History of the Medical Home Concept

“Every child deserves a medical home” is one of the American Academy of Pediatrics’ (AAP) essential child health outcomes for the 21st century. With increasing health care costs, technology, survivorship, specialization, and fragmentation of care, the medical home is steadily gaining interest and standing in the public eye. Today’s policy makers, those who are involved with children, and parents are increasingly using the term to describe the concept as the form of high-quality health care. With so much attention focused on this concept as the standard of care for all infants, children, adolescents, young adults, and particularly children with special health care needs (CSHCN), it is important to define this term and how its definition has evolved. Whereas the term was originally used to describe a place—a single source of all medical information about a patient—the term now refers to a partnership approach with families to provide primary health care that is accessible, family centered, coordinated, comprehensive, continuous, compassionate, and culturally effective.1The first known documentation of the term “medical home” appeared in Standards of Child Health Care, a book published by the AAP in 1967 and written by the AAP Council on Pediatric Practice (COPP). The book defines a medical home as one central source of a child’s pediatric records and emphasizes the importance of centralized medical records to CSHCN. “For children with chronic diseases or disabling conditions, the lack of a complete record and a ‘medical home’ is a major deterrent to adequate health supervision. Wherever the child is cared for, the question should be asked, ‘Where is the child’s medical home?’ and any pertinent information should be transmitted to that place” (pp 77–79).2The COPP, noting that care for CSHCN is often provided by many different practitioners who work in disparate locations independent of each other, was concerned about the duplication and gaps in services that occur as a result of this lack of communication and coordination. To resolve these problems, the COPP advocated for 3 steps to spread the word about the importance of the medical home: “The first requirement is the teaching of all medical students that a medical home and a complete central record of a child’s medical care are the sine qua non of proper pediatric supervision. Second, the concept must spread from physicians to all agencies and people caring for children—schools, child guidance clinics, well-infant stations, surgical specialists, emergency departments, and so forth. The third step is the indoctrination of parents (pp 78–79).”3Although Standards of Child Health Care was, at the time it was published, an important guide for pediatric practice, it did not define AAP policy. It was not until the 1970s that the AAP began to address the policy implications of the term “medical home.”In 1974, the COPP held a meeting to begin developing a policy statement titled “Fragmentation of Health Care Services for Children.” The COPP noted that the “delays, gaps, duplications, and diffused responsibilities which characterize fragmented care are expensive, inefficient, and sometimes hazardous to health” and that “implicit in these the AAP constitution’s standards is a commitment to the principle that each child deserves a ‘medical home.’ ”3 The draft policy statement called for centralization of medical records and for pediatricians to become advocates for their patients so that they may receive continuous care, without financial or social barriers. Later, it was added that “the term ‘medical home’ should replace the term ‘family physician,’ ‘pediatrician,’ or ‘personal physician,’ and like terms on all questionnaires and forms requesting identification of the source of continuing child health care.”4These versions of the statement were initially rejected by the AAP Board of Directors (BOD) on the grounds that the BOD believed that it could not determine terminology to that degree. Later, the BOD revisited the statement, recognizing that the intent of the statement was to clarify for third parties the concept of a single medical home for every child. In 1977, the statement was published with the following reference to medical home: “Quality medical care is also best provided when all the child’s medical data are together in one place, (a medical home) readily accessible to the responsible physician or physicians.”5 In April 1979, the importance of the medical home—defined as the repository for medical records, in a manner ensuring continuity of care—was reiterated in the policy statement “Children Having Care from Multiple Sources.”6All AAP chapter presidents were asked to create a child health plan for their respective chapters. In 1978–1979 in North Carolina, there were efforts to provide what they called a medical home to all children through a “Child Health Planning” process. According to Dr Steve Edwards, the North Carolina chapter president was “shot down” by state legislators who were concerned that pediatricians were taking over too much of the parents’ responsibility. The state legislators did not, at the time, understand the meaning of the term “medical home,” and they misunderstood the intentions of the pediatricians. Consequently, the concept was no longer used in North Carolina chapter’s child health plan discussions. Although the legislation was never approved, the drafts referred to children having a “health care home” with the following characteristics: 1) commitment to the individual, 2) primary services, 3) full-time accessibility, 4) service continuity, 5) comprehensive record-keeping, 6) competent medical management, and 7) cost-effective care. The responsibilities of the child and the family in the health care home were defined as 1) continued acceptance and contact, 2) conformance with recommendations of prevention and promotion, 3) adequate information flow, and 4) compliance with administrative requirements.The North Carolina Child Health Plan did not advocate for a single organizational model for the health care home but rather recommended a combination of private, public, and joint ventures that best meet the needs of all of the children in a community. Again, this draft legislation was never approved, but the discussions that led to the development of the draft reflect the changing meaning of the medical home.Nationally, the medical home concept began to evolve from a centralized medical record to a method of providing primary care from a community level, recognizing the importance of addressing the needs of the total child and family in relationship to health, education, family support, and the social environment. The concept assumed a bottom-up, or grassroots, approach rather than a top-down approach and shifted toward prevention, wellness, and early intervention. This concept initiated an approach toward developing a single-tiered system of care, especially for CSHCN.Concerned about the initiatives that lacked the primary care component, Merle McPherson, MD, director of the federal Maternal and Child Health Bureau’s (MCHB) Division of Services for Children with Special Health Care Needs, took note of an approach that was developed and championed in the 1980s by Dr Calvin Sia in Hawaii. A continuous system of care for CSHCN that originates in the pediatrician’s office and involves an inherent partnership between the parent and the primary care pediatrician was provided. This system, with the primary care pediatrician (who is geographically and financially accessible) as the point of first contact for the child and family, enabled families to receive continuous and comprehensive care and ensured that there was linkage to all medical and nonmedical services and resources from infancy through adolescence.In 1978–1979, Hawaii under Dr Sia’s leadership, unlike North Carolina, successfully led a campaign to have the medical home concept adopted into their Child Health Plan that stated, “Every child deserves a medical home.” This campaign required a year of persistent effort by representatives from the Hawaii chapter, the University of Hawaii John A. Burns School of Medicine Department of Pediatrics at Kapi’olani Medical Center for Women and Children, the Hawaii Department of Health, and the Hawaii Medical Association. This was the birth of the medical home concept as we know it today. It stated that a medical home would be family centered; be community based (geographically and financially accessible and available); offer continuity, comprehensive, and coordinated care; and use the resources of related services in the neighborhood.Five years later, in 1984, the medical home concept was implemented through the Hawaii Healthy Start Home Visiting Program for the prevention of child abuse and neglect. The following year, in 1985, the concept was integrated into the Hawaii Emergency Medical Services for Children Program by ensuring that children and families, as part of the medical home, were the central point of the system.7 In the same year, the Hawaii Medical Association was awarded a grant from MCHB, under the Special Projects of Regional and National Significance (SPRANS) initiative, to train primary care physicians to become a medical home for CSHCN. Finally, in 1986, the Hawaii Early Intervention Program under PL 99-457 Part H: Individuals With Disabilities Education Act Amendment of 1986 for infants and toddlers was launched to include the medical home into each discipline: family support, health, and education.Nationally, as the medical home concept evolved and gained greater recognition, barriers to implementing a medical home for all children became apparent. Three major barriers8 in implementing the concept were 1) training pediatricians to understand the medical home concept; 2) communication and care coordination for related services in health, family support, and education/special education; and 3) reimbursement for periodic well-child supervision and care coordination.In Hawaii, a federal SPRANS grant enabled the Hawaii Medical Association to overcome the first of these barriers by developing a medical home training manual that involved interdisciplinary teamwork and that brought pediatricians together with families and related child health care professionals. The training addressed the communication and care coordination barriers between individuals and agencies by suggesting the Hawaii’s Healthy Start home visitors act as links to the medical home. At the same time, Healthy Start and the Hawaii’s Early Intervention Program were strategically placed within the Hawaii Department of Health rather than in the Department of Education, which was the experience of most states. The Hawaii Early Intervention Program provided the leadership for the enactment of a state law (Act 109) that created support for all families with children who had developmental delays, were biologically at risk, and especially who were environmentally at risk. Public health nursing played a major role in this evolving system of care. The reimbursement barrier was addressed by introducing into the Hawaii State Legislature an increased budget for Early and Periodic Screening, Diagnosis, and Treatment (under Medicaid) and a mandated Well Child Health Supervision bill. Additional support for families and early intervention providers was requested for Hawaii’s Early Intervention Program. Introducing family advocates and including them in the planning process was an important key in the legislative successes.As part of the MCHB SPRANS grant in Hawaii, leadership from the project traveled nationally to promote the medical home concept. In 1987, Surgeon General Koop held the first major conference for CSHCN. In 1989, the first AAP conference on the medical home was held in Hawaii. This conference was followed by consultation to introduce the medical home training program to interdisciplinary teams of pediatricians, families, and other health care-related professionals in Florida, Minnesota, Nebraska, Pennsylvania, Washington, and other states. These significant events set the foundation for the developments that occurred in the 1990s when the AAP and MCHB assumed a more direct role in the refinement and implementation of the medical home concept.In 1992, the AAP published its first policy statement defining the medical home: The AAP believes that the medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family centered, coordinated, and compassionate. It should be delivered or directed by well-trained physicians who are able to manage or facilitate essentially all aspects of pediatric care. The physician should be known to the child and family and should be able to develop a relationship of mutual responsibility and trust with them. These characteristics define the “medical home” and describe the care that has traditionally been provided by pediatricians in an office setting. In contrast, care provided through emergency departments, walk-in clinics, and other urgent-care facilities is often less effective and more costly.7By 1993, the AAP established a Division of Community Pediatrics in support of its flagship program Community Access to Child Health (CATCH) that embraces at its core the medical home concept. CATCH promoted the vision that every child in every community has a medical home and other needed services to reach optimal health and well-being; that pediatricians can make a difference in their community. Through the efforts of dedicated CATCH pediatricians, access to child health care and the medical home concept became a reality to many. The CATCH program developed a network of pediatricians and a groundswell of support from families and communities promoting improved child health care not only for CSHCN but for all children.The second major program of the Division of Community Pediatrics was the medical home Training Project, a national adaptation of the Hawaii Medical Home Project. From 1994 through 1999, the AAP received a grant from MCHB that enabled the continuation of this project into what became known as the Medical Home Program for Children With Special Needs. The Medical Home Program for Children With Special Needs produced materials to educate pediatricians, parents, and other health care professionals nationwide about the medical home concept. Among the materials produced were a fact sheet describing the concept in lay terms, a compendium of information about the medical home and managed care, a guide for appropriate use of Current Procedural Terminology codes to improve reimbursement for provided services, a pamphlet on the importance of early intervention, and an updated version of The Medical Home Training Program.9Thus, the Medical Home Project has been closely linked to the CATCH network.9 As the interest in community pediatrics increased, the AAP Division of Community Pediatrics expanded to become a Department of Pediatrics. The Department has promoted major national efforts such as Breastfeeding Promotion in Physicians’ Office Practices, Childhood Immunization Support Program, Healthy Child Care America, Healthy Tomorrows Partnership for Children Program, Medical Home Initiatives for Children With Special Needs, Screening Initiatives, Native American Child Health, Pediatrics Collaborative Care Program: Oral and Mental Health Initiatives, and Reaching Children: Building Systems of Care. This has helped ensure widespread dissemination of the medical home concept and application of this concept to all children, not only CSHCN.In 1999, the MCHB grant ended and the AAP Department of Community Pediatrics was awarded a 5-year cooperative agreement with MCHB to establish and operate the National Center of Medical Home Initiatives for Children With Special Needs (National Center). Nearly all of the materials and resources developed by the National Center, including links to medical home activities in other states, can be accessed through the comprehensive web site at www.medicalhomeinfo.org. The goals of the National Center are to The National Center provides support to pediatricians, families, and other medical and nonmedical providers who care for CSHCN. Specifically, parents, pediatricians, administrators, and other health care professionals have access to educational and advocacy materials, screening tools, guidelines for care, and a national medical home mentorship program.Most important, in 2002, the AAP, in consortium with the National Center’s Project Advisory Committee, published the policy statement “The Medical Home.” This statement expanded on the definition of medical home described in the original 1992 policy statement. The 2002 policy statement retains the original 7 components of a medical home (accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective) and describes the services that should be provided within this framework. The 2002 statement continued to explain the medical home model of care by providing an definition that activities that should occur within a medical are an important of the medical home concept and are essential to ensuring that of care are With this principle in the National Center with for Children, and the National Association of and to develop an updated and more comprehensive version of the Medical Home Training Program that was originally developed through the Hawaii SPRANS This as each that its and are the training program is AAP Medical Home Training Program on how to ensure that CSHCN have a medical The program educational including for screening of care, for patients and families, and with special health care needs to work and of these components is within the of in a medical home. The has been written so that the materials can be to information and address the health care the National Center to provide to individuals who are to create medical it was that this effort could only so It was that individuals required a more system in at the state to support their or As a the National Center called on key to a medical home to their state in developing to support the of medical state of pediatricians, family a CATCH families, CSHCN and other key leadership in the a to the that their vision for a coordinated system of care for CSHCN that would provide access to medical by the year As the National Center to facilitate the development of these teams state teams that have toward their goals have been as to guide state teams in their work toward their medical home have received from the MCHB to these state medical home is the first step in a child who has special health care it is important that early and continuous screening is in the medical home to ensure that 1) children with special health care needs are as early as so that they and their families can be appropriate services to address those needs and 2) children with special health care needs receive continuous screening and to or that may with their development and at the National Center have in to ensure that screening is integrated in the medical home. have related to public health screening have related to medical screening vision developmental that all children in the have a medical home has been the of the of the and the of the 21st century. Although this has not been efforts to ensure that all children have a medical home have In the the AAP, the MCHB, and other agencies and began to the toward of the Healthy that called for implementing a system of services for all children in the Although much has been CSHCN many in comprehensive, coordinated, and health to these are by key who services, and develop medical home within pediatric toward the development of a pediatric to the of the medical home in of care are federal policy such as the MCHB, the National of Child Health and and the for and National Center for and major pediatric such as the American Board of the Pediatric and the and such as the which the Community Pediatrics Training such as these in the vision to create a of pediatricians who can on that all children and the medical home concept was integrated into federal that address of health care, all of the major pediatric representatives in to and pediatric and the of pediatric the on the of Pediatric Education its recommendations were that children should receive primary care services through a and pediatric medical at all must be based on the health needs of children in the of the family and such as the Community Pediatrics Training of to medical to pediatric and a about community in to ensure that they were providing medical 2002, medical pediatrics have received A of these are using this to the medical home concept to as the or core foundation for pediatric training in community of the for Healthy that children with special health care needs receive comprehensive care within a medical home. In 2002, Health and Services to from federal agencies many to support for those with within the on the Among the recommendations was that the MCHB the in developing and implementing a plan to appropriate services for children and with special health care needs and their of the plan include The development and implementation of the medical home concept has received support from the MCHB, the federal the AAP, through and the Pediatric and national and state family As pediatricians the increasingly to the standards of care by ensuring in partnership with families that all children have access to a medical home, of the essential AAP child health outcomes of the 21st is to In from medical home as a concept to medical home as an implemented health care every child in the have a central source of health care that is family centered, accessible, continuous, coordinated, comprehensive, compassionate, and culturally to John AAP who in the information that was the foundation of this