Medical Home and Pediatric Primary Care Utilization Among Children With Special Health Care Needs

Nawal  Ali Ahmed 

The medical home is a team based health care delivery model led by a physician, P.A., or N.P. that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is “an approach to providing comprehensive primary care for children, youth and adults”. The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health.[1]

The medical home have been established through the cohesive efforts of the National Academy of Pediatrics, National Academy of Family Physicians, National College of Physicians ,and National Osteopathic Association. Care coordination is an essential component of the medical home and requires additional resources such as health information technology, appropriately trained staff to provide coordinated care through team-based models.[2]

Levels of morbidity in 789 children 7 to 11 years of age attending two primary care pediatric clinics in a health maintenance organization were examined in relation to psychiatric disturbance. Children identified by pediatricians as disturbed had more than twice as many physical illness episodes as non-identified children. Children identified by the standard psychiatric assessment had the same number of physical illness episodes as no disturbed children.[3]

High cost of care was recently supplemented by a finding that CSHCN health

expenditures were on average three times higher and hospital expenses were four times higher than those of healthier children (Cohen et al., 2010).

Some studies found that CSHCN made a significantly higher number of physician office visits than did children without special health care needs (Houtrow, Kim, Chen, & Newacheck, 2007; Martin, Crawford, &Probst, 2007). Weller, Minkovitz, and Anderson (2003)

noted higher rates of hospitalizations and emergency department (ED) visits among CSHCN with severe functional limitations but found no differences in the number of pediatric primary care (PPC) office visits. According to the 2008 National Survey of Children’s Health, children with special needs had more wellchild visits than did other children (Cooley, McAllister,

Sherrieb, & Kuhlthau, 2009). Nageswaran, Roth, Kluttz-Hile, & Farel (2007) reported higher rates of health care needs among CSHCN with greater functional limitations but found no increase in preventive or health assessment office visits. Similarly, a 2004 study found no difference between children with and without special health care needs in terms of preventive care (Bethell, Read,&Brockwood, 2004). Some evidence indicates that CSHCN receive less preventive and well child care than their healthy peers because their health care needs may dominate the time and conversation during PPC office visits (Ayyangar, 2002).

In recent years, an increasing emphasis has been placed on improving health care delivery for CSHCN in the context of the family and community (American Academy of Pediatrics, 2009; Coker, Rodrigues, & Flores, 2010; National Association of Pediatric Nurse Practitioners, 2009). The American Academy of Pediatrics defined medical home not only as the central location for receiving medical services but also a source of preventive care and a resource for community information and support (American Academy of Pediatrics, 2002). The National Association of Pediatric Nurse Practitioners (2009) supported the approach and proposed to expand the medical home concept to all children and their families in the United States. The Patient Protection and Affordable Care Act (2010) emphasized the need

for strong primary care based on the medical home model. The Law also stipulates medical home provisions for persons with chronic medical conditions (Sec. 2703).

limitations but found no differences in the number of pediatric primary care (PPC) office visits.

Situation Analysis

A medical home play a significant role in addressing health care needs of CSHCN, because CSHCN with medical homes had a greater number of PPC office visits than did children without medical homes. younger CSHCN (< 6 years) had more PPC visits than did older children. Female gender was associated with having more PPC visits than male gender. The minority groups were more likely to have fewer PPC visits than were White children.

As functional limitations of CSHCN increased, so did the likelihood of more PPC visits. A positive association was found between an increased educational level of the household and the number of PPC visits for the CSHCN. Children living in rural areas were more likely to have more PPC visits than their peers in urban areas. CSHCN with public health insurance were more likely than those who were uninsured or with private insurance to have six or more annual PPC visits. The higher number of PPC doctor visits for children with medical homes was not surprising. A few studies reported similar outcomes. For instance, Ferrante, Balasubramanian, Hudson, and Crabtree (2010) examined major patient-centered medical home characteristics and found that they were associated with a larger number of doctor visits in the previous 2 years for adult patients. Strickland and colleagues (2009) demonstrated that a significantly greater proportion of children without a medical home (23%) had unmet health care needs compared with children with a medical home (8%).[4]

The special needs interview completion rate demonstrated an overall interest of families with CSHCN to provide data. Specifically, the special needs interview

completion rate was 96% compared with the national weighted response rate of 56%.

However, the study design has a number of limitations. Because it was a cross sectional design, we cannot assert cause and effect relationships. Because the

data analyzed in this study were based on caregiver/guardian responses, they may be

subject to response and recall biases. The interviews were conducted using landline

residential telephones; however, the 2009 data collected by the Centers for Disease Control and Prevention indicated that about 25% of U.S. households did not have landline telephones, as they rely exclusively on cellular phones (Blumberg & Luke, 2010). Additionally, these data were collected before current health care reform initiatives; the results could be different now as awareness of the medical home concept is higher in the medical community and general population. [5]

In Yemen Access to health services is difficult to define. It is a multidimensional process that in addition to the quality of care, involves geographical accessibility, availability of the right type of care for those who need it, financial accessibility, and acceptability of service. Geographic accessibility, the distance that must be traveled in order to use health facility, may present an important barrier of access to health services. Studies in developing countries have presented strong evidence that physical proximity of health service can play an important role in the use of primary healthcare In Yemen, we have demonstrated that driving distance and driving time are important predictors for developing severe malaria in comparison to mild malaria .It is hypothesized that long distance can be a significant obstacle to reaching health facilities, and a disincentive even to trying to seek care .The recent advances of Geographic Information Systems(GIS) have provided an important tool for healthcare

planning particularly in measuring access to health services. Major progress was made in industrialized countries where the detailed data inputs such as detailed road network are available .For example, Brabyn and Skelly used cost path analysis in order to determine the minimum travel time and distance to the closest hospital via road network in New Zealand .More recently there was an attempt to produce a single index for the overall access to health services from combined physical access to the resources and the amount of resources available Application of such methods in developing countries, however, remained constrained by the lack of data inputs even in a hard copy form. [5]

Yemen is the most populous and poorest country in the Arabian Peninsula. Access to health services is problematic because of the vast geographical area and the sparse

population distribution across the rural areas in addition to a poorly developed road networks and lack of proper public transport. Over 70% of Yemen’s population of

(19.7 million) live in rural areas (Population Census, 2004) where primary healthcare covers about 30% of the population (WHO, 2003). [5]

Measuring geographical access to health services using self-reported data is not reliable because it is difficult for patients to remember the distance they have traveled or the time of the journey .Instead physical access to the nearest health service is usually estimated by straight-line distance, driving distance or travel time .Driving distance and travel time is difficult to obtain where there is no transport system or well-developed road networks. Straight-line distances are easily obtained but its relationship with driving distance or travel time is not always clear. This study aimed to investigate the relationship between different measures of distance to health services in Yemen and to determine the association between these measures and utilization of preventive health services. It demonstrates that straight-line distance is strongly linked to driving distance and travel time. Straight-line distance, like driving distance and driving time, is an independent predictor for vaccination of children, a reasonable proxy for preventative medical services. [5]

When CSHCN age, gender, ethnicity/race, functional status, insurance status, household education, residence, and income were included in the model, CSHCN with a medical home were 1.6 times more likely to have six or more annual pediatric primary care office visits than were children without a medical home. Female CSHCN, younger CSHCN, children with public health insurance, children with severe functional limitations, and CSHCN living in rural areas also were more

likely to have a larger number of visits. [4]