ADDRESSING PEDIATRIC SUBSPECIALTY
ACCESS PROBLEMS THROUGH DELIVERY
SYSTEM IMPROVEMENTS
Peggy McManus
Co-Director
Maternal and Child Policy Research Center
Washington, DC
Mchpolicy.org
February 7, 2006
PRESENTATION OVERVIEW
 Pediatric subspecialty workforce problem
Federal Expert Work Group on Pediatric
Subspecialty Capacity
 Importance of addressing demand
 Promising practices in referral, consultation,
and collaborative management
DEFINING THE PROBLEM
 Pediatric subspecialists among the growing
list of health professions facing current &
projected shortages
 Insufficient numbers & maldistribution have
long been a concern
 What’s new is changing demand for PS care
ADDRESSING DEMANDS
 Increasing prevalence & severity of certain chronic
childhood conditions
 Increasing survival of children with complex
conditions resulting from medical/surgical advances
 Changing patterns of care, with PCPs referring
more to PS
 Increasing preference by families to see PS
 Changing managed care and hospital markets &
shifts in health insurance status of children
EVIDENCE THAT DEMAND
EXCEEDS SUPPLY
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Small numbers relative to population and need
Excessive appointment waiting and travel times
Family and PCP difficulties obtaining referrals
Unmet specialty care needs by families
Significant recruitment and retention problems
High levels of stress and burnout among PS
Declining participation in Medicaid/SCHIP &
managed care
FEDERAL EXPERT WORK
GROUP ON PS CAPACITY
 Federal Maternal and Child Health Bureau formed
work group in 2004
 Purpose: to identify scope of problems, promising
practices, and develop recommendations
 Membership: 24 from AAP, ABP, NACHRI, Title V,
AAMC, Family Voices, AACAP, etc.
 MCH Policy Research Center provides staff support
PEDIATRIC
SUBSPECIALISTS
 30 pediatric subspecialties: adolescent medicine, allergy/
immunology, anesthesiology, cardiology, clinical genetics, critical care medicine,
dermatology, developmental-behavioral pediatrics, emergency medicine,
endocrinology, gastroenterology, hematology/oncology, infectious diseases,
medical toxicology, neonatal/perinatal medicine, nephrology,
neurodevelopmental disabilities, neurology, ophthalmology, orthopedics,
otolaryngology, pathology, psychiatry, pulmonology, radiology, rehabilitative
medicine, rheumatology, sports medicine, surgical specialties, urology
 Except for neonatalogy, all other PS experiencing some level of
workforce capacity problem
 Some worse than others: child & adolescent psychiatry, neurology,
developmental-behavioral pediatrics, endocrinology, rheumatology,
gastroenterology, orthopedics, surgical specialties
DELIVERY SYSTEM
DESIGN IMPROVEMENTS
 “It is vital that all providers within the Medical Home
model of care understand their interdependent roles and
effectively serve the child and family.” (Antonelli, Stille,
Freeman)
 Improvements identified: referral (transfer of care),
consultation (one-time or time-limited), and collaborative
management approaches (ongoing shared management)
 Care coordination/case management, telemedicine,
expanded nurse roles, informatics not addressed
PROMISING REFERRAL
APPROACHES
 Referral Guidelines
 Pre-Appointment Management of Referrals
 Referral Management for Special
Populations
 Pre-Visit Contacts
REFERRAL GUIDELINES
 Madigan Army Medical Center’s Referral Guidelines: offers
guidance on initial diagnosis and management, ongoing
management objectives, indications for specialty referral, &
criteria for return to primary care
 Institute for Clinical Systems Improvement’s Care
Guidelines (for providers & for families): presents algorithm
for addressing symptom review, triage, diagnosis,
prevention, appropriate treatment & follow-up, & criteria for
specialty referral
PRE-APPOINTMENT
MANAGEMENT OF REFERRALS
 University of Wisconsin Medical Foundation’s
Rheumatology Pre-Appointment Management: Office staff
collect referral information, records, labs & xrays. Specialist
decides if: 1) appointment request approved (& scheduled as
urgent or routine & with brief, usual or extended time), 2)
further info. requested from referring MD, 3) care continued
with referring doctor following conversation with patient &
PCP, 4) other more appropriate consultation arranged, or 5)
appointment not provided if referral inappropriate or records
not provided.
 Each of 3 rheumatologists devote 45 minutes/week for more
than 100 referred patients. Only 59% of referred patients
actually required a specialty appointment.
REFERRAL MANAGEMENT
FOR SPECIAL POPULATIONS
 Referral Management Initiative at NY’s Children’s Health
Project (also in DC, Dallas, So. Florida, & L.A.) for
homeless children. PCP ranks severity of child’s referral
problem (immediate, urgent, routine) & case manager makes
appointment. Reminders by mail, phone, and in person (with
shelter staff). CM assures no insurance or transportation
obstacles, assists at PS office, including translation services,
& facilitates transfer of information between PC and PS.
 Evaluation results: increased appointment adherence, 7% to
61%, reduced time between referral & appointment, fewer
barriers to care, and fewer PCP/PS communication problems
PRE-VISIT CONTACTS
 Chapel Hill Pediatrics and Adolescents: Pre-visit contacts
conducted by phone by care coordinator with selected
special-needs families identified based on severity score and
MD’s recommendation
 Families asked about ER, hospital, or specialist visits since
last visit, including reasons, records, labs, x-rays, outcomes.
Also, asked about 3 major areas or concerns that need to be
addressed during preventive/chronic care visit.
 Results: Improved family satisfaction, sufficient
appointment time, improved coding for time & complexity
PROMISING CONSULTATION
APPROACHES
 Child Psychiatry Consultation & Liaison
 Title V Pediatric Subspecialty Consultation
 Family Practice Pediatric Consultation
Child Psychiatry Consultation &
Liaison
 Targeted Child Psychiatry Services at UMass Medical
Center (Worcester): Regional team of 2 child psychiatrists,
nurse, social worker, & care coordinator working with 22
primary care practices. By paging child psychiatrist, PCP
receives either 1) answers to questions, 2) referral to team
coordinator to access routine behavioral care, 3) face-to-face
or telephone transitional assistance by team social worker, or
4) referral to team psychiatrist for acute medication or
diagnostic consultation.
 Half of referred children managed by telephone consult,
16% scheduled within 3 weeks for 90 min. eval. At UMass
psychiatry unit and returned to PCP with treatment plan.
Only a third referred to CMHCs for ongoing care.
Title V Pediatric Subspecialty
Consultation
 Illinois Division of Specialized Care: 20
pediatric subspecialties are available for PCP
phone consultation. Medical home providers
simply call and ask about the management of
a specific condition. Specialists reimbursed
$300 to respond to 7 phone consults and
PCPs are reimbursed if child is enrolled in
the state’s Title V program.
Family Practice Pediatric
Consultation
 Ventura County (CA) Medical Center: Network of 8
family practice clinics and residency program uses
a pediatrician “anchor” and monthly onsite
pediatric subspecialist consults from 3 So. Calif.
medical schools to provide evaluation and ongoing
support for family practitioners serving as medical
homes for children with special needs.
PROMISING COLLABORATIVE
MANAGEMENT APPROACHES
 Service Agreements
 Co-Management and Multidisciplinary
Approaches
Service Agreements
 Used by NICHQ’s Epilepsy Collaborative, the VA, and others: Service
agreements developed in partnership with PCPs/specialists to formalize
collaborative process. Consist of 1) core clinical competencies
describing conditions & services provided by PCP and PS; 2) referral
agreements, including referral guidelines, work-up recommendations, &
preferred communication processes; 3) access agreements, defining
waiting times for emergency, routine, and ongoing referrals, questions,
consults, & evaluations; 4) graduation criteria for return to PCP, & 5)
QA agreements, identifying standards of care, education & training
processes, and measures.
 Process involves 2 meetings with an objective facilitator.
 Benefits– PCPs have more timely access and feedback from specialist,
and PS have reduced demand & more appropriate referrals
Co-Management and
Multidisciplinary Approaches
 Special Needs Program (SNP) at Children’s Hospital of
Wisconsin: Tertiary care/primary care medical home
partnership for medically fragile children needing multiple
specialties, with frequent hospitalizations & tertiary clinic
visits, & multiple community services. SNP team = 4
nurses, 2 part-time MDs, 1 coordinator, 1 AA. All children
have pediatric case manager. Subset have SNP physician
coordinating with PCP 24/7 & providing inpatient,
outpatient, and emergency consults, home visits, &
arbitrating divergent PS opinions & Tx options.
 Evaluation: In 2004, $5 million saved with 46 children,
primarily from fewer tertiary hospital admissions and
shorter LOS