Medical Home Model Thrives at UCLA

Diana Mahoney
New England Bureau

It's helping to keep young families together, inciting residents to take on extra work, and providing long-term professionals with new inspiration toward excellence.

But the Medical Home Project at Mattel Children's Hospital at the University of California, Los Angeles, does not offer an easy road, said Dr. Thomas Klitzner, a pediatric cardiologist and director of the project. “There are many questions yet to be answered and many challenges still to be overcome.”

Still, the early results from the UCLA project suggest the medical home model of care is a worthy goal to pursue, and both the American Academy of Pediatrics and the American Academy of Family Practice are inclined to agree. The AAP has declared that one of the essential child health outcomes for the 21st century is that every child should have access to a medical home. For its part, the AAFP earlier this year proposed a version of the medical home model as the future of their specialty.

The medical home, as described by the AAP, is a model for providing primary health care that is “accessible, family-centered, coordinated, comprehensive, continuous, compassionate, and culturally effective.” In practical terms, it is the locus of care, where all a patient's medical records are managed and where a designated care coordinator handles referrals for an array of medical and nonmedical problems, ranging from coordinating specialist referrals to accessing community services. It may even include providing taxi vouchers to make sure patients can get to their appointments.

While the pediatric medical home concept is meant to encompass all children, it is particularly relevant for those who require multiple medical, psychological, and/or educational services. And as advances in “high-tech” medicine have made kids with such gear as ventriculoperitoneal shunts, gastrostomy tubes, indwelling central lines, tracheostomies, pacemakers, and home ventilators more common in the community, the number of children in need of a medical home has increased substantially.

Who Comes to the Home?

The program enrolls only children with at least one, but more often multiple diagnoses that make them eligible for California Children's Services (CCS), the state's Title V program for children with special health care needs. Typically, an “eligible” diagnosis is one that requires substantial care and service coordination that families are unable to afford.

Among the 32 patients enrolled in the UCLA Medical Home Project so far, the average number of CCS-eligible diagnoses per patients is 2.5. Close to half of the patients are from single-parent families or foster care, and more than two-thirds of the patients come from non-English-speaking homes.

Dr. Klitzner offered a case in point, explaining how the medical home is helping the teenaged mother of an infant with heart disease. She probably would have surrendered her child to medical foster care but for the support of the medical home's family liaison, who helps her navigate the obstacle course that defines caring for a child with complex medical needs.

A Home Apart

There are three major differences between the care received by patients in the medical home program—many of whom are Spanish speakers—and the general patient population. “First, they have access to a family contact person—a full-time, Spanish-speaking family liaison/medical home coordinator who facilitates access to all of the medical home services,” Dr. Klitzner said.

Not only does the liaison help the medical home families negotiate the outpatient and inpatient settings at the medical center, but also “this person serves as a ‘buy-in’ for the residents—an extra person to help with the logistics of care,” he said.

Second, all medical home appointments get double the standard time allotment. “The appointment center personnel know that medical home patients automatically get 40-minute appointments rather than 20 minutes, which gives the patients and families the extra time that they need to address their many issues, and it gives the residents more time to spend with the patients, to better get a feel for their needs,” Dr. Klitzner noted.

Finally, all of the documentation and materials related to the medical home patients have a highly visible logo developed for the program, which enables a sort of “brand identification,” Dr. Klitzner said. “Everything [the patients] have—their appointment cards, their clinic charts—is marked with that logo, so that when anyone in the medical center sees that logo, they know they're dealing with a medical home patient. It triggers them to remember the medical home principles and to go out of their way to apply them. It also tells them they can page the family liaison if they need help with something,” he said.

The Resident Factor

Each of the medical home patients is assigned to 1 of 50 resident physicians, and each has access to a medical home pager and a hotline providing continuous access to the medical home.

Dr. Klitzner explains that some of the pediatric residents in the continuity clinic—where the model program has been implemented—have so fully invested themselves in the program that they have to be discouraged from taking on more medical home patients than the program directors recommend.

Residents care for between two and six medical home patients, and they are all categorical residents. “These are the residents who are going to be the subspecialists and researchers of the future, not our community health residents, who already get significant community exposure,” Dr. Klitzner said. “We believe it is the categorical residents who we most need to reach in order to best disseminate the medical home principles throughout all of pediatrics.”

The medical home principles are also part of the residents' educational curriculum, as is routine exposure to community service leaders, regional center directors, and allied health directors.

Balancing the logistics of residency training with the medical home principle of maintaining consistency of care has been an ongoing challenge, said Dr. Klitzner. “Residents have erratic hours and multiple demands on their time, so it's often difficult to ensure that they will be available when their medical home patients need them,” he said. “This is a problem that we are actively addressing, because it's not fair to say we have a medical home model if the residents can't provide continuity.”

Coordinating Care

The coordination of care between primary care providers and subspecialists—another one of the core medical home principles—has been challenging as well, “even though, in our case, they're within the same institution,” Dr. Klitzner said. “This is a real obstacle, and something we need to constantly work on. We have a grant to initiate pilot studies that involve coordinating between our subspecialists at UCLA and primary care providers at more rural sites to learn lessons on how to better communicate, and hopefully that can translate [to the medical home project],” he said.

One of the communication barriers can simply be chalked up to inexperience. Many of these professionals have had limited exposure to the medical home concept and therefore lack a full understanding of what is expected of them, Dr. Klitzner noted. “The social workers and nurse practitioners have a better sense of the family-centered model of care than the physicians, particularly the subspecialists, so we're trying to increase awareness, through the logo, through grand rounds presentations, and other mechanisms.”

Another challenge has been figuring out which coordination tasks are beyond the realm of what should be expected from a medical home. “We are essentially dealing with a Medicaid population with limited resources and highly intensive needs, including transportation, housing, financial problems, child care,” Dr. Klitzner said.

Filling In the Gaps

In terms of unanswered questions, “there are a lot,” Dr. Klitzner said. “How much time per patient does the family liaison need? Is one family liaison enough? What is the maximum caseload for residents? What are the effects on patient satisfaction? There isn't extensive literature on the outcome of medical home programs, so we're learning as we go.”

The UCLA group has enough preliminary data on time requirements to begin addressing some of these questions. “We can see that the initial intake time tapers off, and we can start modeling, based on a 40-hour week, maximum caseloads and such,” Dr. Klitzner said. Patient satisfaction outcomes will take longer to assess. “We have to be careful not to overwhelm families, and we don't want to give the impression of being too institutional, so we are not going to begin asking those questions until patients have been in the program for a while,” he said.

Anecdotally, the project “feels” successful, Dr. Klitzner said. He mentioned the unexpected ripple effect the program, just 1 year into its 5-year Healthy Tomorrows Partnership for Children Program grant from the AAP. Exposure to the medical home mentality, it seems, has made primary care providers, specialists, ancillary health care professionals, and even administrative personnel more attuned to the auxiliary needs of all patients, not just those enrolled in the medical home project.

“Throughout the medical center, we've seen a diffusion of the medical home concept, even though the project itself is small and reaches only a small percentage of eligible patients. There's been an enhancement of translation services, cultural sensitivity, electronic medical records for care coordination, discharge planning, and an overall awareness that patients are more than their illness.”

Similarly, the residency programs have been touched.

“In our round of interviews for [pediatric] cardiology fellows, two or three of the interviewees asked about the medical home project. The fact that there's this awareness of the project and this recognition that it's a good thing is very gratifying,” Dr. Klitzner said.

And of course, there are stories like that of the teenaged mother. “She faces a lot of challenges, but because of her child's medical home, she had the confidence to take her baby home and give it a try. That's not a guarantee that everything will work out, but still, the fact that a small pilot program can have that effect is a huge payoff,” he said.

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