Medical Homes and Young Children:
Frequently Asked Questions (FAQs)
These FAQs and responses are based on the May 2012 Build paper, Medical Homes and Young
Children.
What is a medical home?
A medical home is a health practitioner or office providing ongoing and continuous
primary and routine care for a patient, as well as overseeing any subspecialty care
needed by the patient. Often referred to as a “patient-centered medical home,” the
medical home practitioner or office is expected to establish a relationship with the
patient that is on a continuing basis, find out and know the patient’s medical history and
context, and involve the patient in making decisions about care and treatment.
Why are medical homes particularly important for young children?
There are two reasons medical homes are particularly important for young children.
First, young children are growing and developing at a rapid rate, both biologically and
socially. While “health maintenance” may be the primary need for most adults, “healthy
development” is the primary need for all young children. Tracking developmental
progress and identifying and responding to sources of potential concern regarding that
development is critical and is most likely to occur when the child health practitioner
(pediatrician, family practitioner, nurse practitioner, or physician assistant) has an
ongoing relationship with the child and family.
Second, during the earliest years (0-3) in particular, almost all children see a child health
practitioner for a well-child visit at least annually and usually more often for infections
or illnesses. Unlike for school-aged children, there is no other formal “system” that sees
all or most children and therefore is in a position to identify and respond to
developmental concerns (for instance, fewer than one in four children ages 0-3 are in
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any formal child-care setting). A medical home can play a critical role as the screener for
and “first responder” to all factors that can negatively affect healthy child development.
What special considerations exist in developing medical homes for young children?
There are three special considerations that apply to medical homes for young children
as opposed to those for adults and even older children.
First, in medical homes for young children, being “patient-centered” means being
“family-centered.” Parents are their children’s first and most important teacher, nurse,
safety officer, and guidance counselor. Medical homes must know the family and
involve and instruct the family in carrying out any care and treatment plans for the child.
In medical terms, one of the key roles of primary health care for young children is
providing “anticipatory guidance” to parents about their child’s development and how
to respond to and support that development.
Second, medical homes for young children must be particularly aware of the child’s
environment (family and community) as well as the child’s own biological condition and
developmental progress. Medical homes must be equipped to identify and respond to
“social determinants of health,” which often are present in the child’s life before the
young child has a diagnosable biomedical conditions or developmental delay. In addition
to referring children to subspecialty medical services, medical homes must be able to
refer children and their families to services and supports that address other social
concerns impacting healthy child development. In other words, effective prevention or
health promotion services for young children require identifying and responding to “risk
factors” and supporting and strengthening “protective factors.”
Third, medical homes for young children need to take a “two generation” approach that
involves some level of screening and assessment of parents. A child’s healthy
development is dependent on parental capacity to respond to the child. Domestic
situations, parental mental-health or substance-abuse issues, and lack of parent
knowledge of child development all can affect children’s health in profound ways.
These, in turn, may require at least recommending services directed to parents or family
rather than to the child.
Where do medical homes fit into developing effective early childhood systems?
Clearly, child health services play a key role in ensuring that children start school healthy
and prepared for success in school – but they do not play the only role. Children need
early-learning experiences and environments that stimulate their growth and learning,
and they need stable and nurturing families to support their overall development. They
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also may require specialized professional services that involve non-medical as well as
medical care (e.g, addressing developmental delays, responding to instances of abuse
and neglect and other forms of trauma, and providing adaptive responses to physical
disabilities and conditions) that ensure children’s inclusion in normative child activities.
The medical home neither is the single source for providing these services nor
necessarily the first or central point of contact for ordering and then directing them, but
the medical home can and should be part of a system that ensures children and their
families receive what they need.
In this context, medical homes need to play five different roles (the five Cs) as part of an
overall early-childhood system:
Coverage: Establish a system where all children have access to and receive health
services through a medical home.
Clinical care: Provide the full range of clinical health services (including anticipatory
guidance and developmental screening and surveillance) according to recognized,
evidence-informed clinical protocols (e.g. Bright Futures).
Coordination: Provide appropriate and effective referrals to both subspecialty care and
other professional and community services to address diagnosed health conditions and
social determinants of health.
Consultation: Provide guidance to other practitioners serving young children (e.g. early
care and education programs, family support centers, parent and family groups,
recreation programs) that enable them to respond to children’s health needs in
appropriate ways that are aligned with medical home practices.
Community health: Work within the larger community to identify and respond to
environmental and other concerns that require community-wide (population-based), as
opposed to individual child or patient, responses.
What can states do to establish medical homes for young children?
States can play major roles in establishing medical homes and ensuring that all children
receive high-quality care through those medical homes.
Particularly for young children, states are major financers of child health coverage,
through both Medicaid and the child health insurance program. In fact, nationally, over
35 percent of young children (0-5) receive their health coverage through one of these
public programs, and a majority of children with special health care needs or with risk
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factors related to social determinants are covered by them. How states establish their
Medicaid and CHIP programs is key to medical home establishment and expansion. This
involves decisions on what and how to reimburse primary child health practitioners and
how to support their care coordination roles. States also have substantial regulatory
control over many private health insurance plans covering children, and can establish
overall standards of care for children.
States are at different stages in developing medical home policies and practices overall,
and for young children in particular. As with any change in practice, there are different
stages of development and diffusion – and states can further the development and
diffusion of medical homes in several ways. While described below somewhat
sequentially, these do not necessarily have to be adopted in this order, and work can be
underway simultaneously to achieve them.
Define and promote medical homes for young children. States can draw attention to the
importance of developing medical homes for young children by defining them in statute
and promoting their development, including supporting an infrastructure for
practitioner and public education on developing medical homes for young children.
Establish demonstration programs and develop flagship practices that embody medical
homes, ideally within broader early-childhood systems. States can directly finance
programs or initiatives to establish high-quality medical homes in locations where there
is leadership and a readiness to do so, creating flagship practices than become
guideposts for other practices.
Establish payment, monitoring, accountability and continuous-improvement systems
(particularly within publicly financed health systems) that promote widespread adoption
of medical home practice. States can develop payment mechanisms needed to
adequately support medical home practices for young children within Medicaid and
CHIP, with different monitoring, technical assistance, and accountability provisions that
support diffusion and widespread adoption. This applies to both medical homes
themselves, and to the care coordination.
Establish regulatory frameworks that set medical homes as the standard for routine
practice. Finally, states oversee medical practice and medical insurance, support medical
education, and play a role in health workforce development. All this work has
implications to medical home development for young children. As the major costs in the
health system are for the treatment of chronic health needs and largely in the adult
population (much under the federal Medicare program), there is not always the
attention given to children in such regulatory activities – nor the special attention
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needed for developmental health as contrasted with health maintenance. At the same
time, the future health of the nation and the prevalence of such chronic health
conditions will in significant measure determine future drivers of health care costs.
Incorporating provisions to strengthen the development and practice of medical homes
for young children into state regulatory frameworks and health policies are important to
addressing the three goals for health care reform – improving quality, improving health
outcomes and containing costs.
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