2019-20 TOW #11: The Medical Home & Children with Special Needs

Among the most fulfilling aspects of primary care is longitudinal relationships with families and addressing comprehensive, holistic needs over time. There is a growing body of data on the health benefits of medical homes, especially for children with special health care needs, and also for typically developing children.

Materials for this week:

Take-home points:

  1. What are the principles and goals of a “medical home”? The “medical home” (or  “health care home” to encompass health maintenance and health promotion) is a model promoted by national agencies including the AAP to provide comprehensive, family-centered, community-based care for patients, especially Children with Special Health Care Needs (CSHCN). The medical home model seeks to provide care that is accessiblefamily-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. A key part is to overcome barriers of fragmented services and provide care that is proactive, not always reactive.
  2. How many qualify as “Children with Special Health Care Needs (CSHCN)? Large population-based surveys estimate that 13% to 20% of children and youth meet the definition of CSHCN, as defined by parent report. This is probably an underestimate, and many children have two or more conditions.
  3. How does socioeconomic status affect prevalence of CSHCN? Unfortunately, there remain large inequities in chronic health conditions, access to health care services, and unmet specialty care needs based on social determinants of health. National data indicate higher odds for special needs among children living in poverty.
  4. Who should be involved within a medical home? Being an effective medical home requires a team approach. The primary care physician often develops the plan of care, with implementation and coordination managed by nurses, care coordinators, social workers, and the family. Collaboration with school nurses, visiting nurses, and home health aides is also crucial.
  5. What does a care plan include? One of the recommended strategies to help coordinate services for CSHCN is to develop care plans. Suggested care plan components include diagnoses/problem list, care team contact information, patient and family strengths and challenges, prior surgeries and/or procedures, recent lab and other diagnostic studies, assistive technology, and patient and family goals.

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