Healthcare Transition and the Medical Home

Chapter

Abstract

The purpose of this chapter is that the reader will understand the role of the pediatric medical home in the context of healthcare transition. The medical home is a model of care that provides a reliable and familiar entry into a comprehensive care system and fosters communication and collaboration between and among patients, families, clinicians, support staff, and the larger community. The medical home model is endorsed by pediatricians, internists, family medicine physicians, osteopathic providers, and emergency physicians. When established as a reliable touchpoint for preventive, acute, and chronic care, this model represents system-level support for transition and transfer to both an adult model and adult site of care. While adherence to condition-specific medical and lifestyle regimens is a critical piece of care for adolescents and young adults with special healthcare needs (AYASHCN), the medical home model offers enhanced opportunities to provide a holistic approach to AYASHCN.

Keywords

Transition to adult care Adolescent Young adult Primary care Chronic illness 

References

  1. 1.
    American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. 2007. http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf. Accessed 18 Apr 2017.
  2. 2.
    American College of Emergency Physicians. Clinical & Practice Management. The patient-centered medical model. 2015. https://www.acep.org/Clinical---Practice-Management/The-Patient-Centered-Medical-Home-Model/. Accessed 18 Apr 2017.
  3. 3.
    Rosen DS, Blum RW, Britto MT, Sawyer SM, Siegel DM, Society for Adolescent Medicine. Transition to adult health care for adolescents and young adults with chronic conditions: position paper of the Society for Adolescent Medicine. J Adolesc Health. 2003;33(4):309–11.CrossRefGoogle Scholar
  4. 4.
    Strickland BB, Jones JR, Ghandour RM, Kogan MD, Newacheck PW. The medical home: health care access and impact for children and youth in the United States. Pediatrics. 2011;127(4):604–11.  https://doi.org/10.1542/peds.2009-3555.CrossRefPubMedGoogle Scholar
  5. 5.
    Rapoff MA. Adherence to pediatric medical regimens. In: Issues in clinical child psychology. 2nd ed. New York, NY: Springer Science + Business Media; 2010.Google Scholar
  6. 6.
    Garcia-Huidobro D, Shippee N, Joseph-DiCaprio J, O'Brien JM, Svetaz MV. Effect of patient-centered medical home on preventive services for adolescents and young adults. Pediatrics. 2016;137(6):e20153813.CrossRefGoogle Scholar
  7. 7.
    American Academy of Pediatrics, National Center for Medical Home Implementation. Why is medical home important? 2016. https://medicalhomeinfo.aap.org/overview/Pages/Evidence.aspx. Accessed 18 Apr 2017.
  8. 8.
    Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the chronic care model in the new millennium. Health Aff (Millwood). 2009;28(1):75–85.  https://doi.org/10.1377/hlthaff.28.1.75.CrossRefGoogle Scholar
  9. 9.
    Group Health Research Institute. Improving chronic illness care. The Chronic Care Model. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. Accessed 18 Apr 2017.
  10. 10.
    American Academy of Pediatrics, National Center for Medical Home Implementation. About us. https://medicalhomeinfo.aap.org/about/Pages/default.aspx. Accessed 18 Apr 2017.
  11. 11.
    American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, Transitions Clinical Report Authoring Group, Cooley WC, Sagerman PJ. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011;128(1):182–200.  https://doi.org/10.1542/peds.2011-0969. CrossRefGoogle Scholar
  12. 12.
    Klein DA, Goldenring JM, Adelman WP. HEEADSSS 3.0: the psychosocial interview for adolescents updated for a new century fueled by media. Contemp Pediatr. 2014. http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/content/tags/adolescent-medicine/heeadsss-30-psychosocial-interview-adolesce?page=full. Accessed 18 Apr 2017.
  13. 13.
    National Alliance to Advance Adolescent Health, Center for Health Care Transition Improvement. Side-by-side version. Six Core Elements of Health Care Transition 2.0. 2014. http://www.gottransition.org/resourceGet.cfm?id=206. Accessed 18 Apr 2017.
  14. 14.
    Stille C, Turchi RM, Antonelli R, Cabana MD, Cheng TL, Laraque D, et al. The family-centered medical home: specific considerations for child health research and policy. Acad Pediatr. 2010;10(4):211–7.CrossRefGoogle Scholar
  15. 15.
    Ladapo J, Chokshi D. Continuity of care for chronic conditions: threats, opportunities, and policy. Health Aff Blog. 2014. http://healthaffairs.org/blog/2014/11/18/continuity-of-care-for-chronic-conditions-threats-opportunities-and-policy-3/. Accessed 19 Apr 2017.
  16. 16.
    Brownlee B, Van Borkulo N. Empanelment: establishing patient-provider relationships. Seattle, WA: Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.Google Scholar
  17. 17.
    American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians, Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement – guidelines for care of children in the emergency department. Pediatrics. 2009;123(4):1233–43.  https://doi.org/10.1542/peds.2009-1807. CrossRefGoogle Scholar
  18. 18.
    Goudie A, Havercamp S, Jamieson B, Sahr T. Assessing functional impairment in siblings living with children with disability. Pediatrics. 2013;132(2):e476–e83.  https://doi.org/10.1542/peds.2013-0644. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Herzer M, Godiwala N, Hommel KA, Driscoll K, Mitchell M, Crosby LE, et al. Family functioning in the context of pediatric chronic conditions. J Dev Behav Pediatr. 2010;31(1):26–34.  https://doi.org/10.1097/DBP.0b013e3181c7226b.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Fanaroff JM, Committee on Medical Liability and Risk Management. Consent by proxy for non-urgent pediatric care. Pediatrics. 2017;139(2):e20163911.CrossRefGoogle Scholar
  21. 21.
    Middleman AB, Olson KA. Confidentiality in adolescent health care. In: English A, Blake D, Torchia MM, editors. UpToDate. 2017. https://www.uptodate.com/contents/confidentiality-in-adolescent-health-care#H5. Accessed 2 May 2017.
  22. 22.
    Committee on Practice and Ambulatory Medicine. Use of chaperones during the physical examination of the pediatric patient. Pediatrics. 2011;127(5):991–3.CrossRefGoogle Scholar
  23. 23.
    Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurance on adolescents’ willingness to disclose information and seek future health care. JAMA. 1997;278(12):1029–34.CrossRefGoogle Scholar
  24. 24.
    Center for Advancing Health Policy and Practice, Boston University School of Public Health. The Catalyst Center: National Center for Health Insurance and Financing for Children and Youth with Special Health Care Needs (CYSHCN). http://cahpp.org/project/the-catalyst-center/. Accessed 2 May 2017.
  25. 25.
    HealthCare.gov. Individuals & families. People under 30. How to get or stay on a parent’s plan. https://www.healthcare.gov/young-adults/children-under-26/. Accessed 9 May 2017.
  26. 26.
    Autism Speaks. Family services. visual tools. https://www.autismspeaks.org/family-services/resource-library/visual-tools. Accessed 2 May 2017.
  27. 27.
    American Psychological Association. Enhancing your interactions with people with disabilities. http://www.apa.org/pi/disability/resources/publications/enhancing.aspx. Accessed 2 May 2017.
  28. 28.
    Cooley WC, Cheetham T. Integrating young adults with intellectual and developmental disabilities into your practice: tips for adult health care providers. National Alliance to Advance Adolescent Health. Practice Resource – No. 3. 2015. http://www.gottransition.org/resourceGet.cfm?id=367. Accessed 2 May 2017.
  29. 29.
    National Committee for Quality Assurance (NCQA). Patient Centered Medical Home (PCMH). PCMH 2017 Standards. http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/pcmh-2017. Accessed 2 May 2017.
  30. 30.
    Institute for Healthcare Improvement. Changes. Decrease demand for appointments. http://www.ihi.org/resources/Pages/Changes/DecreaseDemandforAppointments.aspx. Accessed 2 May 2017.
  31. 31.
    Chariatte V, Berchtold A, Akre C, Michaud PA, Suris JC. Missed appointments in an outpatient clinic for adolescents, an approach to predict the risk of missing. J Adolesc Health. 2008;43(1):38–45.CrossRefGoogle Scholar
  32. 32.
    Topuz K, Uner H, Oztekin A, Yildirim MB. Predicting pediatric clinic no-shows: a decision analytic framework using elastic net and Bayesian belief network. Ann Oper Res. 2017.  https://doi.org/10.1007/s10479-017-2489-0.
  33. 33.
    Carroll G, Massarelli E, Opzoomer A, Pekeles G, Pedneault M, Frappier JY, et al. Adolescents with chronic disease. Are they receiving comprehensive health care? J Adolesc Health Care. 1983;4(4):261–5.CrossRefGoogle Scholar
  34. 34.
    Center for Adolescent Health & the Law. State minor consent laws: a summary. 3rd ed. Chapel Hill, NC; 2010. http://www.cahl.org/state-minor-consent-laws-a-summary-third-edition/. Accessed 2 May 2017.
  35. 35.
    Hargreaves DS, Elliott MN, Viner RM, Richmond TK, Schuster MA. Unmet health care needs in US adolescents and adult health outcomes. Pediatrics. 2015;136(3):513–20.CrossRefGoogle Scholar
  36. 36.
    Safety Net Medical Home Initiative. About the initiative. http://www.safetynetmedicalhome.org/about-initiative. Accessed 2 May 2017.
  37. 37.
    Shah AK, Stadtlander M. Building better care “Empanelment”. 1st ed. Portland, OR: Multnomah County Health Department; 2009. http://www.safetynetmedicalhome.org/sites/default/files/Clinical-Standards-Empanelment.pdf. Accessed 22 May 2017Google Scholar
  38. 38.
    Simon TD, Cawthon ML, Stanford S, Popalisky J, Lyons D, Woodcox P, et al. Pediatric medical complexity algorithm: a new method to stratify children by medical complexity. Pediatrics. 2014;133(6):e1647–54.CrossRefGoogle Scholar
  39. 39.
    American Medical Association Steps Forward, Sinsky S. Pre-visit planning online module. https://www.stepsforward.org/modules/pre-visit-planning. Accessed 18 Apr 2017.
  40. 40.
    Centers for Medicare & Medicaid Services. Frequently asked questions. What is the definition of “new patient” for billing evaluation and management (E/M) services? https://questions.cms.gov/faq.php?id=5005&faqId=1969. Accessed 2 May 2017.
  41. 41.
    Gliklich RE, Dreyer NA, Leary MB. Registries for evaluating patient outcomes: a user’s guide. 3rd ed. Rockville, MD: Agency for Healthcare Research and Quality; 2014. Report No. 13(14)-EHC111; https://effectivehealthcare.ahrq.gov/ehc/products/420/1897/registries-guide-3rd-edition-vol-1-140430.pdf. Accessed 2 May 2017Google Scholar
  42. 42.
    National Center for Medical Home Implementation. Building your medical home. An introduction to pediatric primary care transformation. Managing your patient population. https://medicalhomes.aap.org/Pages/Managing-Your-Patient-Population.aspx. Accessed 2 May 2017.
  43. 43.
    National Committee for Quality Assurance. HEDIS 2017 technical specifications for physician measurement (epub). http://store.ncqa.org/index.php/catalog/product/view/id/2507/s/hedis-2018-technical-specifications-for-physician-measurement-epub/. Accessed 2 May 2017.
  44. 44.
    American Academy of Pediatrics, Materials & Tools. Bright futures: guidelines for health supervision of infants, children, and adolescents. 4th ed. https://brightfutures.aap.org/materials-and-tools/Pages/default.aspx. Accessed 19 Apr 2017.
  45. 45.
    Montori VM. NEJM catalyst care redesign talk: the invisible work of the patient. http://catalyst.nejm.org/videos/invisible-work-patient-disruption/. Accessed 2 May 2017.
  46. 46.
    Romley JA, Shah AK, Chung PJ, Elliott MN, Vestal KD, Schuster MA. Family-provided health care for children with special health care needs. Pediatrics. 2017;139(1):e20161287.CrossRefGoogle Scholar
  47. 47.
    Hummel J, Evans P. Providing clinical summaries to patients after each office visit: a technical guide. 2012. https://www.healthit.gov/sites/default/files/measure-tools/avs-tech-guide.pdf. Accessed 8 May 2017.
  48. 48.
    Lail J, Schoettker PJ, White DL, Mehta B, Kotagal UR. Applying the chronic care model to improve care outcomes at a pediatric medical center. Jt Comm J Qual Patient Saf. 2017;43(3):101–12.CrossRefGoogle Scholar
  49. 49.
    Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272–8.CrossRefGoogle Scholar
  50. 50.
    McManus M, White P, Harwood C, Molteni R, Kanter D, Salus T. 2017 Coding and reimbursement tip sheet for transition from pediatric to adult health care. National Alliance to Advance Adolescent Health. Practice Resource No. 2. 2017. http://www.gottransition.org/resourceGet.cfm?id=352. Accessed 8 May 2017.
  51. 51.
    Bodenheimer T. Building teams in primary care: lessons from 15 case studies. California Health Care Foundation; 2007. http://www.chcf.org/publications/2007/07/building-teams-in-primary-care-lessons-from-15-case-studies. Accessed 22 May 2017.
  52. 52.
    American Academy of Pediatrics, National Center for Medical Home Implementation. Co-management between primary and specialty care. 2017. https://medicalhomeinfo.aap.org/about/Pages/January-2017.aspx. Accessed 8 May 2017.
  53. 53.
    O'Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med. 2011;171(1):56–65.PubMedGoogle Scholar
  54. 54.
    HealthIT.gov. What is EHR Interoperability and why is it important? 2013. https://www.healthit.gov/providers-professionals/faqs/what-ehr-interoperability-and-why-it-important. Accessed 8 May 2017.
  55. 55.
    Kerr LM. Writing letters of medical necessity. Medical Home Portal, Department of Pediatrics, University of Utah. 2011. https://www.medicalhomeportal.org/issue/writing-letters-of-medical-necessity. Accessed 8 May 2017.
  56. 56.
    Con D, De Cruz P. Mobile phone apps for inflammatory bowel disease self-management: a systematic assessment of content and tools. JMIR Mhealth UHealth. 2016;4(1):e13.CrossRefGoogle Scholar
  57. 57.
    U.S. Department of Health and Human Services, U.S. Food & Drug Administration. Examples of mobile apps for which the FDA will exercise enforcement discretion. 2016. https://www.fda.gov/MedicalDevices/DigitalHealth/MobileMedicalApplications/ucm368744.htm. Accessed 8 May 2017.
  58. 58.
    McAllister J. National center for medical home implementation. Co-management letter and agreement. https://medicalhomes.aap.org/Documents/CoManagementAgreement.pdf. Accessed 8 May 2017.
  59. 59.
    National Alliance to Advance Adolescent Health. Transition readiness. http://www.gottransition.org/providers/leaving-3.cfm. Accessed 8 May 2017.
  60. 60.
    National Committee for Quality Assurance. HEDIS 2017 Standards, Volume 2. Summary table of measures, product lines and changes. http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2017/HEDIS%202017%20Volume%202%20List%20of%20Measures.pdf?ver=2016-06-27-135433-350. Accessed 8 May 2017.
  61. 61.
    Center of Excellence for Pediatric Quality Measurement, Division of General Pediatrics, Boston Children’s Hospital. Measuring the preparation for transition from pediatric-focused to adult-focused health care: the adolescent assessment for preparation for transition (ADAPT) survey. 2014. https://www.rmhpcommunity.org/sites/default/files/resource/ADAPT-survey-materials.pdf. Accessed 8 May 2017.
  62. 62.
    National Quality Forum. Pediatric measures. Final Report. Measure 2789. Adolescent assessment of preparation for transition (ADAPT) to adult-focused health care. Washington, DC; 2016.Google Scholar
  63. 63.
    United States Department of Agriculture, Food and Nutrition Service. Women, infants, and children (WIC). 2017. https://www.fns.usda.gov/wic/women-infants-and-children-wic. Accessed 8 May 2017.
  64. 64.
    Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;359(12):1202–5.CrossRefGoogle Scholar
  65. 65.
    Center for Health Care Transition Improvement, Got Transition. Guardianship and alternatives for decision-making support. 2012. http://www.gottransition.org/resourceGet.cfm?id=17. Accessed 8 May 2017.
  66. 66.
    National Center for Medical Home Implementation. For Practices. Family-centered care. 2016. https://medicalhomeinfo.aap.org/tools-resources/Pages/For-Practices.aspx. Accessed 8 May 2017.
  67. 67.
    U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality. Chapter 2: What is care coordination? In: Care coordination measures atlas update. 2014. https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/chapter2.html. Accessed 8 May 2017.
  68. 68.
    The Advisory Board, Nursing Executive Center. Achieving Top-of-License Nursing Practice. Best practices for elevating the impact of the frontline nurse. 2013. https://www.advisory.com/-/media/Advisory-com/Research/NEC/Research-Study/2013/Achieving-Top-of-License-Nursing-Practice/Achieving-Top-of-License-Nursing-Practice.pdf. Accessed 8 May 2017.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Chronic CareJames M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical CenterCincinnatiUSA
  2. 2.Complex Care CenterDivision of General PediatricsCincinnatiUSA

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