Abstract
Objective
To examine primary care pediatricians' (PCPs) beliefs about whether the family-centered
medical home (FCMH) should be in primary or subspecialty care for children with different
degrees of complexity; and to examine practice characteristics associated with these
beliefs.
Methods
Data from the American Academy of Pediatrics Periodic Survey (PS 79) conducted in
2012 were analyzed. Outcomes were agreement/strong agreement that 1) primary care
should be the FCMH locus for most children with special health care needs (CSHCN)
and 2) subspecialty care is the best FCMH locus for children with rare or complex
conditions. In multivariate models, we tested associations between outcomes and practice
barriers (eg, work culture, time, cost) and facilitators (eg, having a care coordinator)
to FCMH implementation.
Results
Among 572 PCPs, 65% agreed/strongly agreed primary care is the best FCMH setting for
most CSHCN, and 43% agreed/strongly agreed subspecialty care is the best setting for
children with complexity. Cost and time as barriers to FCMH implementation were oppositely
associated with the belief that primary care was best for most CSHCN (cost: adjusted
odds ratio [AOR] 2.31, 1.36–3.90; time: AOR 0.48, 0.29–0.81). Lack of skills to communicate
and coordinate care was associated with the belief that specialty care was the best
FCMH for children with complexity (AOR 1.99, 1.05–3.79).
Conclusions
A substantial minority endorsed specialty care as the best FCMH locus for children
with medical complexity. Several barriers were associated with believing primary care
to be the best FCMH for most CSHCN. Addressing medical complexity in FCMH implementation
may enhance perceived value by pediatricians.
Keywords
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References
- The medical home.Pediatrics. 2002; 110: 184-186
- A review of the evidence for the medical home for children with special health care needs.Pediatrics. 2008; 122: e922-e937
- Effect of an enhanced medical home on serious illness and cost of care among high-risk children with chronic illness: a randomized clinical trial.JAMA. 2015; 77030: 2640-2648
American Academy of Pediatrics. AAP agenda for children—strategic plan. Available at: https://www.aap.org/en-us/about-the-aap/aap-facts/AAP-Agenda-for-Children-Strategic-Plan/Pages/AAP-Agenda-for-Children-Strategic-Plan.aspx. Accessed July 31, 2015.
- How the Affordable Care Act will strengthen the nation's primary care foundation.J Gen Intern Med. 2011; 26: 1201-1203
- About half of the states are implementing patient-centered medical homes for their Medicaid populations.Health Aff. 2012; 31: 2432-2440
- Contrasting trajectories of change in primary care clinics: lessons from New Orleans safety net.Ann Fam Med. 2013; 11: S60-S67
- Readiness of primary care practices for medical home certification.Pediatrics. 2013; 131: 473-482
- Children with medical complexity: an emerging population for clinical and research initiatives.Pediatrics. 2011; 127: 529-538
- The rise in chronic conditions among infants, children, and youth can be met with continued health system innovations.Health Aff (Millwood). 2014; 33: 2099-2105
- Hospital-based comprehensive care programs for children with special health care needs: a systematic review.Arch Pediatr Adolesc Med. 2011; 165: 554-561
- Physician practices and readiness for medical home reforms: policy, pitfalls, and possibilities.Health Serv Res. 2012; 47: 486-508
- Implementation of the patient-centered medical home in the Veterans Health Administration.JAMA Intern Med. 2014; 98108: 1350-1358
- Medical home transformation in pediatric primary care—what drives change?.Ann Fam Med. 2013; 11: S90-S98
- Comfort of general internists and general pediatricians in providing care for young adults with chronic illnesses of childhood.J Gen Intern Med. 2008; 23: 1621-1627
- Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey.Ambul Pediatr. 2008; 8: 11-17
- General pediatricians, pediatric subspecialists, and pediatric primary care.Arch Pediatr Adolesc Med. 1998; 152: 768-773
- Hospital-based programs for children with special health care needs: implications for health reform.JAMA Pediatr. 2011; 165: 570-571
- Toward increased adoption of complex care management.N Engl J Med. 2014; 371: 491-493
- A tertiary care–primary care partnership model for medically complex and fragile children and youth with special health care needs.Arch Pediatr Adolesc Med. 2007; 161: 937-944
- The Harvard Medical School academic innovations collaborative: transforming primary care practice and education.Acad Med. 2014; 89: 1239-1244
- VA experience in implementing patient-centered medical home using a breakthrough series collaborative.J Gen Intern Med. 2014; 29: S563-S571
- Optimizing high-risk care management.JAMA. 2015; 313: 795
- Effects of a medical home and shared savings intervention on quality and utilization of care.JAMA Intern Med. 2015; 175: 1362-1368
- Structuring payment for medical homes.Health Aff (Millwood). 2010; 29: 852-858
- US approaches to physician payment: the deconstruction of primary care.J Gen Intern Med. 2010; 25: 613-618
- Improving Patient Safety With Effective Teamwork and Communication: Literature Review Needs Assessment, Evaluation of Training Tools, and Expert Consultations.Canadian Patient Safety Institute, Edmonton, AB2011
- Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home.Ann Fam Med. 2009; 7: 254-260
- Determinants and impact of generalist–specialist communication about pediatric outpatient referrals.Pediatrics. 2006; 118: 1341-1349
- The “medical neighborhood”: integrating primary and specialty care for ambulatory patients.JAMA Intern Med. 2014; 174: 454-457
- An approach to family-centered coordinated co-management for individuals with conditions identified through newborn screening.Genet Med. 2013; 15: 174-177
- A typology of specialists' clinical roles.Arch Intern Med. 2009; 169: 1062-1068
Article Info
Publication History
Published online: October 30, 2015
Accepted:
October 26,
2015
Received:
August 25,
2015
Footnotes
The authors declare that they have no conflict of interest.
Identification
Copyright
© 2015 Academic Pediatric Association.
