DOI: 10.1542/aapnews.2014355-142014;35;14AAP News 

Patrick M. O'ConnellBeyond the medical home: Coordinating care for children

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2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©published continuously since 1948. AAP News is owned, published, and trademarked by the American AAP News is the official journal of the American Academy of Pediatrics. A monthly publication, it has been

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Volume 35 • Number 5May 2014www.aapnews.org

© 2014 AAP News

by Patrick M. O’Connell • Digital Content Editor

Integrated care coordination is an essential elementof a transformed health care delivery system and shouldbe based on a patient- and family-centered approach that stretches beyondthe primary care physician, according to a new AAP policy statement.

Anchored in the medical home, this system should include collabo-ration and communication with multiple systems and individuals whotreat and assist children, including social and behavioral professionals,educators, advocacy groups, therapy services and families themselves.Coordination also should include payers and insurers, according to thestatement, Patient- and Family-Centered Care Coordination: A Frameworkfor Integrating Care for Children and Youth Across Multiple Systems (Pedi-atrics. 2014;133:e1451-e1460).

The goal of integrated care is to optimize the treatment of children,developing an efficient system for pediatricians, pediatric subspecialistsand surgical specialists to provide services to patients and their families.

Team approachPartnerships across the medical system are essential to this model,

and pediatricians may need to stretch the traditional boundaries of howthey provide care. The integration of primary care services — the bedrock

of the system — with others in the medical carespectrum is part of a comprehensive approach fortackling patients’ needs. This model will lead to lowerhealth care costs, less fragmented care and animproved experience for children and families, thepolicy states.

This framework, said lead author Richard C.Antonelli, M.D., FAAP, allows pediatricians to con-figure the services and resources most needed for chil-

dren and communities. At its core, care coordination means developing new models of care

delivery, value-based services and realizing that the best forms of patient-centered care are delivered by a team, Dr. Antonelli said.

Pediatricians should be thinking, “What are the family-driven needsfor care coordination, and how do these teams effectively address them?”said Dr. Antonelli, who called the concept “disruptive but exciting.” Thepolicy is intended to be broadly focused, realizing that every communityhas different needs, assets and service gaps based on location, populationand cultural factors.

Using this model does not mean altering the basic tenets of the medicalhome model, but broadening a focus for care that involves others withinthe medical system beyond the primary care physician. Coordinationand collaboration with mental and behavioral health professionals, the

education system, the public health system, as well as payers and medicalequipment providers, is essential to providing the best care for patientsand families.

“There is ongoing education needed both for practitioner teams, butalso to think about what’s needed across disciplines — nurses, socialworkers, educational providers. … It needs to be a team approach,”said lead author Renee M. Turchi, M.D., FAAP.

Communication essentialMuch of the process involves effective communication between primary

care providers and subspecialists, and with other health care providers.It also means that pediatricians should be thinkingabout how others outside their practice or office maybe able to help a child or address an issue from a dif-ferent angle or area of expertise.

To optimize integrated care, different people andparts of the medical care process must work together.The goal is to build partnerships to provide the bestpossible care for the child and the family.

“Partnerships are key, and communication isessential,” Dr. Turchi said. “It really has to be patient and family driven.”

To work toward care coordination, physicians should assess the needsof the patient and family and establish goals that are clear for the patient,family and health care team. They also should discuss what is expectedof the family and what physicians expect of themselves, and find outwhere the family needs help.

Pediatricians also need to focus on issues outside of medicine, Dr.Antonelli said, realizing how poverty, literacy, food insecurity, violence,mental health and environmental factors affect children’s health.

Care coordination, Dr. Turchi said, also helps with transitions, notonly pediatric to adult care, but inpatient to outpatient and out of emer-gency care.

Pediatricians should use health information technology, Internet-based resources and new communication channels, but be cautious notto rely too much on these elements. Personal interactions and commu-nication, both with the patient and other providers, remain essentialto top-notch care.

In order for the system of care coordination to work, physicians mayhave to relinquish some control, both to other staff within their officeand others outside the practice, Dr. Turchi said. The integrated way ofoperating may be a culture change for some physicians.

“Primary care physicians are not in this alone,” Dr. Antonelli said.“We’re collectively in this together.”

Beyond the medical home: Coordinating care for children

Dr. Turchi

Dr. Antonelli

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DOI: 10.1542/aapnews.2014355-142014;35;14AAP News 

Patrick M. O'ConnellBeyond the medical home: Coordinating care for children

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