The Medical Home

In this issue are four articles that relate to medical homes (MHs) in pediatric practices. One article is by Zeina Samaan and colleagues from the Cincinnati Children's Hospital. In this article, the authors study the impact of implementing electronic health records in an academic pediatric primary care center. Another article is by Jeanne McAllister and her colleagues from the Center for Medical Home Improvement, Crotched Mountain Foundation, Concord, New Hampshire. This article demonstrates the use of the Medical Home Index and the Medical Home Family Index and Survey to track improvements in practices engaged in the MH learning collaborative. The third and fourth articles are by Tracy Fitzgibbon and colleagues from Regence Blue Shield health plan and Seattle Children's. These articles demonstrate the different and complementary components of case management and care coordination that are performed by case managers at the plan level compared with practitioners at the practice level.

All four of these articles represent translational research that provides additional information toward the goal of fully implementing the MH concept. The MH concept originally was developed through the work of the American Academy of Pediatrics with a focus on children with special healthcare needs (Sia et al., 2004). This concept has been embraced by the American Academy of Pediatrics as a practice paradigm for all children in pediatric practices. In addition, almost all primary care disciplines for adults and children have embraced the MH concept as integral to good patient care.

Currently, the economic incentives in the healthcare system in the United States do not favor the implementation of MH for patients with special needs or those with any kind of complex chronic conditions. Primary care services are generally poorly reimbursed by Medicaid through the fee-for-service system. To ensure adequate revenues to support most private primary care offices, the practices need to maintain high patient volumes and large patient panels. This kind of reimbursement system works against the principles of MH, which require time spent with the patient and the family. The MH principles are broadly defined as primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. These attributes are difficult to attain when primary care practices include individuals who have chronic conditions, and this becomes more difficult as the medical and social complexities of the patient and family increase. Patients with chronic conditions are the most costly in the United States healthcare system, and their care gravitates toward the most costly elements of our healthcare system, emergency departments, hospitals, and specialty care.

The challenges to fully implementing MH are considerable. In a recent review article on the evidence for MH for children with special healthcare needs (Homer et al, 2008), data supported the benefits of MH in adults and in children with asthma and diabetes, but much more collaborative work on children with many different kinds of chronic conditions should be encouraged and supported. If this is not done, the value of MH may be measured only in the high-volume, high-cost adult conditions that occur primarily in the aging population or only in younger patients with high-volume chronic diseases such as asthma, diabetes, depression, or attention-deficit/hyperactivity disorder. To avoid the problem of low numbers of most chronic conditions in children, these conditions can be combined into similar cost and outcome groups to measure short- and long-term outcomes. Outcomes in children can take into account the different expected trajectories of the various chronic conditions that impact children. Outcome measures can be expanded beyond short-term cost-saving measures to include long-term desirable improvements in disease trajectories as well as cultural and family/child functional measures.

It will not be easy to move the healthcare system in the United States away from the current system that is focused more on emergency, hospital, and tertiary care toward a system that is focused on primary care. The articles in this journal join the growing body of literature that identifies the value of the MH system. Much more can be done to further fully implementing MH as a defined part of our medical care system.

John M. Neff, MD

Center for Children with Special Needs, Seattle Children's, Seattle, Washington

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