Evaluation of a statewide medical home program on children and young adults with asthma.

OBJECTIVE: Asthma, the most common chronic condition among children, accounts for significant healthcare utilization and impact on quality of life. Care coordination in a medical home is considered standard practice, but has not been rigorously evaluated. METHODS: We initiated this pilot study of children/young adults with asthma (n = 967), ages: birth to 24 years, receiving care from a subset of pediatric practices (n = 20) participating in the Pennsylvania Medical Home Initiative, Educating Practices in Community-Integrated Care (92 practices statewide). We hypothesized children and youth with asthma receiving care coordination in the context of a formal medical home program would experience favorable associations with healthcare utilization and quality of life measures. RESULTS: A total of 9240 care coordination encounters for this cohort of children/youth occurred over 100 days. The average length of care coordination encounter was 20.7 minutes. The most common care coordination activity was referral management (21%) and the care coordinator in the practice most often contacted parent/family and specialists (75%). Children with more severe asthma had more hospitalizations and emergency department (ED) visits than children with less severe asthma. There was a significant decrease in school absences, ED visits and acute care visits for children/youth with asthma with increasing length of time in a medical home program (p < 0.05). CONCLUSION: Care coordination for children/youth with asthma is feasible and may yield improvements in healthcare utilization, expenditures and quality of life. Larger-scale implementation of care coordination and medical home models for children/youth with asthma and other diagnoses are warranted.

Attitudes, practices, and barriers to adolescent suicide and mental health screening: a survey of pennsylvania primary care providers.

OBJECTIVE: To determine primary care providers' rates of screening for suicide and mental health problems in adolescents and the factors that promote or discourage this practice. PATIENTS AND METHODS: Overall, 671 medical professionals (ie, pediatricians, family physicians, nurse practitioners, physician assistants) completed an electronic survey. The 53 items focused on (1) attitudes, knowledge, and comfort with general psychosocial and suicide screening and (2) current practices and barriers regarding screening and referrals to behavioral health services. RESULTS: Forty percent had a patient attempt suicide in the past year, and 7.7% had 6 or more patients attempt suicide. At a well visit, 67% screened for mental health, and 35.2% screened for suicide risk. Most (61.1%) primary care providers rarely screened for suicide or only when it was indicated. Only 14.2% of primary care providers often used a standardized suicide screening tool. Factors associated with screening were being knowledgeable about suicide risk, being female, working in an urban setting, and having had a suicidal patient. Only 3.0% reported adequate compensation for these practices, and 44% agreed that primary care providers frequently use physical health billing codes for behavioral health services. Nearly 90% said parent involvement was needed if adolescents were to follow through with referrals to mental health services. Only 21% frequently heard back from the behavioral health providers after a referral was made. CONCLUSION: Policy that promotes mental health education for primary care providers, provides reimbursement for mental health screening, and encourages better service integration could increase suicide screening and save healthcare costs and patients' lives.

Collaboration in Pennsylvania: rapidly spreading improved chronic care for patients to practices.

INTRODUCTION: Pennsylvania's Improving Performance in Practice (IPIP) program is administered by the Pennsylvania (PA) chapters of the American Academy of Family Physicians, American College of Physicians, and American Academy of Pediatrics. The project has provided coaching, monthly measurement, and patient registry support for 155 primary-care practices that participate in the 3-year Pennsylvania Chronic Care Initiative led by the PA Governor's Office of Health Care Reform. METHODS: Practices participating in this case study are attending regional Breakthrough Series collaboratives and submitting monthly narrative and clinical outcomes reports. The approaches to education include in-person learning sessions with multidisciplinary practice teams, on-site practice coaching, conference calls, and regular feedback of performance data. More than half will receive financial incentives from more than a dozen participating insurers after becoming nationally recognized Patient Centered Medical Homes by the National Committee for Quality Assurance (NCQA). RESULTS: In the first 6 months, practices showed improvement in diabetes process measures and a high level of engagement in the improvement process. DISCUSSION: Early data reporting, practice preparation for the first learning session, monthly narrative reports from practices, and clear and concrete change packages all seem integral to the improvement process. The future of the PA Chronic Care Initiative will include spreading to more practices and moving beyond the initial work in diabetes and asthma to other aspects of primary care, including prevention.