David M. Keller

The medical home and integrated behavioral health: advancing the policy agenda

There has been a considerable expansion of the patient-centered medical home model of primary care delivery, in an effort to reduce health care costs and to improve patient experience and population health. To attain these goals, it is essential to integrate behavioral health services into the patient-centered medical home, because behavioral health problems often first present in the primary care setting, and they significantly affect physical health. At the 2013 Patient-Centered Medical Home Research Conference, an expert workgroup convened to determine policy recommendations to promote the integration of primary care and behavioral health. In this article we present these recommendations: Build demonstration projects to test existing approaches of integration, develop interdisciplinary training programs to support members of the integrated care team, implement population-based strategies to improve behavioral health, eliminate behavioral health carve-outs and test innovative payment models, and develop population-based measures to evaluate integration.

Toward the Development of Advocacy Training Curricula for Pediatric Residents: A National Delphi Study

BACKGROUND Training in child advocacy is now required in pediatric residency program curricula. No national consensus exists regarding the content of such advocacy training. OBJECTIVE To identify an operational definition of advocacy, as well as knowledge, skills, and attitude objectives for advocacy training in pediatric residency programs. METHODS Professionals experienced in pediatric advocacy and training (n = 53) were invited to participate in a sequence of surveys to define the content of a pediatric residency advocacy curriculum that would result in acquisition of appropriate knowledge, skills, and attitudes related to advocacy for children. Three rounds of surveys were distributed, collected, and analyzed using a modified Delphi technique, in which the results from an antecedent survey were used to refine responses in a subsequent survey. RESULTS Participants (n = 36), comprising a group of experienced leaders with diverse training and experience in child advocacy and resident education, created a consensus definition for advocacy. They initially identified 179 possible objectives for advocacy curricula. Through the iterative process of the Delphi technique, 32 of those objectives were identified as necessary for inclusion in a child advocacy curriculum for pediatric residents. CONCLUSIONS Using a modified Delphi technique, a group of experienced leaders in pediatric advocacy were able to reach consensus on an operational definition of child advocacy and a set of objectives for a resident advocacy curriculum. Programs may use these findings to assist in developing an advocacy curriculum based on their own faculty assets and community resources.

Children and the Patient Protection and Affordable Care Act: Opportunities and Challenges in an Evolving System

The Patient Protection and Affordable Care Act (ACA), passed in 2010, focused primarily on the problems of adults, but the changes in payment for and delivery of care it fosters will likely impact the health care of children. The evolving epidemiology of pediatric illness in the United States has resulted in a relatively small population of medically fragile children dispersed through the country and a large population of children with developmental and behavioral health issues who experience wide degrees of health disparities. Review of previous efforts to change the health care system reveals specific innovations in child health delivery that have been designed to address issues of child health. The ACA is complex and contains some language that improves access to care, quality of care, and the particular needs of the pediatric workforce. Most of the payment models and delivery systems proposed in the ACA, however, were not designed with the needs of children in mind and will need to be adapted to address their needs. To assure that the needs of children are met as systems evolve, child health professionals within and outside academe will need to focus their efforts in clinical care, research, education, and advocacy to incorporate child health programs into changing systems and to prevent unintended harm to systems designed to care for children.

Development of a brief questionnaire to identify families in need of legal advocacy to improve child health

OBJECTIVE To determine whether the medical-legal advocacy screening questionnaire (MASQ), a simple 10-item questionnaire, is able to screen families in a primary care setting for possible referral to legal services more effectively than the clinical interview alone. METHODS Family Advocates of Central Massachusetts (FACM) is a medical-legal collaboration that assists low-income families with legal issues that affect child health. A convenience sample of parents seen at each of 5 medical practices associated with FACM was recruited to complete the MASQ prior to a routine child health care visit. Physicians blinded to the result assessed family need for referral to FACM after their usual clinical encounter. The sensitivity and specificity of both the MASQ and provider assessment were calculated. RESULTS Two hundred fifty-five parents from 5 practices participated in the study. The MASQ identified 85 patients in need of legal services. Prior to reviewing the MASQ, the primary care providers identified 35 families in need of referral to the FACM. After completion of both the MASQ and the medical encounter, 37 families agreed to referral. The MASQ had sensitivity of 0.81 and specificity of 0.75 in predicting program referral. Provider assessment had sensitivity of 0.65 and specificity of 0.95 of predicting program referral. CONCLUSIONS Routine use of the MASQ would likely identify more patients in pediatric practices who would accept referral to legal assistance than reliance on provider impression alone after a routine clinical encounter.

Is There a Psychiatrist in the House? Integrating Child Psychiatry Into the Pediatric Medical Home

The Patient-Centered Medical Home (PCMH) is a model of primary care practice incorporating core principles of accessibility, coordination, comprehensiveness, continuity, cultural competence, and respecting and valuing the preferences of families. As our nation struggles to reformourhealthcaresystem,thePCMHmodelis widely acknowledged to be the foundation of a high-value, effective system of care that better meets the needs of patients and produces better health outcomes. Although most PCMH initiatives currently underway around the country focus on the management of chronic diseases of adults, the model has its roots in pediatric practice and the care of children with special health care needs. These features were codified in the Joint Statement on the Principles of the Medical Home, 1

Evaluation of Community-Based Health Projects: The Healthy Tomorrows Experience

OBJECTIVES. To address the “millennial morbidities,” pediatricians must partner with community-based organizations to develop interventions. Little is known about the capacity of the resulting programs for program evaluation or the importance of evaluation in project success and sustainability. The objective of this study was to examine the capacity of community-based health programs to conduct project evaluations and determine the impact of project evaluation on project outcome. METHODS. Project directors from 149 community-based programs funded from 1989 to 2003 through the Healthy Tomorrows Partnership for Children Program were surveyed regarding their project experience with evaluation and documentation of project outcomes and the current status of their project. RESULTS. Program directors from 123 (83%) programs completed the survey. Despite barriers to the evaluation process, 83% of the respondents indicated that their evaluations produced useful information. Programs that were described by respondents as “well evaluated” were more likely to report that the evaluation was implemented as planned and that the evaluation included outcome measures. Projects were more likely to be sustained in their original form when at least 1 outcome was reported on the survey. CONCLUSIONS. Evaluation of community-based programs, although challenging, is beneficial to project success and sustainability. Policy makers and funding agencies should consider ways to encourage community partnerships to incorporate evaluation into their planning process.

UNDERSTANDING AND PREVENTING SUBSTANCE ABUSE BY ADOLESCENTS: A Guide for Primary Care Clinicians

Psychoactive drug use by teens is a common occurrence. This article examines the influences that promote and deter experimentation with and hazardous use of psychoactive substances. Clinical guidance is offered on how to assess and intervene with teens and their parents at various developmental phases and levels of involvement with drugs. Understanding how youth make decisions to change their behavior can assist a clinician in helping a teenager avoid these problems.

Associations between the patient-centered medical home and preventive care and healthcare quality for non-elderly adults with mental illness: A surveillance study analysis

BackgroundPatient-centered medical homes (PCMHs) may improve outcomes for non-elderly adults with mental illness, but the extent to which PCMHs are associated with preventive care and healthcare quality for this population is largely unknown. Our study addresses this gap by assessing the associations between receipt of care consistent with the PCMH and preventive care and healthcare quality for non-elderly adults with mental illness.MethodsThis surveillance study used self-reported data for 6,908 non-elderly adults with mental illness participating in the 2007–2012 Medical Expenditure Panel Survey. Preventive care and healthcare quality measures included: participant rating of all healthcare; cervical, breast, and colorectal cancer screening; current smoking; smoking cessation advice; flu shot; foot exam and eye exam for people with diabetes; and follow-up after emergency room visit for mental illness. Multiple logistic regression models were developed to compare the odds of meeting preventive care and healthcare quality measures for participants without a usual source of care, participants with a non-PCMH usual source of care, and participants who received care consistent with the PCMH.ResultsCompared to participants without a usual source of care, those with a non-PCMH usual source of care had better odds of meeting almost all measures examined, while those who received care consistent with the PCMH had better odds of meeting most measures. Participants who received care consistent with the PCMH had better odds of meeting only one measure compared to participants with a non-PCMH usual source of care.ConclusionsCompared with having a non-PCMH usual source of care, receipt of care consistent with the PCMH does not appear to be associated with most preventive care or healthcare quality measures. These findings raise concerns about the potential value of the PCMH for non-elderly adults with mental illness and suggest that alternative models of primary care are needed to improve outcomes and address disparities for this population.

Policy, Politics, and Procedure: Our Role in Building Systems That Improve the Health of Children

From the Department of Pediatrics, University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora, Colo Presented as the Presidential Address at the Academic Pediatric Association 2014 annual meeting in Vancouver, British Columbia on May 5, 2014. The author has indicated that he has no conflicts of interest to disclose. Address correspondence to David Keller, MD, Department of Pediatrics, Children’s Hospital Colorado, 13123 E 16th Ave, B065, Aurora, CO 80045 (e-mail: david.keller@childrenscolorado.org).

The patient-centered medical home model: healthcare services utilization and cost for non-elderly adults with mental illness

Abstract Background: The patient-centered medical home (PCMH) model is designed to improve health outcomes while containing the cost of care. However, the evidence is inconclusive. Aims: The aim of this study was to examine the associations between receipt of care consistent with the PCMH and healthcare services utilization and expenditures for non-elderly adults with mental illness in the USA. Method: A surveillance study was conducted using self-reported data for 6908 non-elderly adults with mental illness participating in the 2007–2012 Medical Expenditure Panel Survey. Healthcare services utilization and expenditures were compared for study participants who received care consistent with the PCMH, participants with a non-PCMH usual source of care (USC), and participants without a USC. Results: Differences in utilization and expenditures between participants who received care consistent with the PCMH and participants who had a non-PCMH USC were not statistically significant for any healthcare services category. Conclusions: Receipt of care consistent with the PCMH was not significantly associated with differences in healthcare services utilization or expenditures compared to having a non-PCMH USC. Research assessing whether the PCMH is cost-effective for non-elderly adults with mental illness is needed.