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Pediatric Medical Home: Foundations, Challenges, and Future Directions
Pediatric Medical Home: Foundations, C h a l l e n g e s , an d F u t u re D i re ct i o n s Harsh K. Trivedi, MDa,b,*, Nancy A. Pattison, Lourival Baptista Neto, MDd,e
MD
c
,
KEYWORDS Primary care Medical home Child and adolescent psychiatry History Challenges Future directions Health care delivery/access Health policy
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.1 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
A version of this article was previously published in the Child and Adolescent Psychiatric Clinics of North America, 19:2. This work was not supported by any grant. a Vanderbilt Medical School, 21st Avenue South, Nashville, TN 37232, USA b Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South, 1157, Nashville, TN 37212, USA c Department of Psychiatry, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA d Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University/ NYSPI, Unit 78, 1051 Riverside Drive, New York, NY 10032, USA e New York Presbyterian Hospital, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA * Corresponding author. Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South 1157, Nashville, TN 37212. E-mail address: [email protected] Pediatr Clin N Am 58 (2011) 787–801 doi:10.1016/j.pcl.2011.06.014 pediatric.theclinics.com 0031-3955/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
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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.1 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.2 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.1 Box 1 reviews AAP’s first official policy defining the medical home from 1992.3 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.1 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 Box 1 Major components of AAP medical home policy statement from 1992 Medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family centered, coordinated, and compassionate Delivered or directed by well-trained physicians who are able to manage or facilitate essentially all aspects of pediatric care Physician should be known to the child and family Physician should be able to develop mutually responsible and trusting relationship with patient and family Acknowledges that attainment of medical home is unobtainable for many children because of geographic barriers, personnel constraints, practice patterns, and economic and social forces 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 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 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 Whether physically present or not, physician acts as child’s advocate and assume control and ultimate responsibility for care provided. Data from American Academy of Pediatrics ad hoc task force on definition of the medical home: the medical home. Pediatrics 1992;90:774.
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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.4 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.5 Specific recommendations in the 2002 AAP medical home policy6 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. 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.7 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, physiciandirected 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
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Box 2 Desirable characteristics of a medical home 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 Act10 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,
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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.) From The medical home. American Academy of Pediatrics, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Pediatrics 2002;110(1):184–6; with permission.
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
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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.8 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.9 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.10 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. BriggsGowan and colleagues11 studied the prevalence of psychiatric disorders among 5to 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 colleagues12 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
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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.13 This is in addition to a long-standing body of evidence regarding the effects of maternal depression on infant attachment,14 behavioral problems,15 and psychopathology.16 Consider, in addition, the effects of socioeconomic status,17 language and racial disparities,18 geographic issues,19 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 colleagues20 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 colleagues21 indicates that only 1 Table 1 Pediatrician agreement about being responsible based on child’s condition/problem Agree Pediatricians Should be Responsible for: Child’s Problem/ Condition
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)
Data from Stein REK, Horwitz SM, Storfer-Isser A, et al. Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambul Pediatr 2008;8(1):11–17.
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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.” 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
Table 2 Primary care pediatrician and child and adolescent psychiatrist agreement with pediatrician responsibility for identifying, treating, and referring child mental health problems Agree that Pediatricians Should be Responsible for
PCPs (n 5 132) N
Weighted %
CAPs (n 5 31) N
Weighted %
P Value
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
Data from Heneghan A, Garner AS, Storfer-Isser A, et al. Pediatricians’ role in providing mental health care for children and adolescents: do pediatricians and child and adolescent psychiatrists agree? J Dev Behav Pediatr 2008;29(4):262–9.
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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.22 Systemic Factors
Although patient/family and provider factors are significant, the greatest impediments to successful adoption of the medical home lies within systemic factors. Current systemic issues include lack of standardized definitions, presence of administrative and financial barriers to its adoption, lack of technological interoperability and confidentiality concerns, lack of adequate training of medical professionals, relative supply/demand of specific types of providers, and a lack of evidence of large-scale feasibility and population-level improvement in health outcomes. Although the medical home model exists and attempts have been made to create operational definitions of how this should form the basis of a medical practice, there are currently several stakeholders, each with varying views. A few rhetorical questions are included to illustrate how complicated the nuances can be. Should a pediatric medical home located in the outpatient clinic of a major tertiary care Children’s Hospital in New York City look and function exactly the same as a pediatric medical home located in a rural family practitioner’s office 75 miles from Missoula, Montana? Should a general pediatrician be expected to evaluate, manage, and treat the same level of patient severity as a developmental-behavioral pediatrician in the same medical home practice? How will the medical home model equilibrate with regard to varying expectations of providers and patients about when to refer patients to specialty providers, for which conditions, and after how much clinical intervention has occurred at the medical home site? How will patient outcomes be measured to ensure that each provider is functioning according to the medical home model and using optimal decision making to maximize medical home gains? Which assessment tool(s) will become universally accepted for evaluating medical home practices? Will accreditation become necessary to engage in medical practice or will it be the higher bar that only certain practices will meet? Will payers uniformly pay a premium for patients receiving care in these medical home sites? These and many additional questions will need to be figured out as the medical home is rolled out. With our fragmented system of health care, there are also significant administrative and financial barriers to successful adoption of the medical home. The American Academy of Child and Adolescent Psychiatry (AACAP) Health Care Access and Economics Committee and the AAP Mental Health Task Force recently published a white paper for reducing administrative and financial barriers to access and collaboration as a method to improve mental health services in primary care.23 Administrative barriers cited by this group include mental health intake procedures that bypass the primary care clinician, limited access to effective psychosocial interventions, lack of procedural and diagnostic parity in mental health and physical health benefits, inadequate communication and comanagement mechanisms, lack of coverage for recommended assessment and treatment services, and limited or no coverage for out-of-network providers (even when in-network providers are not able to see new clients). Financial barriers include lack of payment for visits with parents only (without child present as identified patient), lack of payment for other non–face-to-face components of care and consultation, insufficient payment for mental health services including management of emerging problems or symptoms not meeting a diagnostic
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threshold, insurance plan policies precluding payment to primary care clinicians when mental health diagnostic codes are reported, high out-of-pocket expenses for certain medications, and application of “incident to” payment methodology to prevent coverage of colocated services. Although there has been a significant push recently for the adoption of meaningful use IT solutions in health care, several significant concerns remain unaddressed. Although many practices are beginning to use EHRs and e-prescribing, interoperability of different software platforms drastically impedes the ability of medical homes to effectively and efficiently collaborate with other providers.5 Anecdotally, some physicians have found that even when newer versions of the same software programs are rolled out within the same practice, vendors are disallowing access to data in the previous software version out of concerns about liability if the newer software either omits or erroneously migrates the wrong information. Likewise, as medicine shifts to IT solutions, the potential for breach of confidentiality also increases. Because of the stigma of mental illness, this is of particular concern to the mental health community. Even if these concerns could be addressed, there are also fundamental issues in the training of physicians to care for psychiatric illnesses. Nationally, there has been a trend to decrease the length of psychiatry rotations in medical schools24 with many offering little to no exposure to child psychiatry. It can easily be said that a first year house officer in Psychiatry is more likely to know how to appropriately diagnose and manage asthma or diabetes; than a first year Pediatrics resident is likely to know how to appropriately diagnose and manage ADHD or first break psychosis. When these medical students graduate and enter a pediatrics residency, the Accreditation Council for Graduate Medical Education Residency Review Committee (RRC) training requirements do not mandate any mental health training thus leading to minimal development of knowledge base and clinical management of psychiatric illnesses. How then can primary care pediatricians be expected to safely and effectively diagnose, manage, and refer all children walking into their primary care pediatric practices with mental health problems? Even for those medical home practices that are keen to adopt mental health diagnosis and management, there is the problem of supply/demand of providers. Although screening has been shown to be feasible in pediatric practices,25 a common problem is where to refer the patients who are severely ill and require specialty care. Children’s mental health faces a significant shortage of all levels of providers. For example, in child and adolescent psychiatry, 7000 are in practice although there is currently a need for 30,000.26 Imbalances also exist on the primary care end of this equation. In a commentary regarding whether everyone can have a medical home, Pan27 notes that the growth in the number of general pediatricians will greatly exceed the growth of the pediatric population by 2020. Likewise, this growth is expected to exceed sufficiency and create a competitive situation where there may not be enough pediatric patients for primary care pediatricians and family practitioners. Pan suggests “Family medicine could partially or wholly withdraw from the care of children and focus on the aging population, or they could compete directly with pediatrics for the primary care of children and adolescents. An alternative to these options is for family medicine and pediatrics to collaborate in providing medical homes for all children and their families. Collaboration is an important option for the future.” On the issue of an evidence base, although studies have been done to elucidate the effectiveness of medical homes for CSHCN, significant data are lacking as to whether the medical home model can be justified for nonmedically complicated children. Homer and colleagues28 looked at the evidence for medical homes for children with
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special health care needs. After reviewing more than 30 studies, they found that there is moderate support for the conclusion that “medical homes provide improved health related outcomes for children with special health care needs,” however, “more research encompassing all or most of the attributes of the medical home need to be undertaken.” In an era of health care reform and concerns about the ballooning cost of health care, robust data are needed on clinically significant improvements in health, actual cost-effectiveness of this health care delivery model, as well as, data justifying expansion of the medical home model to include all comers.
FUTURE DIRECTIONS
The argument in favor of increasing access to high-quality mental health care by promoting primary care–mental health integration is compelling. Using the medical home as a platform makes sense and could decrease costs in the long-term. This could be achieved by focusing on prevention and health promotion, which could lead to less frequent emergency room visits or hospitalizations. The current health care debate has the potential to push health care delivery toward the medical home model. Child psychiatry and pediatric primary care providers have a great opportunity to use the medical home model as a platform to further integrate mental health and primary care. Pediatric primary care providers can provide additional mental health care through incorporating screenings and directly treating less severely mentally ill patients. Pediatric mental health providers can support primary care providers through a combination of colocation, consultation and enhanced collaboration. The concept of less fragmented and better-coordinated care system models needs to be universal and must include mental health. Successful adoption of the medical home model will require a comprehensive plan to address the challenges reviewed more than. Specific action items to aid in the adoption of the medical home are discussed in the following paragraphs. One of the largest barriers to overcome is stigma. Australia and New Zealand have focused extensively in destigmatizing mental illness. Like Minds Like Mine (http:// www.likeminds.govt.nz) is a high-profile national campaign funded by the Ministry of Health in New Zealand. This program has won a prestigious advertising award and has featured well-known New Zealanders talking about their experience of mental illness. Those featured include athletes, musicians, business people, and others with prominence in the community. The general public would benefit from a more open environment to discuss their mental health concerns as well as a better understanding of fundamental concepts, such as the fact that mental illness is just as real as heart disease or cancer; and that it is quite treatable. Next comes the issue of developing a greater knowledge base and improved clinical acumen in the provider community. Improved psychiatric education in medical schools and in postgraduate residency training is a fundamental step in that process. Mental health needs to be taught as a common problem in routine medical visits. Greater emphasis needs to be placed on psychiatry, and more specifically, child psychiatry as a core medical school rotation. In 2009, the AAP published a policy statement on Mental Health Competencies for Pediatric Primary Care.29 The statement suggests strategies for mental health education, describes the many challenges and states, “attainment of the mental health competencies proposed is a future goal, not a current expectation.” Currently, pediatric residents have limited exposure to mental health during their training and even when it happens, it is often an elective
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rotation and not considered an important aspect of their training as a physician. The RRC needs to mandate exposure to child psychiatry into pediatric residency training. For those providers who are already in practice, significant efforts need to be put in place to retool their skill set. One innovative method is through the use of standardized assessment and treatment algorithms.30 By beginning with the most common chief complaints presenting to a pediatric primary care office, the use of a programmed text can allow providers to input clinical information to ascertain the next steps in the diagnosis and treatment of common child mental health conditions. With time, as these algorithms are used repeatedly, pediatric primary care providers would become more accomplished in incorporating best practices into their management of psychiatric conditions. A key aspect of such a resource is the inclusion of a primer on how to restructure a primary care practice to efficiently treat and manage youth and families dealing with mental health problems; how to incorporate the standard use of pediatric rating scales31 and screening tools,32 such as the pediatric symptom checklist, within routine primary care appointments; and incorporation of when to refer criteria so that primary care providers are not left managing cases that are beyond their level of expertise.30 The next major hurdle comes in the form of creating viable practice models. One such method is to colocate pediatric mental health providers with primary care providers. This would allow for greater provision of direct patient care in the primary care setting; perhaps including assessment and treatment of more complex patients by mental health providers; serve as an in-house consultation service to primary care providers; and can allow for greater collaboration for shared cases. Colocation would also improve access to mental health care to patients with other serious or chronic illnesses, such as diabetes or heart conditions, whose medical course and recovery are impaired by a coexisting mental health disorder, such as depression. In addition, improved behavioral outcomes that affect overall wellness in children, such as obesity, can be addressed in collaboration between the mental health and primary care provider. Colocation also allows for greater access to appropriate treatment of mild or moderate mental health disorders by either direct service from the mental health provider or through treatment provided directly by the primary care provider as a result of easier consultation. For more complex cases, improved referral and linkage to mental health specialty care is advantageous. This health care delivery model can only be successful if coding and billing limitations are addressed to make it financially viable. More broadly, administrative and financial barriers identified in the Joint AACAP/AAP white paper23 also need to be addressed. In 2006, in a landmark decision with national implications, the US District Court in Springfield, MA, ruled that the Commonwealth of Massachusetts was violating the federal Medicaid Act by failing to provide home-based mental health services to an estimated 15,000 children with serious emotional disturbance. The class lawsuit was known as Rosie D versus Romney and was based on the broad interpretation of the federal Medicaid Act, in particular the EPSDT mandate. Attorneys for the plaintiff class contended that state officials violated the Medicaid Act by failing to comply with its EPSDT mandate. As a result, Massachusetts has greatly enhanced their requirements for screening and treatment of developmental and mental health issues for children and adolescents. The Massachusetts Child Psychiatry Access Program (MCPAP) is a collaborativecare model that focuses on expanding the role of the mental health provider as a consultant to pediatric primary care offices. As opposed to a straight colocation model, MCPAP provides pediatricians with immediate access to telephone
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consultation, outpatient evaluation, care coordination, and educational resources to support the provision of care for children in the primary care setting. Instead of simply accepting consults, MCPAP clinicians help to educate primary care providers about appropriate next steps and may eliminate the need for a referral to a child psychiatry specialist for uncomplicated patients. For more complex cases, MCPAP provides care coordination to facilitate referral to a child and adolescent psychiatrist for treatment. Pediatric practices participating in MCPAP agree to maintain appropriate involvement in the monitoring and coordination of care for children with mental health problems. Perhaps, a more immediate and attainable intervention is the promotion of mental health education through Collaborative Office Rounds (COR). COR have been established in various communities for the purpose of enhancing mental health knowledge and skills of primary care providers and their communication with mental health specialists.33–35 It has typically been done through a 1- to 2-hour session per month that involves psychiatrists and/or developmental-behavioral pediatricians and primary care providers in a case-based discussion. COR could be considered as 1 starting point to developing relationships between mental health specialists and primary care providers that would then develop into more formalized consultation systems. Financing and sustaining a COR program can sometimes pose a significant obstacle. In some places, COR programs have been funded through grants. Innovative programs funded by public and private payers to support COR would be beneficial. Likewise, investment in developing and researching collaborative models of care between child psychiatry and primary care is needed to further elucidate best practices. True improvement in child mental health will not occur without a significant increase in the availability of child mental health providers. Passage of the Child Health Care Crisis Relief Act36 in Congress to provide loan forgiveness and scholarships to individuals who study in graduate and medical programs in child mental health is crucial to the success of the medical home. There is a significant need to show improved outcomes for children within medical homes, particularly when using the broader definition to include all children. Because of economic realities in health care, it will also be imperative to show long-term cost savings to gain broader acceptance from private ensurers. There is currently a medical home demonstration project being conducted by the Center for Medicare and Medicaid Services to investigate the value of the medical home for care of adults with chronic conditions.5 It will be important to have such a study for children as well as in the general population for those without chronic medical conditions. A great opportunity to incorporate the medical home model as a health care delivery platform is currently on the horizon to improve mental health care by further integrating mental health and primary care. Significant resources will be needed to address the multitude of challenges present in preventing its successful adoption. The presence of a robust evidence base to support its adoption will be key. REFERENCES
1. Sia C, Tonniges T, Osterhus E, et al. History of the medical home concept. Pediatrics 2004;113:1473–8. 2. Moore B, Tonniges T. The “every child deserves a medical home” training program: more than a traditional continuing medical education course. Pediatrics 2004;113(Suppl):1479–84. 3. American Academy of Pediatrics ad hoc task force on definition of the medical home: the medical home. Pediatrics 1992;90:774.
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4. Institute of Medicine. Crossing the chasm: a new health system for the 21st century. Washington, DC: National academy Press; 2001. 5. Wegner S, Antonelli R, Turchi R. The medical home – improving quality of primary care for children. Pediatr Clin North Am 2009;56:953–64. 6. American Academy of Pediatrics, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The medical home. Pediatrics 2002;110(1):184–6, Reaffirmed Pediatrics 2008;122(2):450. 7. Joint principles of the patient-centered medical home. March 2007. Available at: http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/ jointprinciplespcmh0207.Par.0001.File.tmp/022107medicalhome.pdf. Accessed February 8, 2010. 8. Cooper S, Valleley RJ, Polaha J, et al. Running out of time: physician management of behavioral health concerns in rural pediatric primary care. Pediatrics 2006;118:132–8. 9. The National Research Council and the Institute of Medicine. Preventing mental health, emotional and behavioral disorders among young people: progress and possibilities. Washington, DC: National Academies Press; 2009. 10. Thielke S, Vannoy S, Unutzer J. Integrating mental health and primary care. Clinics in Office Practice. Prim Care 2007;34:571–92. 11. Briggs-Gowan MJ, Horowitz SM, Schwab-Stone ME, et al. Mental health in pediatric settings: distribution of disorders and factors related to service use. J Am Acad Child Adolesc Psychiatry 2000;39(7):841–9. 12. Pescosolido BA, Jensen PS, Martin JK, et al. Public knowledge and assessment of child mental health problems: findings from the National Stigma Study-Children. J Am Acad Child Adolesc Psychiatry 2008;47(3):339–49. 13. Lesesne CA, Visser SN, White CP. Attention-deficit/hyperactivity disorder in school-aged children: association with maternal mental health and use of health care resources. Pediatrics 2003;111:1232–7. 14. Lyons-Ruth K, Connell DB, Grunebaum HU. Infants at social risk: maternal depression and family support services as mediators of infant development and security of attachment. Child Dev 1990;61:85–98. 15. Webster-Stratton C, Hammond M. Maternal depression and its relationship to life stress, perceptions of child behavior problems, parenting behaviors, and child conduct problems. J Abnorm Child Psychol 1988;16:299–315. 16. Beardslee WR, Bemporad J, Keller MB, et al. Children of parents with a major affective disorder: a review. Am J Psychiatry 1983;140:825–32. 17. Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey. Am J Public Health 2006;96(7):1–8. 18. Flores G, Tomany-Korman SC. The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children. Pediatrics 2008;121:e1703–14. 19. Gopal KS, Strickland BB, Ghandour RM, et al. Geographic disparities in access to the medical home among US CSHCN. Pediatrics 2009;124:S352–60. 20. Stein REK, Horwitz SM, Storfer-Isser A, et al. Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambul Pediatr 2008;8:11–7. 21. Rushton J, Bruckman D, Kelleher K. Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med 2002;156:592–8.
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22. Heneghan A, Garner AS, Storfer-Isser A, et al. Pediatricians’ role in providing mental health care for children and adolescents: do pediatricians and child and adolescent psychiatrists agree? J Dev Behav Pediatr 2008;29:262–9. 23. American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics and American Academy of Pediatrics Task Force of Mental Health. Improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics 2009;123:1248–51. 24. Serby M, Schmeidler J, Smith J. Length of psychiatry clerkships: recent changes and the relationship to recruitment. Acad Psychiatry 2002;26:102–4. 25. Zuckerbrot RA, Maxon L, Pagar D, et al. Adolescent depression screening in primary care: feasibility and acceptability. Pediatrics 2007;119:101–8. 26. Kim WJ, Enzer N, Bechtold D, et al. Meeting the mental health needs of children and adolescents: addressing the problems of access to care. Report of the Task Force on Workforce Needs. Washington, DC: American Academy of Child and Adolescent Psychiatry; 2001. 27. Pan RJ. A Jacobian future: can everyone have a medical home? Pediatrics 2006; 118:1254–6. 28. Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics 2008;122(4): e922–37. 29. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health Task Force on Mental Health. The future of pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009;124:410–21. 30. Trivedi HK, Kershner JD. Practical child and adolescent psychiatry for pediatrics and primary care. Cambridge (UK): Hogrefe and Huber; 2009. 31. Navon M, Nelson D, Pagano M, et al. Use of the Pediatric Symptom Checklist in strategies to improve preventative behavioral healthcare. Psychiatr Serv 2001;52: 800–4. 32. Stancin T, Palermo TM. A review of the behavioral screening practices in pediatric settings: do they pass the test? J Dev Behav Pediatr 1997;18:183–93. 33. DeMaso DR, Knight JR, editors. Collaboration essentials for pediatric and child and adolescent psychiatric residents: working together to treat the child. American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics. Boston: Children’s Hospital Boston; 2004. 34. Fishman ME, Kessel W, Heppel DE, et al. Collaborative office rounds: continuing education in the psychosocial/developmental aspects of child health. Pediatrics 1997;99(4):e5. 35. Connor DF, McLaughlin TJ, Jeffers-Terry M, et al. Targeted child psychiatric services: a new model of pediatric primary care clinician—child psychiatry collaborative care. Clin Pediatr 2006;45:423–34. 36. Child Health Care Crisis Relief Act of 2009. HR 1932, 11th Cong, 1st session. 2009. Available at: http://www.thomas.gov. Accessed February 8, 2010.
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KEYWORDS Primary care Medical home Child and adolescent psychiatry History Challenges Future directions Health care delivery/access Health policy
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.1 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
A version of this article was previously published in the Child and Adolescent Psychiatric Clinics of North America, 19:2. This work was not supported by any grant. a Vanderbilt Medical School, 21st Avenue South, Nashville, TN 37232, USA b Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South, 1157, Nashville, TN 37212, USA c Department of Psychiatry, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA d Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University/ NYSPI, Unit 78, 1051 Riverside Drive, New York, NY 10032, USA e New York Presbyterian Hospital, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA * Corresponding author. Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South 1157, Nashville, TN 37212. E-mail address: [email protected] Pediatr Clin N Am 58 (2011) 787–801 doi:10.1016/j.pcl.2011.06.014 pediatric.theclinics.com 0031-3955/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
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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.1 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.2 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.1 Box 1 reviews AAP’s first official policy defining the medical home from 1992.3 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.1 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 Box 1 Major components of AAP medical home policy statement from 1992 Medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family centered, coordinated, and compassionate Delivered or directed by well-trained physicians who are able to manage or facilitate essentially all aspects of pediatric care Physician should be known to the child and family Physician should be able to develop mutually responsible and trusting relationship with patient and family Acknowledges that attainment of medical home is unobtainable for many children because of geographic barriers, personnel constraints, practice patterns, and economic and social forces 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 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 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 Whether physically present or not, physician acts as child’s advocate and assume control and ultimate responsibility for care provided. Data from American Academy of Pediatrics ad hoc task force on definition of the medical home: the medical home. Pediatrics 1992;90:774.
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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.4 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.5 Specific recommendations in the 2002 AAP medical home policy6 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. 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.7 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, physiciandirected 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
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Box 2 Desirable characteristics of a medical home 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 Act10 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,
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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.) From The medical home. American Academy of Pediatrics, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Pediatrics 2002;110(1):184–6; with permission.
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
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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.8 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.9 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.10 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. BriggsGowan and colleagues11 studied the prevalence of psychiatric disorders among 5to 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 colleagues12 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
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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.13 This is in addition to a long-standing body of evidence regarding the effects of maternal depression on infant attachment,14 behavioral problems,15 and psychopathology.16 Consider, in addition, the effects of socioeconomic status,17 language and racial disparities,18 geographic issues,19 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 colleagues20 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 colleagues21 indicates that only 1 Table 1 Pediatrician agreement about being responsible based on child’s condition/problem Agree Pediatricians Should be Responsible for: Child’s Problem/ Condition
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)
Data from Stein REK, Horwitz SM, Storfer-Isser A, et al. Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambul Pediatr 2008;8(1):11–17.
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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.” 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
Table 2 Primary care pediatrician and child and adolescent psychiatrist agreement with pediatrician responsibility for identifying, treating, and referring child mental health problems Agree that Pediatricians Should be Responsible for
PCPs (n 5 132) N
Weighted %
CAPs (n 5 31) N
Weighted %
P Value
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
Data from Heneghan A, Garner AS, Storfer-Isser A, et al. Pediatricians’ role in providing mental health care for children and adolescents: do pediatricians and child and adolescent psychiatrists agree? J Dev Behav Pediatr 2008;29(4):262–9.
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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.22 Systemic Factors
Although patient/family and provider factors are significant, the greatest impediments to successful adoption of the medical home lies within systemic factors. Current systemic issues include lack of standardized definitions, presence of administrative and financial barriers to its adoption, lack of technological interoperability and confidentiality concerns, lack of adequate training of medical professionals, relative supply/demand of specific types of providers, and a lack of evidence of large-scale feasibility and population-level improvement in health outcomes. Although the medical home model exists and attempts have been made to create operational definitions of how this should form the basis of a medical practice, there are currently several stakeholders, each with varying views. A few rhetorical questions are included to illustrate how complicated the nuances can be. Should a pediatric medical home located in the outpatient clinic of a major tertiary care Children’s Hospital in New York City look and function exactly the same as a pediatric medical home located in a rural family practitioner’s office 75 miles from Missoula, Montana? Should a general pediatrician be expected to evaluate, manage, and treat the same level of patient severity as a developmental-behavioral pediatrician in the same medical home practice? How will the medical home model equilibrate with regard to varying expectations of providers and patients about when to refer patients to specialty providers, for which conditions, and after how much clinical intervention has occurred at the medical home site? How will patient outcomes be measured to ensure that each provider is functioning according to the medical home model and using optimal decision making to maximize medical home gains? Which assessment tool(s) will become universally accepted for evaluating medical home practices? Will accreditation become necessary to engage in medical practice or will it be the higher bar that only certain practices will meet? Will payers uniformly pay a premium for patients receiving care in these medical home sites? These and many additional questions will need to be figured out as the medical home is rolled out. With our fragmented system of health care, there are also significant administrative and financial barriers to successful adoption of the medical home. The American Academy of Child and Adolescent Psychiatry (AACAP) Health Care Access and Economics Committee and the AAP Mental Health Task Force recently published a white paper for reducing administrative and financial barriers to access and collaboration as a method to improve mental health services in primary care.23 Administrative barriers cited by this group include mental health intake procedures that bypass the primary care clinician, limited access to effective psychosocial interventions, lack of procedural and diagnostic parity in mental health and physical health benefits, inadequate communication and comanagement mechanisms, lack of coverage for recommended assessment and treatment services, and limited or no coverage for out-of-network providers (even when in-network providers are not able to see new clients). Financial barriers include lack of payment for visits with parents only (without child present as identified patient), lack of payment for other non–face-to-face components of care and consultation, insufficient payment for mental health services including management of emerging problems or symptoms not meeting a diagnostic
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threshold, insurance plan policies precluding payment to primary care clinicians when mental health diagnostic codes are reported, high out-of-pocket expenses for certain medications, and application of “incident to” payment methodology to prevent coverage of colocated services. Although there has been a significant push recently for the adoption of meaningful use IT solutions in health care, several significant concerns remain unaddressed. Although many practices are beginning to use EHRs and e-prescribing, interoperability of different software platforms drastically impedes the ability of medical homes to effectively and efficiently collaborate with other providers.5 Anecdotally, some physicians have found that even when newer versions of the same software programs are rolled out within the same practice, vendors are disallowing access to data in the previous software version out of concerns about liability if the newer software either omits or erroneously migrates the wrong information. Likewise, as medicine shifts to IT solutions, the potential for breach of confidentiality also increases. Because of the stigma of mental illness, this is of particular concern to the mental health community. Even if these concerns could be addressed, there are also fundamental issues in the training of physicians to care for psychiatric illnesses. Nationally, there has been a trend to decrease the length of psychiatry rotations in medical schools24 with many offering little to no exposure to child psychiatry. It can easily be said that a first year house officer in Psychiatry is more likely to know how to appropriately diagnose and manage asthma or diabetes; than a first year Pediatrics resident is likely to know how to appropriately diagnose and manage ADHD or first break psychosis. When these medical students graduate and enter a pediatrics residency, the Accreditation Council for Graduate Medical Education Residency Review Committee (RRC) training requirements do not mandate any mental health training thus leading to minimal development of knowledge base and clinical management of psychiatric illnesses. How then can primary care pediatricians be expected to safely and effectively diagnose, manage, and refer all children walking into their primary care pediatric practices with mental health problems? Even for those medical home practices that are keen to adopt mental health diagnosis and management, there is the problem of supply/demand of providers. Although screening has been shown to be feasible in pediatric practices,25 a common problem is where to refer the patients who are severely ill and require specialty care. Children’s mental health faces a significant shortage of all levels of providers. For example, in child and adolescent psychiatry, 7000 are in practice although there is currently a need for 30,000.26 Imbalances also exist on the primary care end of this equation. In a commentary regarding whether everyone can have a medical home, Pan27 notes that the growth in the number of general pediatricians will greatly exceed the growth of the pediatric population by 2020. Likewise, this growth is expected to exceed sufficiency and create a competitive situation where there may not be enough pediatric patients for primary care pediatricians and family practitioners. Pan suggests “Family medicine could partially or wholly withdraw from the care of children and focus on the aging population, or they could compete directly with pediatrics for the primary care of children and adolescents. An alternative to these options is for family medicine and pediatrics to collaborate in providing medical homes for all children and their families. Collaboration is an important option for the future.” On the issue of an evidence base, although studies have been done to elucidate the effectiveness of medical homes for CSHCN, significant data are lacking as to whether the medical home model can be justified for nonmedically complicated children. Homer and colleagues28 looked at the evidence for medical homes for children with
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special health care needs. After reviewing more than 30 studies, they found that there is moderate support for the conclusion that “medical homes provide improved health related outcomes for children with special health care needs,” however, “more research encompassing all or most of the attributes of the medical home need to be undertaken.” In an era of health care reform and concerns about the ballooning cost of health care, robust data are needed on clinically significant improvements in health, actual cost-effectiveness of this health care delivery model, as well as, data justifying expansion of the medical home model to include all comers.
FUTURE DIRECTIONS
The argument in favor of increasing access to high-quality mental health care by promoting primary care–mental health integration is compelling. Using the medical home as a platform makes sense and could decrease costs in the long-term. This could be achieved by focusing on prevention and health promotion, which could lead to less frequent emergency room visits or hospitalizations. The current health care debate has the potential to push health care delivery toward the medical home model. Child psychiatry and pediatric primary care providers have a great opportunity to use the medical home model as a platform to further integrate mental health and primary care. Pediatric primary care providers can provide additional mental health care through incorporating screenings and directly treating less severely mentally ill patients. Pediatric mental health providers can support primary care providers through a combination of colocation, consultation and enhanced collaboration. The concept of less fragmented and better-coordinated care system models needs to be universal and must include mental health. Successful adoption of the medical home model will require a comprehensive plan to address the challenges reviewed more than. Specific action items to aid in the adoption of the medical home are discussed in the following paragraphs. One of the largest barriers to overcome is stigma. Australia and New Zealand have focused extensively in destigmatizing mental illness. Like Minds Like Mine (http:// www.likeminds.govt.nz) is a high-profile national campaign funded by the Ministry of Health in New Zealand. This program has won a prestigious advertising award and has featured well-known New Zealanders talking about their experience of mental illness. Those featured include athletes, musicians, business people, and others with prominence in the community. The general public would benefit from a more open environment to discuss their mental health concerns as well as a better understanding of fundamental concepts, such as the fact that mental illness is just as real as heart disease or cancer; and that it is quite treatable. Next comes the issue of developing a greater knowledge base and improved clinical acumen in the provider community. Improved psychiatric education in medical schools and in postgraduate residency training is a fundamental step in that process. Mental health needs to be taught as a common problem in routine medical visits. Greater emphasis needs to be placed on psychiatry, and more specifically, child psychiatry as a core medical school rotation. In 2009, the AAP published a policy statement on Mental Health Competencies for Pediatric Primary Care.29 The statement suggests strategies for mental health education, describes the many challenges and states, “attainment of the mental health competencies proposed is a future goal, not a current expectation.” Currently, pediatric residents have limited exposure to mental health during their training and even when it happens, it is often an elective
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rotation and not considered an important aspect of their training as a physician. The RRC needs to mandate exposure to child psychiatry into pediatric residency training. For those providers who are already in practice, significant efforts need to be put in place to retool their skill set. One innovative method is through the use of standardized assessment and treatment algorithms.30 By beginning with the most common chief complaints presenting to a pediatric primary care office, the use of a programmed text can allow providers to input clinical information to ascertain the next steps in the diagnosis and treatment of common child mental health conditions. With time, as these algorithms are used repeatedly, pediatric primary care providers would become more accomplished in incorporating best practices into their management of psychiatric conditions. A key aspect of such a resource is the inclusion of a primer on how to restructure a primary care practice to efficiently treat and manage youth and families dealing with mental health problems; how to incorporate the standard use of pediatric rating scales31 and screening tools,32 such as the pediatric symptom checklist, within routine primary care appointments; and incorporation of when to refer criteria so that primary care providers are not left managing cases that are beyond their level of expertise.30 The next major hurdle comes in the form of creating viable practice models. One such method is to colocate pediatric mental health providers with primary care providers. This would allow for greater provision of direct patient care in the primary care setting; perhaps including assessment and treatment of more complex patients by mental health providers; serve as an in-house consultation service to primary care providers; and can allow for greater collaboration for shared cases. Colocation would also improve access to mental health care to patients with other serious or chronic illnesses, such as diabetes or heart conditions, whose medical course and recovery are impaired by a coexisting mental health disorder, such as depression. In addition, improved behavioral outcomes that affect overall wellness in children, such as obesity, can be addressed in collaboration between the mental health and primary care provider. Colocation also allows for greater access to appropriate treatment of mild or moderate mental health disorders by either direct service from the mental health provider or through treatment provided directly by the primary care provider as a result of easier consultation. For more complex cases, improved referral and linkage to mental health specialty care is advantageous. This health care delivery model can only be successful if coding and billing limitations are addressed to make it financially viable. More broadly, administrative and financial barriers identified in the Joint AACAP/AAP white paper23 also need to be addressed. In 2006, in a landmark decision with national implications, the US District Court in Springfield, MA, ruled that the Commonwealth of Massachusetts was violating the federal Medicaid Act by failing to provide home-based mental health services to an estimated 15,000 children with serious emotional disturbance. The class lawsuit was known as Rosie D versus Romney and was based on the broad interpretation of the federal Medicaid Act, in particular the EPSDT mandate. Attorneys for the plaintiff class contended that state officials violated the Medicaid Act by failing to comply with its EPSDT mandate. As a result, Massachusetts has greatly enhanced their requirements for screening and treatment of developmental and mental health issues for children and adolescents. The Massachusetts Child Psychiatry Access Program (MCPAP) is a collaborativecare model that focuses on expanding the role of the mental health provider as a consultant to pediatric primary care offices. As opposed to a straight colocation model, MCPAP provides pediatricians with immediate access to telephone
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consultation, outpatient evaluation, care coordination, and educational resources to support the provision of care for children in the primary care setting. Instead of simply accepting consults, MCPAP clinicians help to educate primary care providers about appropriate next steps and may eliminate the need for a referral to a child psychiatry specialist for uncomplicated patients. For more complex cases, MCPAP provides care coordination to facilitate referral to a child and adolescent psychiatrist for treatment. Pediatric practices participating in MCPAP agree to maintain appropriate involvement in the monitoring and coordination of care for children with mental health problems. Perhaps, a more immediate and attainable intervention is the promotion of mental health education through Collaborative Office Rounds (COR). COR have been established in various communities for the purpose of enhancing mental health knowledge and skills of primary care providers and their communication with mental health specialists.33–35 It has typically been done through a 1- to 2-hour session per month that involves psychiatrists and/or developmental-behavioral pediatricians and primary care providers in a case-based discussion. COR could be considered as 1 starting point to developing relationships between mental health specialists and primary care providers that would then develop into more formalized consultation systems. Financing and sustaining a COR program can sometimes pose a significant obstacle. In some places, COR programs have been funded through grants. Innovative programs funded by public and private payers to support COR would be beneficial. Likewise, investment in developing and researching collaborative models of care between child psychiatry and primary care is needed to further elucidate best practices. True improvement in child mental health will not occur without a significant increase in the availability of child mental health providers. Passage of the Child Health Care Crisis Relief Act36 in Congress to provide loan forgiveness and scholarships to individuals who study in graduate and medical programs in child mental health is crucial to the success of the medical home. There is a significant need to show improved outcomes for children within medical homes, particularly when using the broader definition to include all children. Because of economic realities in health care, it will also be imperative to show long-term cost savings to gain broader acceptance from private ensurers. There is currently a medical home demonstration project being conducted by the Center for Medicare and Medicaid Services to investigate the value of the medical home for care of adults with chronic conditions.5 It will be important to have such a study for children as well as in the general population for those without chronic medical conditions. A great opportunity to incorporate the medical home model as a health care delivery platform is currently on the horizon to improve mental health care by further integrating mental health and primary care. Significant resources will be needed to address the multitude of challenges present in preventing its successful adoption. The presence of a robust evidence base to support its adoption will be key. REFERENCES
1. Sia C, Tonniges T, Osterhus E, et al. History of the medical home concept. Pediatrics 2004;113:1473–8. 2. Moore B, Tonniges T. The “every child deserves a medical home” training program: more than a traditional continuing medical education course. Pediatrics 2004;113(Suppl):1479–84. 3. American Academy of Pediatrics ad hoc task force on definition of the medical home: the medical home. Pediatrics 1992;90:774.
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4. Institute of Medicine. Crossing the chasm: a new health system for the 21st century. Washington, DC: National academy Press; 2001. 5. Wegner S, Antonelli R, Turchi R. The medical home – improving quality of primary care for children. Pediatr Clin North Am 2009;56:953–64. 6. American Academy of Pediatrics, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The medical home. Pediatrics 2002;110(1):184–6, Reaffirmed Pediatrics 2008;122(2):450. 7. Joint principles of the patient-centered medical home. March 2007. Available at: http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/ jointprinciplespcmh0207.Par.0001.File.tmp/022107medicalhome.pdf. Accessed February 8, 2010. 8. Cooper S, Valleley RJ, Polaha J, et al. Running out of time: physician management of behavioral health concerns in rural pediatric primary care. Pediatrics 2006;118:132–8. 9. The National Research Council and the Institute of Medicine. Preventing mental health, emotional and behavioral disorders among young people: progress and possibilities. Washington, DC: National Academies Press; 2009. 10. Thielke S, Vannoy S, Unutzer J. Integrating mental health and primary care. Clinics in Office Practice. Prim Care 2007;34:571–92. 11. Briggs-Gowan MJ, Horowitz SM, Schwab-Stone ME, et al. Mental health in pediatric settings: distribution of disorders and factors related to service use. J Am Acad Child Adolesc Psychiatry 2000;39(7):841–9. 12. Pescosolido BA, Jensen PS, Martin JK, et al. Public knowledge and assessment of child mental health problems: findings from the National Stigma Study-Children. J Am Acad Child Adolesc Psychiatry 2008;47(3):339–49. 13. Lesesne CA, Visser SN, White CP. Attention-deficit/hyperactivity disorder in school-aged children: association with maternal mental health and use of health care resources. Pediatrics 2003;111:1232–7. 14. Lyons-Ruth K, Connell DB, Grunebaum HU. Infants at social risk: maternal depression and family support services as mediators of infant development and security of attachment. Child Dev 1990;61:85–98. 15. Webster-Stratton C, Hammond M. Maternal depression and its relationship to life stress, perceptions of child behavior problems, parenting behaviors, and child conduct problems. J Abnorm Child Psychol 1988;16:299–315. 16. Beardslee WR, Bemporad J, Keller MB, et al. Children of parents with a major affective disorder: a review. Am J Psychiatry 1983;140:825–32. 17. Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey. Am J Public Health 2006;96(7):1–8. 18. Flores G, Tomany-Korman SC. The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children. Pediatrics 2008;121:e1703–14. 19. Gopal KS, Strickland BB, Ghandour RM, et al. Geographic disparities in access to the medical home among US CSHCN. Pediatrics 2009;124:S352–60. 20. Stein REK, Horwitz SM, Storfer-Isser A, et al. Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambul Pediatr 2008;8:11–7. 21. Rushton J, Bruckman D, Kelleher K. Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med 2002;156:592–8.
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22. Heneghan A, Garner AS, Storfer-Isser A, et al. Pediatricians’ role in providing mental health care for children and adolescents: do pediatricians and child and adolescent psychiatrists agree? J Dev Behav Pediatr 2008;29:262–9. 23. American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics and American Academy of Pediatrics Task Force of Mental Health. Improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics 2009;123:1248–51. 24. Serby M, Schmeidler J, Smith J. Length of psychiatry clerkships: recent changes and the relationship to recruitment. Acad Psychiatry 2002;26:102–4. 25. Zuckerbrot RA, Maxon L, Pagar D, et al. Adolescent depression screening in primary care: feasibility and acceptability. Pediatrics 2007;119:101–8. 26. Kim WJ, Enzer N, Bechtold D, et al. Meeting the mental health needs of children and adolescents: addressing the problems of access to care. Report of the Task Force on Workforce Needs. Washington, DC: American Academy of Child and Adolescent Psychiatry; 2001. 27. Pan RJ. A Jacobian future: can everyone have a medical home? Pediatrics 2006; 118:1254–6. 28. Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics 2008;122(4): e922–37. 29. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health Task Force on Mental Health. The future of pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009;124:410–21. 30. Trivedi HK, Kershner JD. Practical child and adolescent psychiatry for pediatrics and primary care. Cambridge (UK): Hogrefe and Huber; 2009. 31. Navon M, Nelson D, Pagano M, et al. Use of the Pediatric Symptom Checklist in strategies to improve preventative behavioral healthcare. Psychiatr Serv 2001;52: 800–4. 32. Stancin T, Palermo TM. A review of the behavioral screening practices in pediatric settings: do they pass the test? J Dev Behav Pediatr 1997;18:183–93. 33. DeMaso DR, Knight JR, editors. Collaboration essentials for pediatric and child and adolescent psychiatric residents: working together to treat the child. American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics. Boston: Children’s Hospital Boston; 2004. 34. Fishman ME, Kessel W, Heppel DE, et al. Collaborative office rounds: continuing education in the psychosocial/developmental aspects of child health. Pediatrics 1997;99(4):e5. 35. Connor DF, McLaughlin TJ, Jeffers-Terry M, et al. Targeted child psychiatric services: a new model of pediatric primary care clinician—child psychiatry collaborative care. Clin Pediatr 2006;45:423–34. 36. Child Health Care Crisis Relief Act of 2009. HR 1932, 11th Cong, 1st session. 2009. Available at: http://www.thomas.gov. Accessed February 8, 2010.
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