The medical home concept has been in existence since the late 1960s and has recently been significantly broadened to encompass comprehensive primary care for all patient populations throughout the lifespan. This article provides (1) a review of the foundations and evolution of the medical home concept; (2) an analysis of patient/family, provider, and systemic challenges to developing an effective pediatric medical home particularly in relation to children’s mental health needs; and (3) a discussion of future directions for its further adoption and successful implementation.
Foundations and evolution of the medical home
The term “medical home” first appeared in the 1967 American Academy of Pediatrics (AAP) publication Standards of Child Health Care . It was originally coined to delineate a central location that would serve as a repository for a child’s medical records. The impetus for its creation was to ensure that neither gaps in care nor duplication of services occurred for children with special health care needs (CSHCN) who were commonly being treated by multiple providers.
The AAP Council on Pediatric Practice further broadened the term in 1974 to include a broader vision for function, inclusivity, and nomenclature. It was proposed that pediatricians would become the advocates for continuity of care without regard for financial or social constraints. Likewise, this iteration included the concept that “every child deserves a medical home.” It also included a more controversial notion: to eliminate all mention of pediatrician, family physician, and related terms in favor of exclusively using medical home. This last provision delayed adoption of medical home in an official policy of the AAP until 1979, when the central location and provision of continuity of care were accepted as central tenets.
Attempts were then made for adoption of medical home models across multiple states. A review of early Every Child Deserves a Medical Home Training Programs found that pediatricians had difficulty in understanding the medical home concept. It was also difficult to communicate and manage care coordination across multiple systems. A key issue was the difficulty of securing reimbursement for this potentially time- and labor-intensive model of health care delivery. After gaining federal grant support from the Maternal and Child Health Bureau and legislative victories for improved reimbursement via state legislatures and through Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), the medical home model was applied to multiple states primarily for CSHCN. Box 1 reviews AAP’s first official policy defining the medical home from 1992.
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Medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family centered, coordinated, and compassionate
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Delivered or directed by well-trained physicians who are able to manage or facilitate essentially all aspects of pediatric care
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Physician should be known to the child and family
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Physician should be able to develop mutually responsible and trusting relationship with patient and family
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Acknowledges that attainment of medical home is unobtainable for many children because of geographic barriers, personnel constraints, practice patterns, and economic and social forces
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Comprehensive health care should include provision of preventive care, assurance of care for acute illnesses, provision of care for an extended period of time to enhance continuity, identification and referral for subspecialty consultation, interaction with school and community agencies regarding special health needs, and maintenance of a central record that is accessible and confidential
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Potential for provision of such care as listed above at other venues including hospital outpatient clinics, school-based and school-linked clinics, community health centers, health department clinics, and others
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Potential for provision of such care as listed above by physicians or other health care providers under physician direction, such as nurses, nurse practitioners, and physician assistants
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Whether physically present or not, physician acts as child’s advocate and assume control and ultimate responsibility for care provided.
During the 1990s, the medical home was further disseminated by inclusion as a core element in the Community Access to Child Health (CATCH) program, by creation of a national Medical Home Training Project, and by establishment of a National Center of Medical Home Initiatives for Children with Special Needs. During this time, the Institute of Medicine (IOM) released a report entitled Crossing the quality chasm: a new health system for the 21st century. The report highlighted concerns regarding safety and quality in the health care system, inability to translate research knowledge into clinical practice, inefficient and duplicative use of services, lack of application of information technology (IT) solutions, inability to shift to a model of managing chronic conditions, and patient experiences of difficulty in navigating this fragmented health care system. It then presented 6 major aims for a quality health care system; that the system should be safe, effective, patient-centered, timely, efficient, and equitable.
The most recent iteration of AAP medical home policy focuses on creating an operational definition. An initial read of the medical home as the first stop for obtaining health care for all ages may seem like a resurrection of the gatekeeper mandate from 20 years ago. In that system, the patient was obligated to see the primary care physician for every aspect of medical care and without which approval would not be granted for referral to consultation or subspecialty care. The medical home is in actuality a team approach in which the multiple needs of the patient and family are addressed by the medical home team (consisting of the physician, physician extenders, nurses, care managers, and others) working collaboratively with specialists, the patient, and the family. The model works well for children and adolescents, especially those with complex medical issues. The medical home is a place, such as a physician’s office, community health center, or a school-based student health service; and a process, a change in the health care system by which patients are provided high-quality, cost-effective medical care.
Specific recommendations in the 2002 AAP medical home policy include that “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”; and the “provision of care coordination service in which the family, the physician, and other service providers work to implement a specific care plan as an organized team.” It also further delineated family centered care; provided for the discussion of unbiased information with the family about available services; and included the provision of culturally sensitive care. A list of desirable characteristics of the medical home is provided in Box 2 .
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 Act requirements
Family centered
The medical home physician is known to the child or youth and family
Mutual responsibility and trust exist 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 the 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 reasons 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.)
In March 2007, the American Academy of Family Physicians, the AAP, the American College of Physicians, and the American Osteopathic Association issued Joint principles of the patient-centered medical home . These principles include patients having a personal physician in a physician-directed medical practice that is accessible, that is whole-person oriented, that provides coordinated care, that is concerned about patient quality and safety, and that receives payment that recognizes the added value provided to patients.
Efforts have similarly been made to quantify how well a particular practice is meeting the qualities of being a medical home. Although many models exist, only 2 of the major assessment programs are described in this article. The National Committee for Quality Assurance (Physician Practice Connections–Patient-Centered Medical Home, http://www.ncqa.org ) has created one such tool, which is endorsed by the AAP. It stresses safety and quality of care, coordinated care, whole-person orientation, physician-directed medical practice, and each patient having an ongoing relationship with a personal physician. It encourages access and adequate reimbursement as a result of the extra resources necessary to provide a medical home. By using a self-reporting Web-based rating system, it results in 3 levels of recognition. Increasing level of complexity and providing more aspects of the medical home model yield elevation to higher levels of the scale. For example, basic IT requirements at Level 1 mandate an electronic practice management system; Level 2 requires more IT, such as an electronic health record (EHR) or e-prescribing capability; and Level 3 requires interoperable IT capabilities. For a practice to be recognized as a medical home, a certain number of points and certain mandated features must be in place.
The Accreditation Association for Ambulatory Health Care (AAAHC, http://www.aaahc.org ) published its first set of standards on assessing a medical practice as a medical home in 2009. Any outpatient medical facility may seek accreditation by AAAHC. During an on-site accreditation survey, the extra qualities or standards that make a medical practice a medical home are assessed. This tool additionally assesses the age ranges that can be served by the medical home model in that practice. For example, in a group practice seeking accreditation as a medical home for all ages, if pediatrics is not covered 24/7, then that practice might opt to only seek accreditation as a medical home for adults and geriatrics. This would not necessarily affect their ability to be accredited as a medical facility overall. Regardless of which program is used, being accredited as a medical home is a symbol of quality. Likewise, as more practices meet medical home standards it is feasible to envision that such accreditation may become mandatory, that it may be a distinction of a superior practice, or that it may ultimately lead to greater reimbursement from payers.
Challenges of the medical home
Pediatric mental health is a major public health issue. Approximately 1 in 4 pediatric primary care visits involve behavioral, emotional, or developmental issues. A report published in 2009 by the IOM and the National Research Council, showed that 14% to 20% of adolescents experience mental, emotional, or behavioral disorders at any given time, with the first symptoms of these disorders occurring 2 to 4 years before the onset of a full-blown disorder. Aligning well with this need, public mental health policies have long endorsed organized systems of care as critical in improving the quality of care. As the health care debate has evolved, strong emphasis has been placed on medical homes as high-quality, cost-effective health care delivery systems. Collaborative-care models, such as medical homes, have been found to be effective in treating mental illness in more than 35 randomized controlled trials. As logical as it seems to shift to a medical home model, early experiences during its development as well as recent research findings point to significant potential barriers to its successful adoption and implementation.
Patient/Family Factors
As much as the medical home model supports the notion of working with a primary care physician who is known to the patient and the family, it is not uncommon for parents to avoid discussing mental health concerns with the pediatrician. Briggs-Gowan and colleagues studied the prevalence of psychiatric disorders among 5- to 9-year-olds presenting to general pediatric practices as well as factors associated with parents’ use of pediatricians as resources concerning emotional/behavioral issues. The study found that the prevalence of any disorder was 16.8% when using a standardized instrument, the Diagnostic Interview Schedule for Children (DISC-R). Most parents (55%) who reported concerns about their child also stated not discussing behavioral/emotional concerns with their pediatrician. Additional research needs to be conducted regarding the replicability of these findings as well as better understanding of the patient/family factors that prevent more forthright reporting of concerns to providers.
One such factor that may prevent parents from seeking help is the stigma of mental illness. In the first nationally representative study of public response to child mental health problems, Pescosolido and colleagues studied public knowledge and assessment of child mental health problems in the National Stigma Study – Children. Of nearly 1400 participants, only 58.5% correctly identified depression and 41.9% correctly identified attention-deficit hyperactivity disorder (ADHD) in children. Surprisingly, a substantial group of participants who correctly identified the presence of a psychiatric disorder rejected the mental illness label (19.1% for ADHD and 12.8% for depression). The study concluded “Unless systematically addressed, the public’s lack of knowledge, skepticism, and misinformed beliefs signal continuing problems for providers, as well as for caregivers and children seeking treatment.”
In those parents willing to seek care, the effect of maternal or caregiver mental health issues on the ability to access care for the child as well as its effect on the child’s symptomatology and functioning cannot be understated. For example, in a recent study of more than 9500 mother-child dyads, maternal mental health was significantly associated with the presence of ADHD in school-aged children supporting a link between maternal mental health and behavioral outcomes in children. This is in addition to a long-standing body of evidence regarding the effects of maternal depression on infant attachment, behavioral problems, and psychopathology. Consider, in addition, the effects of socioeconomic status, language and racial disparities, geographic issues, and other related factors that affect access.
Provider Factors
Although there is support at an organizational level for the medical home model, there is significant variability regarding pediatrician attitudes to being responsible for managing and treating mental health problems. Stein and colleagues recently studied whether practicing pediatricians broadly accepted responsibility for identification of emotional issues in their patients and whether they think their responsibility should be to treat or refer problems that they identify. Through the AAP Periodic Survey of Members, they found that less than one-third agreed that it is their responsibility to treat/manage such problems, except for children with ADHD. Table 1 presents specific data divided by broad psychiatric diagnostic categories. Pediatricians were not asked about more severe psychopathology such as bipolar disorder, psychosis, or pervasive developmental disorders. Inclusion of these diagnoses would likely have yielded even lower outcomes for responsibility to identify and/or treat. In addition, as the investigators point out, “it is striking that the overwhelming majority think that it is their responsibility to refer most conditions, rather than to treat them. This is a major concern because a recent report by Rushton and colleagues indicates that only 1 in 5 children with a psychosocial problem is referred outside the practice, suggesting that few pediatricians are actually doing what they say in terms of referral.”
| Child’s Problem/Condition | Agree Pediatricians Should be Responsible for: | ||
|---|---|---|---|
| Identification, n (Weighted %) | Treating/Managing, n (Weighted %) | Referring, n (Weighted %) | |
| Attention-deficit/hyperactivity disorder | 595 (91) | 452 (70) | 352 (54) |
| Child/adolescent depression | 577 (88) | 158 (25) | 560 (86) |
| Behavior management problems | 552 (85) | 136 (21) | 551 (85) |
| Learning disabilities | 382 (59) | 101 (16) | 581 (89) |
| Anxiety disorders | 536 (83) | 180 (29) | 509 (79) |
| Substance abuse | 576 (88) | 133 (21) | 584 (90) |
| Eating disorders | 597 (91) | 204 (32) | 551 (85) |
In an interesting corollary study, the same researchers conducted a smaller survey of primary care pediatricians and child and adolescent psychiatrists in 7 counties surrounding Cleveland, Ohio. They examined whether the 2 physician groups agreed about the pediatrician’s role in identification, referral, and treatment of childhood mental health disorders; and whether they agreed about the barriers to the identification, referral, and treatment of childhood mental health disorders. Aside from ADHD, both physician groups agreed that pediatricians should be responsible for identifying and referring, but not treating child mental health conditions ( Table 2 ). With regard to barriers, both agreed about the lack of mental health services. Child and adolescent psychiatrists identified pediatrician’s lack of training in identifying child mental health problems as a barrier, whereas pediatricians cited poor confidence in their ability to treat child mental health problems with counseling, long waiting periods to see mental health providers, family failure to follow through on referrals, and billing/reimbursement issues.
| Agree that Pediatricians Should be Responsible for | PCPs (n = 132) | CAPs (n = 31) | P Value | ||
|---|---|---|---|---|---|
| N | Weighted % | N | Weighted % | ||
| ADHD | |||||
| Identifying | 117 | 90.1 | 23 | 73.3 | 0.01 |
| Treating | 110 | 85.6 | 18 | 57.0 | 0.005 |
| Referring | 46 | 35.6 | 17 | 56.8 | 0.04 |
| Child/Adolescent Depression | |||||
| Identifying | 111 | 84.7 | 19 | 62.6 | 0.008 |
| Treating | 17 | 13.3 | 3 | 9.2 | 0.52 |
| Referring | 110 | 83.8 | 23 | 84.7 | 0.91 |
| Behavioral Problems | |||||
| Identifying | 107 | 82.0 | 25 | 78.7 | 0.68 |
| Treating | 21 | 17.2 | 4 | 13.8 | 0.66 |
| Referring | 104 | 79.6 | 22 | 77.5 | 0.80 |
| Learning Disabilities | |||||
| Identifying | 77 | 58.4 | 20 | 61.3 | 0.77 |
| Treating | 14 | 11.1 | 5 | 18.4 | 0.30 |
| Referring | 120 | 91.6 | 24 | 82.8 | 0.16 |
| Anxiety Disorders | |||||
| Identifying | 112 | 85.0 | 22 | 68.2 | 0.04 |
| Treating | 21 | 16.5 | 2 | 7.7 | 0.26 |
| Referring | 106 | 80.9 | 25 | 88.6 | 0.30 |
| Child Substance Abuse | |||||
| Identifying | 113 | 86.3 | 25 | 81.6 | 0.51 |
| Treating | 15 | 11.7 | 2 | 7.7 | 0.55 |
| Referring | 120 | 91.9 | 25 | 84.7 | 0.26 |
| Child Eating Disorders | |||||
| Identifying | 115 | 89.2 | 27 | 87.4 | 0.77 |
| Treating | 20 | 15.5 | 3 | 10.3 | 0.49 |
| Referring | 114 | 86.8 | 24 | 82.0 | 0.52 |
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