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Patient-centered Medical Home 2016 by David Tayloe Jr., MD

Posted: 08/08/2016

In 1967, the American Academy of Pediatrics (AAP), under the leadership of Calvin Sia, MD, FAAP, of Hawaii, began using the term "medical home" to develop an approach to taking good care of children with special health care needs.[i][ii] In 2002, the AAP published a policy statement that explains the value of the medical home concept.[iii]   In 2007, primary care organizations published the Joint Principles for the Patient-Centered Medical Home.[iv] [v] The National Committee for Quality Assurance (NCQA) has developed a Recognition Program through which physicians can demonstrate to payers their efforts to build effective patient-centered medical homes.[vi] [vii]  The Patient-Centered Primary Care Collaborative was developed in 2008 and continues to provide an ongoing forum where health care professionals,  administrators, and policy experts can share experiences and ideas in an effort to improve patients' access to high quality care within the most cost-effective system.[viii]

 Much has been published about the medical home and the essence of good primary care. The American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians all have policy outlining the essence of the patient-centered medical home.   Can we boil all those guidelines down to a simple formula for primary care physicians?  There have been many attempts to do this, and I will reference one[ix] in which the authors state that there are "five components of medical homes:  usual source of care; personal doctor or nurse; family-centered care; coordinated care; and obtaining needed referrals."

In our pediatric practice, our goal, is to give all patients access to a pediatrician who can see their medical record 24-7 and can assist them in achieving optimal health outcomes by providing necessary acute care and comprehensive preventive services.  For patients with special needs, the patient-centered medical home should coordinate services to meet  the chronic health care needs of these patients and to help them achieve optimal outcomes through evidence-based, high quality, cost-effective care.

For Goldsboro Pediatrics,  the key components of the patient-centered medical home are:

1.  Visionary Leadership with Outcome-based Approach to Health Care

As our practice has grown from a one-pediatrician rental office to a 29-provider,  four-office,  integrated network, we have embraced a commitment to outcome-based care.  The managing partner is a pediatrician who is extremely talented in the areas of information technology and practice management.  We have a practice administrator who has his Masters in Business Administration and is gifted in the areas of human resources, information technology, and business.  One of our partners is very involved in community, state, and national health care politics, such that our practice is always working closely to mold the child health programs of Medicaid, CHIP (Child Health Insurance Program), and Blue Cross.  We have mental health professionals on our staff, along with a full-time lactation consultant.  We have focused on multiple bad outcomes in our patient population:  uncontrolled asthma, school failure, poor parent-infant attachment/bonding, obesity, adolescent pregnancy, inadequate school-readiness of kindergarten students, immunization refusal, foster care, and behavioral health conditions.  We have become adept at managing the use of psychotropic medications.   Our quality improvement efforts have resulted in a system of care for children at-risk to experience poor outcomes.

2.  A Team of  Providers Who are Able to Provide State-of-the-Art Care

Our team consists of 16 pediatricians, 8 nurse practitioners, 2 physician assistants, 2 mental health professionals, 1 lactation consultant, many nurses, numerous clerical staff, a practice administrator, and an office manager.  For the past 32 years, we have conducted 3-4 educational seminars per month for pediatricians, nurse practitioners, physician assistants, school-based health center staff,  pediatric providers who work on our air force base, mental health professionals, and lactation consultant.  Community partners are invited to these sessions.  Today, this program is jointly sponsored by the Brody School of Medicine at East Carolina University so that participants can receive up to 36 hours of Category I Continuing Medical Education credit each year.  The practice provides a generous budget for all providers to access appropriate out-of-town, on-line, and print  educational resources.  We are committed to being on the "cutting edge" in our specialty.

3.  24-7 Services to Minimize Unnecessary Emergency Department and Hospital Care

All four offices have routine hours from 8 AM until 5 PM Monday through Friday.  We conduct an 8-9 AM walk-in hour in all offices every weekday.  The main office is open until 8:30 PM Monday through Friday, and until 5 PM on Saturday, Sunday, and most official holidays.  After hours,  patients can call  the main office and talk to a nurse.  The nurse does not send the patients to  the Emergency Department without allowing the families to speak with an on-call pediatrician.  We supervise six school-based health centers that use our electronic health record and are open every minute the schools are in session.  Center enrollees are advised to call our main office when  the schools are closed.  When Medicaid administrators look at Emergency Department utilization, our practice is an outlier on the very low side.

4. Integration of Hospital Care and Office Care

A pediatrician is always on-call for our community hospital where we oversee a pediatric ward and a Level II Neonatal Unit. The census on the pediatric floor ranges from zero to fifteen.  The hospital delivers approximately 1500 babies per year.  Our pediatricians function as neonatologists for the hospital.   The on-call pediatrician provides consultation services for Emergency Department staff,  non-pediatric hospital physicians, and community-based physicians who need help taking care of pediatric patients.  We cannot justify the expense of having a pediatrician in the hospital 24-7, but a pediatrician is always readily available for hospital issues.  The on-call pediatrician can access the medical record system of the practice to assure continuity of care for our hospital patients.   

5.  Business Savvy Physicians and Staff

Our practice administrator and managing partner work with the office manager to assure that we file all third party insurance claims accurately, and receive payment efficiently.   Because we serve over 20,000 children on Medicaid, and never refuse to see a sick child, we have to be very efficient in the way we schedule appointments.  Our providers must help each other out with schedules that result in extremes in the "show" and "no show" categories.  We participate in all third party payer programs that involve extra payment for providing quality care and satisfying acceptable practice parameters.  This requires us to monitor practice patterns such as generic prescription rates, appropriate referrals, and avoidance of unnecessary hospitalizations.  If families are late for appointments, we figure out a way to see the children.  If non-English-speaking families walk-in with sick children, we see the children.  We know that our cash flow depends upon our volume of business, and we constantly encourage staff to bend over backwards to assure we take advantage of all opportunities to provide on-site care for patients.  We allow patients to walk in most all day Monday through Friday for immunization updates and flu vaccine, provided they are up-to-date according to the health supervision guidelines of the AAP.

6.  User Friendly Electronic Medical Record (EMR) System

We were early adopters of EMR (January 1, 2000). We pay for in-office full-time information technology support and contract with consultants to manage data base issues and portal development.  We invest heavily in in-service activities for all staff.  Our staff are very comfortable navigating the EMR.    The practice helped the school-based health centers incorporate our EMR  so that the care of patients is seamless between the centers and the practice.  Any provider can access the EMR off-site.  We are able to document achievement of quality measures for  third party payers and the federal government  through the current EMR system.

7.  Physicians and Staff Skilled at Implementing Quality Improvement Projects

Leaders in our practice have implemented quality improvement projects so that the practice qualifies for optimal payment by Medicaid, CHIP, private health insurance plans, and the federal government.  The most rigorous quality improvement programs have been the Meaningful Use initiative of the federal government and the Patient-Centered Medical Home Recognition Program of the National Committee for Quality Assurance (NCQA). The practice qualified for Stage 1 Meaningful Use payments and is considering applying for Stage 2.  The practice has achieved the highest medical home recognition status for NCQA on three occasions.  These quality improvement programs have stimulated the practice to improve efficiency and to address certain pediatric conditions that lead to poor outcomes in children (obesity, asthma, ADHD (Attention Deficit Hyperactivity Disorder)).  There is overlap between these quality improvement projects and Part IV of the Maintenance of Certification (MOC) program of the American Board of Pediatrics (ABP).   Therefore, when the practice completes all the quality improvement activities required by NCQA, the pediatricians have met all the Part IV MOC requirements of the ABP.

8.  Community-based Care Coordination Staff

Since 1991, the practice has partnered with the NC Medicaid program to develop  Community Care of NC (CCNC).  Through CCNC, the practice qualifies for community-based care coordination staff.  Since the practice has over 20,000 Medicaid enrollees, we qualify for up to four care coordinators.  These people live in our community and understand the local system of care that includes the resources of multiple agencies (health department, housing authority, public schools, Head Start, Smart Start, Child Development Services Agency, department of social services, vocational rehabilitation, mental health, etc.).  When our providers encounter patients with complex medical and/or psychosocial needs, the providers enlist the help of the care coordinators in assuring that special needs patients receive the care and services they need to achieve good outcomes.  There are care coordinators in the tertiary hospitals who work with our community-based care coordinators to provide seamless care for the really complex patients.

9.  Supportive Private and Public Third Party Payers

The practice has worked closely with Medicaid, CHIP, and Blue Cross over the years to assure that cash flow to the practice is sufficient to support the mission of the practice.  The NC Pediatric Society/NC Chapter of the American Academy of Pediatrics, has been instrumental in helping pediatricians develop Medicaid and CHIP programs that are user-friendly for families, children, and pediatricians. Representatives of the Society meet regularly with Blue Cross administrators to discuss practice and payment issues.  A pediatrician in the practice has been seriously involved with the Pediatric Society since 1983, assuring that state government and private insurance plan leaders understand how Medicaid/CHIP/Blue Cross infrastructure and payment affect access, quality, and cost-effectiveness in the community setting.

10.  Providers Who Have Their Fingers on the Pulse of the Community

Goldsboro Pediatrics is the only pediatric practice in Wayne County so the leaders of the practice strive to assure that all children in the county have access to the services and support they need to achieve optimal outcomes.  We have worked with the hospital and other organizations to establish six school-based health centers in schools where there are large numbers of poor children who, for a variety of reasons, do not have access to care in a primary care practice or the health department.  The practice has realized that many children need mental health services, so it has brought mental health professionals into the practice, linked community-based mental health professionals with the school-based health centers, and developed a telemedicine program to give really at-risk patients access to a child psychiatrist at the Brody School of Medicine at ECU.  The practice has led efforts in the community to address such psychosocial issues as obesity,  adolescent pregnancy, child abuse/neglect, and school-readiness. 

As we enter the era of value-based payment, we know that our model may  change.  If we can continue to build our system of care on the 10 key elements above, our children and families will continue to be the beneficiaries of our rich experience as a patient-centered medical home.



[ii]Calvin Sia, Thomas F. Tonniges, Elizabeth Osterhus, Sharon Taba, History of the Medical Home Concept

 Pediatrics:  May 2004, VOLUME 113 / ISSUE Supplement 4


[iii] Medical Home Initiatives for Children With Special Needs Project Advisory Committee, The Medical Home, Pediatrics:  July 2002, VOLUME 110 / ISSUE 1.  This policy is a reaffirmation of the policy posted 122(2):450


[iv] American Academy of Family Physicians. Joint principles of the Patient-Centered Medical Home. Del Med J. 2008; 80(1):21-22.


[v] Joint Principles of the Patient-Centered Medical Home


[vi]NCQA Patient Centered Medical Home Recognition Program


[vii] Burton RA, Devers KJ, Berenson RA. (2012). Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys’ Content and Operational Details. Washington, DC: Urban Institute.

[viii]  Patient-Centered Primary Care Collaborative (PCPCC):

Patient-Centered Primary Care Collaborative
601 Thirteenth Street, NW, Suite 430 North
Washington, DC 20005
P: (202) 417-2081 F: (202) 417-2082

 [ix] Miller J, Nugent C, Russel L. Which components of medical homes reduce the time burden on families of children with special health care needs? Health Services Research. 2015; 50(3):440-460.


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