My pediatric medical home

Figure 1

Figure 2

My experience working as a pediatrician in a pediatric medical home (PMH) is very positive. I have worked here since 2011, and I have been noticing great improvement in patient and family satisfaction.^1-3

Our group is a hospital-based team comprised of 10 to 11 medical providers, including 2 pediatric nurse practitioners (PNPs), 4 to 5 registered nurses (RNs), 15 to 20 licensed practice nurses (LPNS), 2 to 3 medics, and 2 to 3 staff, and together we provide pediatric care to about 9700 patients.

We are divided in 2 groups named Outback and Safari-very cool names for a PMH. In an ideal PMH world, every provider should have 2 LPNs, but because of budget constraints and movements of personnel, every provider is working with at least 1 LPN. Every team has 2 RNs.

A typical day

Our day starts at 7:30 AM (for Richmond Hill Medical Home [RHMH]) with a group meeting aiming to plan and discuss the day ahead. Also at this meeting we could receive information and feedback from leadership. The meetings usually last no more than 10 minutes. No one sits during this meeting and we gather in a T-shaped hallway inside the clinic (Figure 1). The clinic chief or chief nurse chairs these meetings.

The first appointment starts at 7:40 AM and every encounter lasts 20 minutes. Sometimes we have longer encounter for patients with complex concerns/issues such as attention-deficit/hyperactivity disorder (ADHD), autism, behavior disorders, or complex pathologies that require sophisticated management.^2-4

Daily workflow

One typical encounter (Figure 2) starts with the LPN greeting the patient and family in the waiting room and directing them into an examination room for taking vital signs, including measurements of growth parameters. Also, if the visit is for a well-child evaluation, then we provide the parents with appropriate questionnaires for development, autism screening, and depression screening. Screening for ADHD is provided per specific request or parental concerns. Then, the LPN asks medical questions regarding the specifics of the visit, including questions about past medical and family history, allergies, medications, and other issues relevant to the visit. All the information gathered is documented into the patient’s electronic medical record (EMR). After completing this section of the encounter, the LPN briefs the provider on the details.

Thereafter, the provider and the LPN walk into the examination room to meet and greet the patient and family and proceed to assess and evaluate the patient. The provider completes the encounter by asking further questions, performing a physical examination, and discussing with the patient and family the assessment and plans of management. Notably, the provider and the LPN will work this part of the encounter as a team, which allows better completion of the patient medical record and provides to the patient and family a written summary of the encounter including assessment, management, medication, education, and proper follow-up.

Our RNs also perform a triage assessment of the daily calls that improves access of care and greater utilization of same-day appointments, including proper triage of acute cases. Our RN attempts to return patient calls within 24 hours.

Model of care

Our daily work is divided into 2 categories: well-child visits and patients with clinical complaints. A patient or family can book an appointment for a well visit or for any clinical complaints with their primary care pediatrician well in advance. This booking can be online through a web-based program, by phone, or in person.

Moreover, in order to fill the demand for appointments for acute illness, there are always fixed appointments per pediatrician for acute illness (about 6 to 8 per provider per day). These slots are made available only by phone beginning at 6:30 AM on the day of the appointment.

Recent surveys showed that this model has increased patient satisfaction. For example:

1. Satisfaction with provider: improved from 84% to 93.4%.

2. Provider explained what was being done and why: improved from 86.7% to 94.3%.

3. Provider listened: improved from 81.6% to 92.7%.

In summary, my experience working as a pediatrician in a PMH has yielded great improvement in patient and family satisfaction.

References:

1. Ziring PR, Brazdziunas D. Cooley WC, et al. American Academy of Pediatrics. Committee on Children with Disabilities. Care coordination: integrating health and related systems of care for children with special healthcare needs. Pediatrics.1999;104(4 pt 1):978-981.

2. Medical Home Initiatives for Children With Special Needs Project Advisory Committee; American Academy of Pediatrics. The medical home. Pediatrics. 2002;110(1 pt 1):184-186.

3. Turchi RM, Gatto M, Antonelli R. Children and youth with special healthcare needs: there is no place like (a medical) home. Curr Opin Pediatr. 2007;19(4):503-508.

4. Kan K, Choi H, Davis M. Immigrant families, children with special health care needs, and the medical home. Pediatrics. 2016;137(1):e20153221.