors. Most facilitating themes promoted timely communication, understanding of the reasons for referral and the nature of the child's condition, or appropriate definition of generalist and specialist roles. Participants described numerous examples where communication had direct effects on patient outcomes. Generalists and specialists agreed on many issues, although specialists discussed the pros and cons of curbside consults at length whereas generalists emphasized the importance of their own education in the referral-consultation process. CONCLUSIONS: Efforts to improve communication between pediatric generalists and specialists in the care of children with chronic conditions should emphasize the importance of timely information transfer. The content of messages is important, but lack of receipt when needed is more of a problem. Improving generalist-subspecialist communication has great potential to improve the quality of care.