Dr. Genevieve Daftary, Pediatrics Department | 9/15/2013, noon
A pediatric patient and his mother talk with a medical assistant at Codman Square Health Center. CODMAN HEALTH SQUARE
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What does a patient centered medical home (PCMH) look like within primary care pediatrics? What is needed from a pediatric- centered medical home within the context of an urban community health center like Codman Square? Our health center achieved the highest tier of recognition from the National Committee for Quality Assurance in 2012, reflecting our commitment and organizational capacity to provide care that is coordinated, patient centered and responsive to health of the population.
The process of achieving PCMH recognition was a reminder that children are not little adults. Our pediatric population struggles with the affects of asthma, obesity, sickle cell disease and attention deficit disorders, all considered chronic medical conditions within children. However, the management of these conditions and the more common issues affecting children and young adults of language delay, school and learning problems, high risk sexual behaviors, drug use and mood disorders do not typically fit well in the model of chronic disease management and episodic health care encounters that has been used in adult settings. If our aim is to be patient centered, how do we design a medical home that addresses these very important needs of the youngest members of our community?
It is interesting to revisit this question when one considers that the American Academy of Pediatrics (AAP) released one of the earliest concepts of patient centered medical home in its 1992 policy report on Medical Home. “The AAP believes that the medical care of infants, children and adolescents ideally should be accessible, continuous, comprehensive, family-centered, coordinated and compassionate.”
This initial policy statement grew out of almost 30 years of work by the AAP on addressing the care of children with special health care needs (CSHCN) and went on to inform more contemporary versions of this concept. This concept of the medical home was revised and expanded on by a coalition of the AAP, the American Academy of Family Physicians, the American College of Physicians and the American Osteopathic Association in 2007 and released as the Joint Principles of the Patient Centered Medical Home. Ultimately the Agency for Healthcare Research and Quality definition emerged and has largely been used to make decisions about accreditation.
While PCMH emerged from pediatrics and the care of CSHCN, the large majority of pediatric patients, both in our population and more broadly, do not have complex medical needs but do have complex social, developmental and psychological needs that have a large impact on their overall wellness now and in the future.
At Codman Square Health Center we have begun to structure a broader community-oriented perspective on patient-centered medical homes for children. We have done this internally using group visit models for children between birth and one year that emphasize shared community and parenting experiences and allow more time with providers to focus on anticipatory guidance. Additionally, we have incorporated the Project LAUNCH program into our support services for families most in need.
This federal grant has allowed us to have a family resource specialist and an early childhood development specialist available within the health center to support those families and children we identify as being most in need of parenting support, behavior coaching, child care resources and developmental assessments and support. These specialists have performed home and school visits, coordinated resources for families whose children are being evaluated for autism and helped coach young families struggling with homelessness, unemployment and single parenthood.
Externally, we have cultivated strong relationships with schools, recognizing that after early childhood, schools become not just the places where children spend most of their waking hours but also micro-communities that serve as a way to engage with students and parents around a variety of health and wellness topics. We enjoy being a resource for consultation on school health policies and programs, a referral resource for health services and an on-site provider of care.
Our longest and strongest partnerships have been with Tech Boston Academy, where one of our nurse practitioners runs a school-based health center, and Codman Academy Charter Public School, the first and only co-located school within a health center in the country. These relationships with schools fit into a belief that integrating education and health care can achieve real community wellness through the reversal of the effects of systemic poverty. As we work with these and other school partners, we are looking to build systems to promote the growth of healthy children who will go on to be leaders of healthy communities. It is a vision for a new patient-centered approach that we are excited to be a part of building.