Merging Systems Integrating Home Visitation and theFamily-Centered Medical Home

abstractTo improve the health of children and bend the health care cost curvewe must integrate the individual and population approaches to healthand health care delivery The 2012 Institute of Medicine (IOM) reportPrimary Care and Public Health Exploring Integration to ImprovePopulation Health laid out the continuum for integration of primarycare and public health stretching from isolation to merging systemsIntegration of the family-centered medical home (FCMH) and homevisitation (HV) would promote overall efficiency and effectiveness andhelp achieve gains in population health through improving the qualityof health care delivered decreasing duplication reinforcing similarhealth priorities decreasing costs and decreasing health disparitiesThis paper aims to (1) provide a brief description of the goals andscope of care of the FCMH and HV (2) outline the need for integrationof the FCMH and HV and synergies of integration (3) apply the IOMrsquoscontinuum of integration framework to the FCMH and HV and describebarriers to integration and (4) use child developmental surveillanceand screening as an example of the potential impact of HV-FCMHintegration Pediatrics 2013132S74ndashS81

AUTHORS Megan M Tschudy MD MPHa Sara L ToomeyMD MPhil MPH MScb and Tina L Cheng MD MPHa

aDepartment of Pediatrics The Johns Hopkins University Schoolof Medicine Baltimore Maryland and bDivision of GeneralPediatrics Boston Childrenrsquos Hospital Boston Massachusetts

KEY WORDShome visiting family-centered medical home patient-centeredmedical home primary care

ABBREVIATIONSAAPmdashAmerican Academy of PediatricsFCMHmdashfamily-centered medical homeHVmdashhome visitationIOMmdashInstitute of MedicinePCPmdashprimary care provider

Dr Tschudy conceptualized and designed the manuscript anddrafted the initial manuscript Dr Toomey conceptualized anddesigned the manuscript and drafted the initial manuscript DrCheng conceptualized and designed the manuscript and draftedthe initial manuscript and all authors approved the finalmanuscript as submitted

wwwpediatricsorgcgidoi101542peds2013-1021E

doi101542peds2013-1021E

Accepted for publication Aug 26 2013

Address correspondence to Megan M Tschudy MD MPHDepartment of Pediatrics Johns Hopkins University School ofMedicine Rubenstein Health Building 200 N Wolfe St Suite 2085Baltimore MD 21287 E-mail mtschud1jhmiedu

PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)

Copyright copy 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE The authors have indicated they haveno financial relationships relevant to this article to disclose

FUNDING Supported by the HRSA NRSA Fellowship Traininggrant T32 HP10004-16-00 (Dr Tschudy) National Institute of ChildHealth and Human Development grant 1K24HD052559(Dr Cheng) and the DC-Baltimore Research Center on ChildHealth Disparities P20 MD00165 from the National Institute onMinority Health and Health Disparities Its contents are solelythe responsibility of the authors and do not necessarilyrepresent the official views of the funding agencies

POTENTIAL CONFLICT OF INTEREST The authors have indicatedthey have no potential conflicts of interest to disclose

S74 TSCHUDY et al by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

INTEGRATION OF THEFAMILY-CENTERED MEDICAL HOMEAND HOME VISITING INTO THEMEDICAL NEIGHBORHOOD

To improve the health of children andbend thehealthcarecostcurvewemustintegrate the traditional silos of healthdelivery systems1 Moving the family-centered medical home (FCMH) be-yond the office into the community willintegrate the personal and populationapproaches to health and health caredelivery and has the potential to opti-mize each childrsquos life course trajectoryimprove outcomes and reduce costs23

The future of pediatric care is workingin multidisciplinary teams with theshared goal of delivering the right careat the right time and in the right placewith the right providers Although themedical homemaybe the rightplace forsome services the patientrsquos home maybe the right place and home visitorsthe right providers for other servicesContinued health disparities bring ur-gency to integration of these services4ndash6

Recent Affordable Care Act investmentin home visitation (HV) programs andemphasis on the FCMH combined withthe American Academy of Pediatrics(AAP) and Academic Pediatric Associa-tion (APA) endorsement of collabo-ration between home visitors andprimary care providers (PCPs) offera unique opportunity to integrate andimprove services provided to childrenand families6ndash8

This paper aims to (1) provide a briefdescription of the goals and scope ofcare of the FCMH and HV (2) outline theneed for integration of the FCMH and HVand synergies of integration (3) applythe Institute of Medicinersquos (IOM) con-tinuum of integration framework to theFCMH and HV and describe barriers tointegration and (4) use child de-velopmental surveillance and screen-ing as an example of the potentialimpact of HV-FCMH integration

The Family-Centered Medical Home

From an ecological perspective avail-ability of comprehensive primary care isstrongly associated with improved pop-ulation health29 The FCMH was initiallyconceived in pediatrics in the 1960s and1970s as a model for providing com-prehensive pediatric care10 Over thepast 3 decades the medical home modelhas been further refined defining themedical homeas accessible continuouscomprehensive family-centered coordi-nated compassionate and culturally ef-fective1112 The central goal of the FCMHis to facilitate partnerships betweenpatients families clinicians and com-munity resources to improve childrenrsquoshealth and the joint principles for theFCMH have been widely endorsed7

There is modest evidence that FCMHmodels are associated with improvedquality of health care in pediatrics in-cluding children with a medical homehaving fewer unmet health care needsand increased likelihood of receivingpreventive care13ndash17 Evidence exists forpotential cost savings associated withthe growth of the medical homemodel18 It is hypothesized that an ex-panded medical home model will fur-ther decrease health disparities19

Ongoing multisite FCMH demonstrationprojects aim to provide additional evi-dence regarding the effectiveness of theFCMH model of care20

The current scope of practice of theFCMH is deeply rooted in the medicalmodel of care including child healthsupervision and acute and chronicdisease management occurring pri-marily at an office site There is in-creased recognition of the importanceof psychosocial issues in child andfamily health and of a population ap-proach that addresses the socialdeterminants of health New models ofhealth promotion that move beyond themedical model of care are needed tolook beyond the individual patient inthe office to managing the health of

families and patient populations in thecommunity321

Although traditional models of primarycare provide reactive and episodic careduring doctor visits newmodels requireoutreach coordination and educationempowerment with increasing team-work provided by multidisciplinary staffincluding home visitors22 As FCMHsand hospitals are increasingly beingheld accountable to population qualitymeasures interest in home visitation(HV) and community health workermodels have increased23 For instanceHealthcare Effectiveness Data and In-formation Set quality measures thatassess well-child visit attendance ofa primary care practicersquos panel has in-creased interest in medical home out-reach to families and home visitationstrategies Similarly hospital reimburse-ment tied to readmission rates has alsoled some to consider social determi-nants of health and strategies beyondthe health care setting

Home Visitation

HV is a widely disseminated strategy topromote maternal and child health thatis endorsed by state and federal agen-cies professional societies and privatefoundations24 HV for at-risk families wasdeveloped more than a century ago withgoals similar to pediatric primary careincluding promoting the health and de-velopment of children by developinga longitudinal supportive and trustingrelationship with families HV programsinvolve regular home visits by a para-professional or nurse There are multi-ple types of HV programs includingmaternal infant and early childhoodvisiting targeted visiting for childrenfrom at-risk families and child care andschool-based visiting programs

Modelsofmaternaland infantearlyhomevisiting have documented modest evi-dence that high intensity HV programscan improve childphysical andemotionalhealth and development improve school

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S75 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

readiness and prevent child abuseand neglect2526 HV has also beenshown to improve the relationship be-tween the family and their primary careclinician2728 Furthermore HV programshave also demonstrated cost savingslongitudinally with the greatest savingsin those visited who were at greatestrisk29ndash31

The scope of practice for evidence-basedHV programs is wide and varies depend-ing on the individual goals of the programand what type of provider is performingthe home visit Goals of these programsinclude improved pregnancy outcomesprevention of maltreatment and neglectenhanced parent-child interactions earlyidentification of delays and improveddevelopmental trajectories Communityhealth worker programs have also in-creased with emphasis on the sharedculture of the worker and the family23

The scope of HV programs has beenexpanding to address special pop-ulations and to include additional goalssuch as follow-up from hospital dis-charge medical visits to children whohave special health care needs (egasthma care) hospice and palliativecare and environmental evaluations(eg home lead evaluations) Althoughsome HV programs are based in tra-ditional health care settings such ashospitals and primary care practicesmany are operated by state or localpublic health departments or privatecompanies often without connection toprimary care practices HV curriculaare also used in some pediatric resi-dency training programs as a methodto extend the medical home into thecommunity while experientially teach-ing residents social determinants ofhealth and the role of HV staff32

INTEGRATION MOVING FROMISOLATION TO SYSTEMS MERGING

Why is Integration Important

The goals of the FCMH model of careand HV programs are fundamentally

synergistic They share goals of pro-moting the health and development ofchildren often through trusting longitu-dinal relationshipsBothprovidechildrenandtheir familieswithsocialsupportandanticipatory guidance (eg developmentsafety) and linkage to community re-sources and services To fully capitalizeon these synergies the systems shouldbe integrated whenever possible prior-itizing the particular strengths of eachservice and needs of the family

The 2012 IOM report Primary Care andPublic Health Exploring Integration toImprove Population Health laid out thecontinuum for integration of primarycare and public health33 The contin-uum stretches from isolation mutualawareness cooperation collaborationpartnership and finally to mergingsystems (Fig 1) Core principles forintegration include common goals in-volvement of the community in ad-dressing needs and strong leadershipLeadership is needed to bridge dis-ciplines services programs and ju-risdictions sustain integration anddevelop collaborative systems for datasharing and evaluation The time is ripefor planning horizontal integration (iemerging health services with othersectors such as social and civic sec-tors) and vertical integration (ie link-ing primary secondary and tertiaryhealth care services and differenthealth disciplines) for the commongoals that HV and the FCMH share334

Integration of the FCMH and HV couldpromote overall efficiency and effec-tiveness and help achieve gains inpopulation health through improving

the quality of health care delivereddecreasing duplication reinforcing sim-ilar health priorities decreasing costsand decreasing health disparities Thecurrent movement from the FCMH to-ward themedical neighborhoodwhichencompasses the FCMHcombinedwithother clinical health services andcommunity and social service organ-izations at the state and local publichealth levels may also serve as a fa-cilitator35 Because families are morelikely to use health services when theyreflect the familiesrsquo perceived needscommunication between home visi-tors and FCMH clinicians regardingspecific needs is likely to result inmore preventive care use and betterretention in HV programs36 Inte-gration may also allow home visitorsand medical home providers to betterunderstand patientsrsquoand familiesrsquo needsand preferences and more directly ad-dress their concerns

Evidence for Integration

Different degrees of integration of theFCMH and HV systems have been showninmultiple studies to be effective and toimprove health-related outcomes forchildren2223 Hardy and Street foundthat home visits conducted 2 to 3weeks before a well-child visit resultedin fewer missed visits fewer sick andacute care visits decreased hospitali-zation and decreased abuse and ne-glect37 Furthermore at-risk childrenreceiving an intensive HV program incollaboration with a PCP improved in-volvement with and retention in earlyintervention programs38 A program

FIGURE 1The Institute of Medicine continuum of integration of primary care and public health33

S76 TSCHUDY et al by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

that assigned public health home visi-tors to work with PCPs in North Caro-lina resulted in mothers of infantsbeing able to overcome more personaland structural barriers in seeking carefor their child39 Another program inwhich school-based home visitors col-laborated with PCPs in South Carolinaresulted in a greater parental un-derstanding and retention of anticipa-tory guidance and improved satisfactionwith care24

State programs have also been suc-cessful in encouraging integration ofHVand the FCMH North Carolina Linkagesfor Prevention brought together pri-mary care practices and local statehealth departments in Durham to im-prove the delivery of preventive care inpediatric primary care practices andimplement intensive HV to low-incomepregnant women and their infantsHome visitors working in close collab-orationwith PCPs providing 2 to 4 homevisits per month for the first year of liferesulted inhighernumbersofwell-childvisits at 12months and lower likelihoodof being seen for injuries and inges-tions40 The REACH-Futures program inChicago which uses registered nursesfroma community clinicwho are teamedwith public health trained communityhealth workers for an infant HV pro-gram resulted in improved immuniza-tion rates and retention in the primarycare clinic41

Finally aqualitativestudybyNelsonetaldemonstrated that PCPs and homevisitors perceived one of the benefits ofintegration was improved communi-cation This included home visitorsassisting parental communication withPCPs home visitors giving PCPs in-formation about families and homeenvironments home visitors helpingthe family understand the childrsquos med-ical conditions and home visitors andPCPs reinforcing the specific treatmentplan and anticipatory guidance eachother gave3642ndash44

Barriers to Integration

As noted there exists evidence for thefeasibility and effectiveness of inte-grating HV and the FCMH Under-standing the barriers to integration iscritical for dissemination and imple-mentation Integration of HV programsand the FCMH is not an easy task Manymedical home clinicians are not awareof what HV programs operate in theircommunities and what their scope ofpractice entails This results in the in-ability to fully appreciate and take ad-vantage of each otherrsquos skill In additionsome PCPs are concerned that the riseof HV may result in more fragmentedservices for families or may replacesome of the services provided in theircurrent practice43

There are multiple barriers that mustbe overcome for optimal coordinationcommunication and linkage betweenHVand FCMH As is acknowledged in theIOM report the first step of integrationis mutual awareness which is oftenlacking FCMH providers and homevisitors are often separate organ-izations that have different oversightand administration In addition thereare few financial incentives or re-imbursement structures to encourageHV and FCMH providers to interactSignificant barriers to communicationcurrently exist many of which aresimilar to communication strugglesseen between PCPs and subspecialistsThese include inconsistent method andtiming of communication inadequatecontent of communication andconcernfor making families intermediariesbetween home visitor and PCP pro-viders45

Another common barrier to integrationis concern about disclosure of possibleconfidential information from the PCPsto the home visitors or vice versa4346

Families may be apprehensive aboutdisclosing information across ser-vices Furthermore there is concernthat clinicians may be unprepared to

act on family issues the home visitormay find in the home and converselythat home visitor may not be able toaddress the issues of PCP concern37

Finally the perceived and real-timeconstraints related to communicationand potential disruptions to practicealso impede integration efforts

Measurement

Measuring the integration of HV pro-grams and the FCMH is critical to en-courage integration assess the currentstateofcoordinationplannextstepsandassess effectiveness of interventions toincrease collaboration47 Programmaticmeasures process measures and out-comes must be initially assessed andregularly reassessed (Fig 2)

Example Integration ofDevelopmental Surveillance andScreening

Although developmental surveillanceand screening are part of child healthsupervision in the FCMH it is also in thescope of practice for many HV pro-grams Home visitors potentially havemore time with families for deve-lopmental surveillance and would beable to observe children in their naturalhome environment Without integrationit is possible that PCPs and home visitorsmayduplicate efforts providing the samesurveillance and waste time and moneyfor thePCPhomevisitorandfamilyThereis also the potential to provide in-consistent or conflicting information tofamilies regarding childrenrsquos develop-mental milestones

Dividing responsibilities regarding de-velopmental assessment between thehome visitor and the PCP would likelyavoid duplication and allow standard-ized screening with enhanced moni-toring of referrals Developmentalassessment in the home may also beamore effective location forobservationand testing as children might be morecomfortable interacting in their home

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S77 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

environment rather than having to relyon parental report As has been donewith care coordinators multiple PCPscould share a home visitor or group ofhome visitors A clear process and sys-tem for ensuring screening assess-ment referral and follow-up shared bythe FCMHand home visitors could resultin improved child developmental out-comes By dividing responsibilities be-tween the home visitor and PCP therecould be more focused time to addressother steps in the surveillance processas well as other important child andfamily health-related issues

Methods for Integration of HomeVisitation and the Family-CenteredMedical Home

The integration process requiresbreaking down barriers and establish-ing new methods of improved commu-nication48 A first step in facilitatingcommunication is creating a system forthe FCMH provider to know that theirpatient is enrolled in an HV programSecond a regular and preferred method

of communication needs to be estab-lishedMutual awareness between FCMHproviders and HV programs is neces-sary but not sufficient for optimal careand avoidance of duplication and frag-mentation of services Instead to maxi-mize the health of children we mustmove along the integration continuum topartnership and merging of systemsThis requires a clear scope of service forHV and the FCMH bidirectional commu-nication and shared responsibilities foroutcomes Optimally FCMH and HV pro-viders in a region must agree on astrategy allocate responsibilities andservices and monitor implementationand outcomes Table 1 details examplesof different levels along the integrationcontinuum for the FCMH and HV

Medical home and HV integration canresult directly in improved individualchild development andhealth outcomesOn a patient and family level integrationcan translate into information sharingreferring bidirectionally assisting incare coordination reinforcing treat-ment plans and anticipatory guidance

improving maternal depression identi-fication and treatment and improvedchronic disease management Ona population health level integrationpromotes primary secondary and ter-tiarypreventionwithinasingle integratedsystem and can improve identification ofcommunity needs49

When progressing along the integrationcontinuum it is necessary to considerthe current level of integration whichpartners should be included in theprocess and what actions will beneeded for enhanced integration Part-ners should extend beyond home visitorprogramsandindividualFCMHpracticesto include community members andotherstakeholders to fullyassessneedsActions toward integration will likely bedifferent in different regions and de-pendent onwhichpartners are involvedThey can range from a minimum ofshared goals and mutual awareness tosharing of resources whether financialor human and sharing physical spaceand supplies33 Ideally actions shouldwork toward the goal of a shared

FIGURE 2Measures for assessing the coordination of HV programs and FCMH Adapted from reference 47

S78 TSCHUDY et al by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

infrastructure including co-location andbuilding sustainable integrated systemsthat have enduring impact

Multiplemethods have been proposed tofacilitate integration between practi-tioners in the FCMH and home visitorsStates have convened statewide taskforcescomposedof TitleVMaternalChildHealth Medicaid and CHIP programshospital provider groups insurers andfamilies to start integrating service de-livery systems1 States are also usingfunds to integrate public-private servicedelivery systems and promote qualityOne example of a funding mechanism toencourage integration is the Medicaid

Health Home State Plan Option thatprovides funding strategies throughMedicaid to enhance provider reim-bursement for enhanced multidisciplin-ary collaboration

CONCLUSIONS

The FCMH model of primary care de-livery and HV models have synergisticgoals Both are critical in promotingchild development and health in thecontext of their family and communityPediatric primary care providers andhome visitors must be pushed from thecurrent status of playing nicely in the

sandbox together in isolation towardmerging systems of care Health careprofessionals working in pediatricprimary care practices (eg physiciansnurses and social workers) and inother health and education programs(eg home visiting nurses communitycase managers and community healthworkers) must work on the same teamto capitalize on each othersrsquo capa-bilities and expertise increase effi-ciencies and improve the health ofchildren and families

With the vision of extending themedicalhome into the community (eg the med-ical neighborhood) eliminating persis-tenthealthdisparitiesand theAffordableCare Actrsquos support for increased healthcare partnerships this is an optimaltime to integrate the FCMH and HV pro-grams Policies and funding streamsneed to be further aligned to encouragethis integration As HV programs areimplemented in communities connect-ing and partnering with the medicalhome should be a requirement Ulti-mately HV programs should be co-located in the FCMH to optimize com-munication collaboration and childhealth outcomes To truly improve thehealth of all children the integration ofHV and the FCMH should only be the firststep in horizontal and vertical inte-gration of services that promote thehealth development and well being ofchildren and families

REFERENCES

1 VanLandeghem K Schor E New opportuni-ties for integrating and improving healthcare for women children and their fami-lies The Commonwealth Fund and the As-sociation of Maternal and Child HealthPrograms February 2012 Accessed November12 2012 Available at wwwcommonwealth-fundorgPublicationsIssue-Briefs2012FebNew-opportunities-for-integrating-health-care-for-womenaspxcitation

2 Starfield BB Shi L The medical home ac-cess to care and insurance a review of

evidence Pediatrics 2004113(5 suppl)

1493ndash1498

3 Halfon N DuPlessis H Barrett E Looking

back at pediatrics to move forward in ob-

stetrics Curr Opin Obstet Gynecol 200820

(6)566ndash573

4 Toomey SL Chien AT Elliott MN Ratner J

Schuster MA Disparities in unmet care

coordination needs analysis of the na-

tional survey of childrenrsquos health Pediat-

rics 2013131(2)217ndash224

5 Agency for Healthcare Research and Quality(AHRQ) 2011 National Healthcare DisparitiesReport Rockville MD Agency for HealthcareResearch and Quality March 25 2012

6 Affordable care act maternal infant andearly childhood home visiting programsupplemental information request for thesubmission of the statewide needs as-sessment OMB control no 0915-0333

7 American Academy of Family Physicians(AAFP) American Academy of Pediatrics(AAP) American College of Physicians (ACP)

TABLE 1 The Continuum of Integration of the FCMH and HV

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S79 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

readiness and prevent child abuseand neglect2526 HV has also beenshown to improve the relationship be-tween the family and their primary careclinician2728 Furthermore HV programshave also demonstrated cost savingslongitudinally with the greatest savingsin those visited who were at greatestrisk29ndash31

The scope of practice for evidence-basedHV programs is wide and varies depend-ing on the individual goals of the programand what type of provider is performingthe home visit Goals of these programsinclude improved pregnancy outcomesprevention of maltreatment and neglectenhanced parent-child interactions earlyidentification of delays and improveddevelopmental trajectories Communityhealth worker programs have also in-creased with emphasis on the sharedculture of the worker and the family23

The scope of HV programs has beenexpanding to address special pop-ulations and to include additional goalssuch as follow-up from hospital dis-charge medical visits to children whohave special health care needs (egasthma care) hospice and palliativecare and environmental evaluations(eg home lead evaluations) Althoughsome HV programs are based in tra-ditional health care settings such ashospitals and primary care practicesmany are operated by state or localpublic health departments or privatecompanies often without connection toprimary care practices HV curriculaare also used in some pediatric resi-dency training programs as a methodto extend the medical home into thecommunity while experientially teach-ing residents social determinants ofhealth and the role of HV staff32

INTEGRATION MOVING FROMISOLATION TO SYSTEMS MERGING

Why is Integration Important

The goals of the FCMH model of careand HV programs are fundamentally

synergistic They share goals of pro-moting the health and development ofchildren often through trusting longitu-dinal relationshipsBothprovidechildrenandtheir familieswithsocialsupportandanticipatory guidance (eg developmentsafety) and linkage to community re-sources and services To fully capitalizeon these synergies the systems shouldbe integrated whenever possible prior-itizing the particular strengths of eachservice and needs of the family

The 2012 IOM report Primary Care andPublic Health Exploring Integration toImprove Population Health laid out thecontinuum for integration of primarycare and public health33 The contin-uum stretches from isolation mutualawareness cooperation collaborationpartnership and finally to mergingsystems (Fig 1) Core principles forintegration include common goals in-volvement of the community in ad-dressing needs and strong leadershipLeadership is needed to bridge dis-ciplines services programs and ju-risdictions sustain integration anddevelop collaborative systems for datasharing and evaluation The time is ripefor planning horizontal integration (iemerging health services with othersectors such as social and civic sec-tors) and vertical integration (ie link-ing primary secondary and tertiaryhealth care services and differenthealth disciplines) for the commongoals that HV and the FCMH share334

Integration of the FCMH and HV couldpromote overall efficiency and effec-tiveness and help achieve gains inpopulation health through improving

the quality of health care delivereddecreasing duplication reinforcing sim-ilar health priorities decreasing costsand decreasing health disparities Thecurrent movement from the FCMH to-ward themedical neighborhoodwhichencompasses the FCMHcombinedwithother clinical health services andcommunity and social service organ-izations at the state and local publichealth levels may also serve as a fa-cilitator35 Because families are morelikely to use health services when theyreflect the familiesrsquo perceived needscommunication between home visi-tors and FCMH clinicians regardingspecific needs is likely to result inmore preventive care use and betterretention in HV programs36 Inte-gration may also allow home visitorsand medical home providers to betterunderstand patientsrsquoand familiesrsquo needsand preferences and more directly ad-dress their concerns

Evidence for Integration

Different degrees of integration of theFCMH and HV systems have been showninmultiple studies to be effective and toimprove health-related outcomes forchildren2223 Hardy and Street foundthat home visits conducted 2 to 3weeks before a well-child visit resultedin fewer missed visits fewer sick andacute care visits decreased hospitali-zation and decreased abuse and ne-glect37 Furthermore at-risk childrenreceiving an intensive HV program incollaboration with a PCP improved in-volvement with and retention in earlyintervention programs38 A program

FIGURE 1The Institute of Medicine continuum of integration of primary care and public health33

S76 TSCHUDY et al by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

that assigned public health home visi-tors to work with PCPs in North Caro-lina resulted in mothers of infantsbeing able to overcome more personaland structural barriers in seeking carefor their child39 Another program inwhich school-based home visitors col-laborated with PCPs in South Carolinaresulted in a greater parental un-derstanding and retention of anticipa-tory guidance and improved satisfactionwith care24

State programs have also been suc-cessful in encouraging integration ofHVand the FCMH North Carolina Linkagesfor Prevention brought together pri-mary care practices and local statehealth departments in Durham to im-prove the delivery of preventive care inpediatric primary care practices andimplement intensive HV to low-incomepregnant women and their infantsHome visitors working in close collab-orationwith PCPs providing 2 to 4 homevisits per month for the first year of liferesulted inhighernumbersofwell-childvisits at 12months and lower likelihoodof being seen for injuries and inges-tions40 The REACH-Futures program inChicago which uses registered nursesfroma community clinicwho are teamedwith public health trained communityhealth workers for an infant HV pro-gram resulted in improved immuniza-tion rates and retention in the primarycare clinic41

Finally aqualitativestudybyNelsonetaldemonstrated that PCPs and homevisitors perceived one of the benefits ofintegration was improved communi-cation This included home visitorsassisting parental communication withPCPs home visitors giving PCPs in-formation about families and homeenvironments home visitors helpingthe family understand the childrsquos med-ical conditions and home visitors andPCPs reinforcing the specific treatmentplan and anticipatory guidance eachother gave3642ndash44

Barriers to Integration

As noted there exists evidence for thefeasibility and effectiveness of inte-grating HV and the FCMH Under-standing the barriers to integration iscritical for dissemination and imple-mentation Integration of HV programsand the FCMH is not an easy task Manymedical home clinicians are not awareof what HV programs operate in theircommunities and what their scope ofpractice entails This results in the in-ability to fully appreciate and take ad-vantage of each otherrsquos skill In additionsome PCPs are concerned that the riseof HV may result in more fragmentedservices for families or may replacesome of the services provided in theircurrent practice43

There are multiple barriers that mustbe overcome for optimal coordinationcommunication and linkage betweenHVand FCMH As is acknowledged in theIOM report the first step of integrationis mutual awareness which is oftenlacking FCMH providers and homevisitors are often separate organ-izations that have different oversightand administration In addition thereare few financial incentives or re-imbursement structures to encourageHV and FCMH providers to interactSignificant barriers to communicationcurrently exist many of which aresimilar to communication strugglesseen between PCPs and subspecialistsThese include inconsistent method andtiming of communication inadequatecontent of communication andconcernfor making families intermediariesbetween home visitor and PCP pro-viders45

Another common barrier to integrationis concern about disclosure of possibleconfidential information from the PCPsto the home visitors or vice versa4346

Families may be apprehensive aboutdisclosing information across ser-vices Furthermore there is concernthat clinicians may be unprepared to

act on family issues the home visitormay find in the home and converselythat home visitor may not be able toaddress the issues of PCP concern37

Finally the perceived and real-timeconstraints related to communicationand potential disruptions to practicealso impede integration efforts

Measurement

Measuring the integration of HV pro-grams and the FCMH is critical to en-courage integration assess the currentstateofcoordinationplannextstepsandassess effectiveness of interventions toincrease collaboration47 Programmaticmeasures process measures and out-comes must be initially assessed andregularly reassessed (Fig 2)

Example Integration ofDevelopmental Surveillance andScreening

Although developmental surveillanceand screening are part of child healthsupervision in the FCMH it is also in thescope of practice for many HV pro-grams Home visitors potentially havemore time with families for deve-lopmental surveillance and would beable to observe children in their naturalhome environment Without integrationit is possible that PCPs and home visitorsmayduplicate efforts providing the samesurveillance and waste time and moneyfor thePCPhomevisitorandfamilyThereis also the potential to provide in-consistent or conflicting information tofamilies regarding childrenrsquos develop-mental milestones

Dividing responsibilities regarding de-velopmental assessment between thehome visitor and the PCP would likelyavoid duplication and allow standard-ized screening with enhanced moni-toring of referrals Developmentalassessment in the home may also beamore effective location forobservationand testing as children might be morecomfortable interacting in their home

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S77 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

environment rather than having to relyon parental report As has been donewith care coordinators multiple PCPscould share a home visitor or group ofhome visitors A clear process and sys-tem for ensuring screening assess-ment referral and follow-up shared bythe FCMHand home visitors could resultin improved child developmental out-comes By dividing responsibilities be-tween the home visitor and PCP therecould be more focused time to addressother steps in the surveillance processas well as other important child andfamily health-related issues

Methods for Integration of HomeVisitation and the Family-CenteredMedical Home

The integration process requiresbreaking down barriers and establish-ing new methods of improved commu-nication48 A first step in facilitatingcommunication is creating a system forthe FCMH provider to know that theirpatient is enrolled in an HV programSecond a regular and preferred method

of communication needs to be estab-lishedMutual awareness between FCMHproviders and HV programs is neces-sary but not sufficient for optimal careand avoidance of duplication and frag-mentation of services Instead to maxi-mize the health of children we mustmove along the integration continuum topartnership and merging of systemsThis requires a clear scope of service forHV and the FCMH bidirectional commu-nication and shared responsibilities foroutcomes Optimally FCMH and HV pro-viders in a region must agree on astrategy allocate responsibilities andservices and monitor implementationand outcomes Table 1 details examplesof different levels along the integrationcontinuum for the FCMH and HV

Medical home and HV integration canresult directly in improved individualchild development andhealth outcomesOn a patient and family level integrationcan translate into information sharingreferring bidirectionally assisting incare coordination reinforcing treat-ment plans and anticipatory guidance

improving maternal depression identi-fication and treatment and improvedchronic disease management Ona population health level integrationpromotes primary secondary and ter-tiarypreventionwithinasingle integratedsystem and can improve identification ofcommunity needs49

When progressing along the integrationcontinuum it is necessary to considerthe current level of integration whichpartners should be included in theprocess and what actions will beneeded for enhanced integration Part-ners should extend beyond home visitorprogramsandindividualFCMHpracticesto include community members andotherstakeholders to fullyassessneedsActions toward integration will likely bedifferent in different regions and de-pendent onwhichpartners are involvedThey can range from a minimum ofshared goals and mutual awareness tosharing of resources whether financialor human and sharing physical spaceand supplies33 Ideally actions shouldwork toward the goal of a shared

FIGURE 2Measures for assessing the coordination of HV programs and FCMH Adapted from reference 47

S78 TSCHUDY et al by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

infrastructure including co-location andbuilding sustainable integrated systemsthat have enduring impact

Multiplemethods have been proposed tofacilitate integration between practi-tioners in the FCMH and home visitorsStates have convened statewide taskforcescomposedof TitleVMaternalChildHealth Medicaid and CHIP programshospital provider groups insurers andfamilies to start integrating service de-livery systems1 States are also usingfunds to integrate public-private servicedelivery systems and promote qualityOne example of a funding mechanism toencourage integration is the Medicaid

Health Home State Plan Option thatprovides funding strategies throughMedicaid to enhance provider reim-bursement for enhanced multidisciplin-ary collaboration

CONCLUSIONS

The FCMH model of primary care de-livery and HV models have synergisticgoals Both are critical in promotingchild development and health in thecontext of their family and communityPediatric primary care providers andhome visitors must be pushed from thecurrent status of playing nicely in the

sandbox together in isolation towardmerging systems of care Health careprofessionals working in pediatricprimary care practices (eg physiciansnurses and social workers) and inother health and education programs(eg home visiting nurses communitycase managers and community healthworkers) must work on the same teamto capitalize on each othersrsquo capa-bilities and expertise increase effi-ciencies and improve the health ofchildren and families

With the vision of extending themedicalhome into the community (eg the med-ical neighborhood) eliminating persis-tenthealthdisparitiesand theAffordableCare Actrsquos support for increased healthcare partnerships this is an optimaltime to integrate the FCMH and HV pro-grams Policies and funding streamsneed to be further aligned to encouragethis integration As HV programs areimplemented in communities connect-ing and partnering with the medicalhome should be a requirement Ulti-mately HV programs should be co-located in the FCMH to optimize com-munication collaboration and childhealth outcomes To truly improve thehealth of all children the integration ofHV and the FCMH should only be the firststep in horizontal and vertical inte-gration of services that promote thehealth development and well being ofchildren and families

REFERENCES

1 VanLandeghem K Schor E New opportuni-ties for integrating and improving healthcare for women children and their fami-lies The Commonwealth Fund and the As-sociation of Maternal and Child HealthPrograms February 2012 Accessed November12 2012 Available at wwwcommonwealth-fundorgPublicationsIssue-Briefs2012FebNew-opportunities-for-integrating-health-care-for-womenaspxcitation

2 Starfield BB Shi L The medical home ac-cess to care and insurance a review of

evidence Pediatrics 2004113(5 suppl)

1493ndash1498

3 Halfon N DuPlessis H Barrett E Looking

back at pediatrics to move forward in ob-

stetrics Curr Opin Obstet Gynecol 200820

(6)566ndash573

4 Toomey SL Chien AT Elliott MN Ratner J

Schuster MA Disparities in unmet care

coordination needs analysis of the na-

tional survey of childrenrsquos health Pediat-

rics 2013131(2)217ndash224

5 Agency for Healthcare Research and Quality(AHRQ) 2011 National Healthcare DisparitiesReport Rockville MD Agency for HealthcareResearch and Quality March 25 2012

6 Affordable care act maternal infant andearly childhood home visiting programsupplemental information request for thesubmission of the statewide needs as-sessment OMB control no 0915-0333

7 American Academy of Family Physicians(AAFP) American Academy of Pediatrics(AAP) American College of Physicians (ACP)

TABLE 1 The Continuum of Integration of the FCMH and HV

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S79 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

that assigned public health home visi-tors to work with PCPs in North Caro-lina resulted in mothers of infantsbeing able to overcome more personaland structural barriers in seeking carefor their child39 Another program inwhich school-based home visitors col-laborated with PCPs in South Carolinaresulted in a greater parental un-derstanding and retention of anticipa-tory guidance and improved satisfactionwith care24

State programs have also been suc-cessful in encouraging integration ofHVand the FCMH North Carolina Linkagesfor Prevention brought together pri-mary care practices and local statehealth departments in Durham to im-prove the delivery of preventive care inpediatric primary care practices andimplement intensive HV to low-incomepregnant women and their infantsHome visitors working in close collab-orationwith PCPs providing 2 to 4 homevisits per month for the first year of liferesulted inhighernumbersofwell-childvisits at 12months and lower likelihoodof being seen for injuries and inges-tions40 The REACH-Futures program inChicago which uses registered nursesfroma community clinicwho are teamedwith public health trained communityhealth workers for an infant HV pro-gram resulted in improved immuniza-tion rates and retention in the primarycare clinic41

Finally aqualitativestudybyNelsonetaldemonstrated that PCPs and homevisitors perceived one of the benefits ofintegration was improved communi-cation This included home visitorsassisting parental communication withPCPs home visitors giving PCPs in-formation about families and homeenvironments home visitors helpingthe family understand the childrsquos med-ical conditions and home visitors andPCPs reinforcing the specific treatmentplan and anticipatory guidance eachother gave3642ndash44

Barriers to Integration

As noted there exists evidence for thefeasibility and effectiveness of inte-grating HV and the FCMH Under-standing the barriers to integration iscritical for dissemination and imple-mentation Integration of HV programsand the FCMH is not an easy task Manymedical home clinicians are not awareof what HV programs operate in theircommunities and what their scope ofpractice entails This results in the in-ability to fully appreciate and take ad-vantage of each otherrsquos skill In additionsome PCPs are concerned that the riseof HV may result in more fragmentedservices for families or may replacesome of the services provided in theircurrent practice43

There are multiple barriers that mustbe overcome for optimal coordinationcommunication and linkage betweenHVand FCMH As is acknowledged in theIOM report the first step of integrationis mutual awareness which is oftenlacking FCMH providers and homevisitors are often separate organ-izations that have different oversightand administration In addition thereare few financial incentives or re-imbursement structures to encourageHV and FCMH providers to interactSignificant barriers to communicationcurrently exist many of which aresimilar to communication strugglesseen between PCPs and subspecialistsThese include inconsistent method andtiming of communication inadequatecontent of communication andconcernfor making families intermediariesbetween home visitor and PCP pro-viders45

Another common barrier to integrationis concern about disclosure of possibleconfidential information from the PCPsto the home visitors or vice versa4346

Families may be apprehensive aboutdisclosing information across ser-vices Furthermore there is concernthat clinicians may be unprepared to

act on family issues the home visitormay find in the home and converselythat home visitor may not be able toaddress the issues of PCP concern37

Finally the perceived and real-timeconstraints related to communicationand potential disruptions to practicealso impede integration efforts

Measurement

Measuring the integration of HV pro-grams and the FCMH is critical to en-courage integration assess the currentstateofcoordinationplannextstepsandassess effectiveness of interventions toincrease collaboration47 Programmaticmeasures process measures and out-comes must be initially assessed andregularly reassessed (Fig 2)

Example Integration ofDevelopmental Surveillance andScreening

Although developmental surveillanceand screening are part of child healthsupervision in the FCMH it is also in thescope of practice for many HV pro-grams Home visitors potentially havemore time with families for deve-lopmental surveillance and would beable to observe children in their naturalhome environment Without integrationit is possible that PCPs and home visitorsmayduplicate efforts providing the samesurveillance and waste time and moneyfor thePCPhomevisitorandfamilyThereis also the potential to provide in-consistent or conflicting information tofamilies regarding childrenrsquos develop-mental milestones

Dividing responsibilities regarding de-velopmental assessment between thehome visitor and the PCP would likelyavoid duplication and allow standard-ized screening with enhanced moni-toring of referrals Developmentalassessment in the home may also beamore effective location forobservationand testing as children might be morecomfortable interacting in their home

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S77 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

environment rather than having to relyon parental report As has been donewith care coordinators multiple PCPscould share a home visitor or group ofhome visitors A clear process and sys-tem for ensuring screening assess-ment referral and follow-up shared bythe FCMHand home visitors could resultin improved child developmental out-comes By dividing responsibilities be-tween the home visitor and PCP therecould be more focused time to addressother steps in the surveillance processas well as other important child andfamily health-related issues

Methods for Integration of HomeVisitation and the Family-CenteredMedical Home

The integration process requiresbreaking down barriers and establish-ing new methods of improved commu-nication48 A first step in facilitatingcommunication is creating a system forthe FCMH provider to know that theirpatient is enrolled in an HV programSecond a regular and preferred method

of communication needs to be estab-lishedMutual awareness between FCMHproviders and HV programs is neces-sary but not sufficient for optimal careand avoidance of duplication and frag-mentation of services Instead to maxi-mize the health of children we mustmove along the integration continuum topartnership and merging of systemsThis requires a clear scope of service forHV and the FCMH bidirectional commu-nication and shared responsibilities foroutcomes Optimally FCMH and HV pro-viders in a region must agree on astrategy allocate responsibilities andservices and monitor implementationand outcomes Table 1 details examplesof different levels along the integrationcontinuum for the FCMH and HV

Medical home and HV integration canresult directly in improved individualchild development andhealth outcomesOn a patient and family level integrationcan translate into information sharingreferring bidirectionally assisting incare coordination reinforcing treat-ment plans and anticipatory guidance

improving maternal depression identi-fication and treatment and improvedchronic disease management Ona population health level integrationpromotes primary secondary and ter-tiarypreventionwithinasingle integratedsystem and can improve identification ofcommunity needs49

When progressing along the integrationcontinuum it is necessary to considerthe current level of integration whichpartners should be included in theprocess and what actions will beneeded for enhanced integration Part-ners should extend beyond home visitorprogramsandindividualFCMHpracticesto include community members andotherstakeholders to fullyassessneedsActions toward integration will likely bedifferent in different regions and de-pendent onwhichpartners are involvedThey can range from a minimum ofshared goals and mutual awareness tosharing of resources whether financialor human and sharing physical spaceand supplies33 Ideally actions shouldwork toward the goal of a shared

FIGURE 2Measures for assessing the coordination of HV programs and FCMH Adapted from reference 47

S78 TSCHUDY et al by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

infrastructure including co-location andbuilding sustainable integrated systemsthat have enduring impact

Multiplemethods have been proposed tofacilitate integration between practi-tioners in the FCMH and home visitorsStates have convened statewide taskforcescomposedof TitleVMaternalChildHealth Medicaid and CHIP programshospital provider groups insurers andfamilies to start integrating service de-livery systems1 States are also usingfunds to integrate public-private servicedelivery systems and promote qualityOne example of a funding mechanism toencourage integration is the Medicaid

Health Home State Plan Option thatprovides funding strategies throughMedicaid to enhance provider reim-bursement for enhanced multidisciplin-ary collaboration

CONCLUSIONS

The FCMH model of primary care de-livery and HV models have synergisticgoals Both are critical in promotingchild development and health in thecontext of their family and communityPediatric primary care providers andhome visitors must be pushed from thecurrent status of playing nicely in the

sandbox together in isolation towardmerging systems of care Health careprofessionals working in pediatricprimary care practices (eg physiciansnurses and social workers) and inother health and education programs(eg home visiting nurses communitycase managers and community healthworkers) must work on the same teamto capitalize on each othersrsquo capa-bilities and expertise increase effi-ciencies and improve the health ofchildren and families

With the vision of extending themedicalhome into the community (eg the med-ical neighborhood) eliminating persis-tenthealthdisparitiesand theAffordableCare Actrsquos support for increased healthcare partnerships this is an optimaltime to integrate the FCMH and HV pro-grams Policies and funding streamsneed to be further aligned to encouragethis integration As HV programs areimplemented in communities connect-ing and partnering with the medicalhome should be a requirement Ulti-mately HV programs should be co-located in the FCMH to optimize com-munication collaboration and childhealth outcomes To truly improve thehealth of all children the integration ofHV and the FCMH should only be the firststep in horizontal and vertical inte-gration of services that promote thehealth development and well being ofchildren and families

REFERENCES

1 VanLandeghem K Schor E New opportuni-ties for integrating and improving healthcare for women children and their fami-lies The Commonwealth Fund and the As-sociation of Maternal and Child HealthPrograms February 2012 Accessed November12 2012 Available at wwwcommonwealth-fundorgPublicationsIssue-Briefs2012FebNew-opportunities-for-integrating-health-care-for-womenaspxcitation

2 Starfield BB Shi L The medical home ac-cess to care and insurance a review of

evidence Pediatrics 2004113(5 suppl)

1493ndash1498

3 Halfon N DuPlessis H Barrett E Looking

back at pediatrics to move forward in ob-

stetrics Curr Opin Obstet Gynecol 200820

(6)566ndash573

4 Toomey SL Chien AT Elliott MN Ratner J

Schuster MA Disparities in unmet care

coordination needs analysis of the na-

tional survey of childrenrsquos health Pediat-

rics 2013131(2)217ndash224

5 Agency for Healthcare Research and Quality(AHRQ) 2011 National Healthcare DisparitiesReport Rockville MD Agency for HealthcareResearch and Quality March 25 2012

6 Affordable care act maternal infant andearly childhood home visiting programsupplemental information request for thesubmission of the statewide needs as-sessment OMB control no 0915-0333

7 American Academy of Family Physicians(AAFP) American Academy of Pediatrics(AAP) American College of Physicians (ACP)

TABLE 1 The Continuum of Integration of the FCMH and HV

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S79 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

environment rather than having to relyon parental report As has been donewith care coordinators multiple PCPscould share a home visitor or group ofhome visitors A clear process and sys-tem for ensuring screening assess-ment referral and follow-up shared bythe FCMHand home visitors could resultin improved child developmental out-comes By dividing responsibilities be-tween the home visitor and PCP therecould be more focused time to addressother steps in the surveillance processas well as other important child andfamily health-related issues

Methods for Integration of HomeVisitation and the Family-CenteredMedical Home

The integration process requiresbreaking down barriers and establish-ing new methods of improved commu-nication48 A first step in facilitatingcommunication is creating a system forthe FCMH provider to know that theirpatient is enrolled in an HV programSecond a regular and preferred method

of communication needs to be estab-lishedMutual awareness between FCMHproviders and HV programs is neces-sary but not sufficient for optimal careand avoidance of duplication and frag-mentation of services Instead to maxi-mize the health of children we mustmove along the integration continuum topartnership and merging of systemsThis requires a clear scope of service forHV and the FCMH bidirectional commu-nication and shared responsibilities foroutcomes Optimally FCMH and HV pro-viders in a region must agree on astrategy allocate responsibilities andservices and monitor implementationand outcomes Table 1 details examplesof different levels along the integrationcontinuum for the FCMH and HV

Medical home and HV integration canresult directly in improved individualchild development andhealth outcomesOn a patient and family level integrationcan translate into information sharingreferring bidirectionally assisting incare coordination reinforcing treat-ment plans and anticipatory guidance

improving maternal depression identi-fication and treatment and improvedchronic disease management Ona population health level integrationpromotes primary secondary and ter-tiarypreventionwithinasingle integratedsystem and can improve identification ofcommunity needs49

When progressing along the integrationcontinuum it is necessary to considerthe current level of integration whichpartners should be included in theprocess and what actions will beneeded for enhanced integration Part-ners should extend beyond home visitorprogramsandindividualFCMHpracticesto include community members andotherstakeholders to fullyassessneedsActions toward integration will likely bedifferent in different regions and de-pendent onwhichpartners are involvedThey can range from a minimum ofshared goals and mutual awareness tosharing of resources whether financialor human and sharing physical spaceand supplies33 Ideally actions shouldwork toward the goal of a shared

FIGURE 2Measures for assessing the coordination of HV programs and FCMH Adapted from reference 47

S78 TSCHUDY et al by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

infrastructure including co-location andbuilding sustainable integrated systemsthat have enduring impact

Multiplemethods have been proposed tofacilitate integration between practi-tioners in the FCMH and home visitorsStates have convened statewide taskforcescomposedof TitleVMaternalChildHealth Medicaid and CHIP programshospital provider groups insurers andfamilies to start integrating service de-livery systems1 States are also usingfunds to integrate public-private servicedelivery systems and promote qualityOne example of a funding mechanism toencourage integration is the Medicaid

Health Home State Plan Option thatprovides funding strategies throughMedicaid to enhance provider reim-bursement for enhanced multidisciplin-ary collaboration

CONCLUSIONS

The FCMH model of primary care de-livery and HV models have synergisticgoals Both are critical in promotingchild development and health in thecontext of their family and communityPediatric primary care providers andhome visitors must be pushed from thecurrent status of playing nicely in the

sandbox together in isolation towardmerging systems of care Health careprofessionals working in pediatricprimary care practices (eg physiciansnurses and social workers) and inother health and education programs(eg home visiting nurses communitycase managers and community healthworkers) must work on the same teamto capitalize on each othersrsquo capa-bilities and expertise increase effi-ciencies and improve the health ofchildren and families

With the vision of extending themedicalhome into the community (eg the med-ical neighborhood) eliminating persis-tenthealthdisparitiesand theAffordableCare Actrsquos support for increased healthcare partnerships this is an optimaltime to integrate the FCMH and HV pro-grams Policies and funding streamsneed to be further aligned to encouragethis integration As HV programs areimplemented in communities connect-ing and partnering with the medicalhome should be a requirement Ulti-mately HV programs should be co-located in the FCMH to optimize com-munication collaboration and childhealth outcomes To truly improve thehealth of all children the integration ofHV and the FCMH should only be the firststep in horizontal and vertical inte-gration of services that promote thehealth development and well being ofchildren and families

REFERENCES

1 VanLandeghem K Schor E New opportuni-ties for integrating and improving healthcare for women children and their fami-lies The Commonwealth Fund and the As-sociation of Maternal and Child HealthPrograms February 2012 Accessed November12 2012 Available at wwwcommonwealth-fundorgPublicationsIssue-Briefs2012FebNew-opportunities-for-integrating-health-care-for-womenaspxcitation

2 Starfield BB Shi L The medical home ac-cess to care and insurance a review of

evidence Pediatrics 2004113(5 suppl)

1493ndash1498

3 Halfon N DuPlessis H Barrett E Looking

back at pediatrics to move forward in ob-

stetrics Curr Opin Obstet Gynecol 200820

(6)566ndash573

4 Toomey SL Chien AT Elliott MN Ratner J

Schuster MA Disparities in unmet care

coordination needs analysis of the na-

tional survey of childrenrsquos health Pediat-

rics 2013131(2)217ndash224

5 Agency for Healthcare Research and Quality(AHRQ) 2011 National Healthcare DisparitiesReport Rockville MD Agency for HealthcareResearch and Quality March 25 2012

6 Affordable care act maternal infant andearly childhood home visiting programsupplemental information request for thesubmission of the statewide needs as-sessment OMB control no 0915-0333

7 American Academy of Family Physicians(AAFP) American Academy of Pediatrics(AAP) American College of Physicians (ACP)

TABLE 1 The Continuum of Integration of the FCMH and HV

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S79 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

infrastructure including co-location andbuilding sustainable integrated systemsthat have enduring impact

Multiplemethods have been proposed tofacilitate integration between practi-tioners in the FCMH and home visitorsStates have convened statewide taskforcescomposedof TitleVMaternalChildHealth Medicaid and CHIP programshospital provider groups insurers andfamilies to start integrating service de-livery systems1 States are also usingfunds to integrate public-private servicedelivery systems and promote qualityOne example of a funding mechanism toencourage integration is the Medicaid

Health Home State Plan Option thatprovides funding strategies throughMedicaid to enhance provider reim-bursement for enhanced multidisciplin-ary collaboration

CONCLUSIONS

The FCMH model of primary care de-livery and HV models have synergisticgoals Both are critical in promotingchild development and health in thecontext of their family and communityPediatric primary care providers andhome visitors must be pushed from thecurrent status of playing nicely in the

sandbox together in isolation towardmerging systems of care Health careprofessionals working in pediatricprimary care practices (eg physiciansnurses and social workers) and inother health and education programs(eg home visiting nurses communitycase managers and community healthworkers) must work on the same teamto capitalize on each othersrsquo capa-bilities and expertise increase effi-ciencies and improve the health ofchildren and families

With the vision of extending themedicalhome into the community (eg the med-ical neighborhood) eliminating persis-tenthealthdisparitiesand theAffordableCare Actrsquos support for increased healthcare partnerships this is an optimaltime to integrate the FCMH and HV pro-grams Policies and funding streamsneed to be further aligned to encouragethis integration As HV programs areimplemented in communities connect-ing and partnering with the medicalhome should be a requirement Ulti-mately HV programs should be co-located in the FCMH to optimize com-munication collaboration and childhealth outcomes To truly improve thehealth of all children the integration ofHV and the FCMH should only be the firststep in horizontal and vertical inte-gration of services that promote thehealth development and well being ofchildren and families

REFERENCES

1 VanLandeghem K Schor E New opportuni-ties for integrating and improving healthcare for women children and their fami-lies The Commonwealth Fund and the As-sociation of Maternal and Child HealthPrograms February 2012 Accessed November12 2012 Available at wwwcommonwealth-fundorgPublicationsIssue-Briefs2012FebNew-opportunities-for-integrating-health-care-for-womenaspxcitation

2 Starfield BB Shi L The medical home ac-cess to care and insurance a review of

evidence Pediatrics 2004113(5 suppl)

1493ndash1498

3 Halfon N DuPlessis H Barrett E Looking

back at pediatrics to move forward in ob-

stetrics Curr Opin Obstet Gynecol 200820

(6)566ndash573

4 Toomey SL Chien AT Elliott MN Ratner J

Schuster MA Disparities in unmet care

coordination needs analysis of the na-

tional survey of childrenrsquos health Pediat-

rics 2013131(2)217ndash224

5 Agency for Healthcare Research and Quality(AHRQ) 2011 National Healthcare DisparitiesReport Rockville MD Agency for HealthcareResearch and Quality March 25 2012

6 Affordable care act maternal infant andearly childhood home visiting programsupplemental information request for thesubmission of the statewide needs as-sessment OMB control no 0915-0333

7 American Academy of Family Physicians(AAFP) American Academy of Pediatrics(AAP) American College of Physicians (ACP)

TABLE 1 The Continuum of Integration of the FCMH and HV

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S79 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

American Osteopathic Association (AOA)Joint principles of the patient centeredmedical home March 2007 Available atwwwmedicalhomeinfoorgdownloadspdfsJointStatementpdf Accessed September 222012

8 American Academy of Pediatrics Councilon Child and Adolescent Health The role ofhome-visitation programs in improvinghealth outcomes for children and familiesPediatrics 1998101(3 pt 1)486ndash489

9 Starfield B Primary care Balancing healthneeds services and technology 2nd edNew York NY Oxford University Press 1998

10 American Academy of Pediatrics Council onPediatric Practice Standards of child careEvanston IL American Academy of Pediat-rics 1967

11 American Academy of Pediatrics Ad HocTask Force on Definition of the MedicalHome The medical home Pediatrics 199290(5)774

12 Medical Home Initiatives for Children WithSpecial Needs Project Advisory CommitteeAmerican Academy of Pediatrics Themedical home Pediatrics 2002110(1 pt 1)184ndash186

13 Homer CJ Klatka K Romm D et al A reviewof the evidence for the medical home forchildren with special health care needsPediatrics 2008122(4) Available at wwwpediatricsorgcgicontentfull1224e922

14 Cooley WC McAllister JW Sherrieb KKuhlthau K Improved outcomes associatedwith medical home implementation in pe-diatric primary care Pediatrics 2009124(1)358ndash364

15 Stevens GD Vane C Cousineau MR Asso-ciation of experiences of medical homequality with health-related quality of lifeand school engagement among Latinochildren in low-income families HealthServ Res 201146(6pt1)1822ndash1842

16 Strickland BB Jones JR Ghandour RMKogan MD Newacheck PW The medicalhome health care access and impact forchildren and youth in the United StatesPediatrics 2011127(4)604ndash611

17 Toomey SL Chan E Ratner JA Schuster MAThe patient-centered medical home prac-tice patterns and functional outcomes forchildren with attention deficithyperactivitydisorder Acad Pediatr 201111(6)500ndash507

18 Beal AC Doty DM Hernandez SE et alClosing the divide How do medical homespromote equity in health care- Resultsfrom the Commonwealth Fund 2006 HealthCare Quality Survey New York NY TheCommonwealth Fund 2007

19 Wong W Dankwa-mullan I Simon MA VegaWA The patient-centered medical home

a path toward health equity Discussionpaper Institute of Medicine WashingtonDC 2012 Available at httpiomeduGlobalPerspectives2012PatientCenteredMedicalHomeaspx Accessed November 12 2012

20 Patient-centered primary care pilot proj-ects guide Patient-centered primary carecollaborative web site Available at wwwpcpccnetguidepilot-guide Accessed No-vember 11 2012

21 Cheng TL Primary care pediatrics 2004and beyond Pediatrics 2004113(6)1802ndash1809

22 Bohmer RM Managing the new primarycare the new skills that will be neededHealth Aff (Millwood) 201029(5)1010ndash1014

23 Arvey SR Fernandez ME Identifying thecore elements of effective communityhealth worker programs a research agendaAm J Public Health 2012102(9)1633ndash1637

24 Council on Community Pediatrics The roleof preschool home-visiting programs inimproving childrenrsquos developmental andhealth outcomes Pediatrics 2009123(2)598ndash603

25 Olds DL Robinson J Pettitt L et al Effectsof home visits by paraprofessionals and bynurses age 4 follow-up results of a ran-domized trial Pediatrics 2004114(6)1560ndash1568

26 Duggan A Windham A McFarlane E et alHawaiirsquos healthy start program of homevisiting for at-risk families evaluation offamily identification family engagementand service delivery Pediatrics 2000105(1pt 3)250ndash259

27 Minkovitz CS Strobino D Hughart NScharfstein D Guyer B Healthy StepsEvaluation Team Early effects of thehealthy steps for young children programArch Pediatr Adolesc Med 2001155(4)470ndash479

28 Minkovitz CS Strobino D Mistry KB et alHealthy Steps for Young Children sustainedresults at 55 years Pediatrics 2007120(3)Available at wwwpediatricsorgcgicon-tentfull1203e658

29 Olds DL Henderson CR Jr Phelps C Kitzman HHanks C Effect of prenatal and infancy nursehome visitation on government spending MedCare 199331(2)155ndash174

30 Chapman J Siegel E Cross A Home visitorsand child health analysis of selected pro-grams Pediatrics 199085(6)1059ndash1068

31 Karoly L Early childhood interventionsProven results future promise SantaMonica CA RAND Corporation 2005

32 Tschudy MM Pak-Gorstein S Serwint JRHome visitation by pediatric residents -perspectives from two pediatric training

programs Acad Pediatr 201212(5)370ndash374

33 Institute of Medicine (IOM) Primary careand public health Exploring integration toimprove population health Washington DCInstitute of Medicine 2012

34 Cheng TL Solomon BS Translating lifecourse theory to clinical practice to ad-dress health disparities [published onlineahead of print May 16 2013] Matern ChildHealth J

35 Taylor EF Lake T Nysenbaum J Peterson GMeyers D Coordinating care in the medicalneighborhood critical components andavailable mechanisms White paper (pre-pared by Mathematica Policy Researchunder contract no HHSA290200900019ITO2) AHRQ publication no 11-0064 Rock-ville MD Agency for Healthcare Researchand Quality June 2011

36 Newacheck PW Hughes DC Hung YY WongS Stoddard JJ The unmet health needs ofAmericarsquos children Pediatrics 2000105(4pt 2)989ndash997

37 Hardy JB Streett R Family support andparenting education in the home an ef-fective extension of clinic-based preventivehealth care services for poor childrenJ Pediatr 1989115(6)927ndash931

38 Vogler SD Davidson AJ Crane LA SteinerJF Brown JM Can paraprofessional homevisitation enhance early intervention ser-vice delivery J Dev Behav Pediatr 200223(4)208ndash216

39 Stevens R Margolis P Harlan C Bordley CAccess to care a home visitation programthat links public health nurses physiciansmothers and babies J Community HealthNurs 199613(4)237ndash247

40 Margolis PA Stevens R Bordley WC et alFrom concept to application the impactof a community-wide intervention to im-prove the delivery of preventive servicesto children Pediatrics 2001108(3)E42

41 Barnes-Boyd C Fordham Norr K Nacion KWPromoting infant health through homevisiting by a nurse-managed communityworker team Public Health Nurs 200118(4)225ndash235

42 Eckenrode J Ganzel B Henderson CR Jret al Preventing child abuse and neglectwith a program of nurse home visitationthe limiting effects of domestic violenceJAMA 2000284(11)1385ndash1391

43 Nelson CS Tandon SD Duggan AK SerwintJR Communication between key stake-holders within a medical home a qualita-tive study Clin Pediatr (Phila) 200948(3)252ndash262

44 Olds DL Eckenrode J Henderson CR Jr et alLong-term effects of home visitation on

S80 TSCHUDY et al by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

maternal life course and child abuse andneglect Fifteen-year follow-up of a random-ized trial JAMA 1997278(8)637ndash643

45 Stille CJ Primack WA Savageau JAGeneralist-subspecialist communication forchildren with chronic conditions a regionalphysician survey Pediatrics 2003112(6 pt1)1314ndash1320

46 Seid M Varni JW Bermudez LO et alParentsrsquo Perceptions of Primary Caremeasuring parentsrsquo experiences of pediat-

ric primary care quality Pediatrics 2001108(2)264ndash270

47 Toomey SL Cheng TL APA-AAP Workgroup onthe Family-Centered Medical Home Homevisiting and the family-centered medicalhome synergistic services to promote childhealth Acad Pediatr 201313(1)3ndash5

48 Margolis PA Carey T Lannon CM Earp JLLeininger L The rest of the access-to-carepuzzle Addressing structural and personalbarriers to health care for socially disad-

vantaged children Arch Pediatr AdolescMed 1995149(5)541ndash545

49 Cusack CM Knudson AD Kronstadt JL SingerRF Brown AL Practice-based populationhealth information technology to supporttransformation to proactive primary care(prepared for the AHRQ national resourcecenter for health information technology un-der contract no 290-04-0016) AHRQ publica-tion no 10-0092-EF Rockville MD Agency forHealthcare Research and Quality July 2010

SUPPLEMENT ARTICLE

PEDIATRICS Volume 132 Supplement 2 November 2013 S81 by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2013-1021E2013132S74Pediatrics

Megan M Tschudy Sara L Toomey and Tina L ChengHome

Merging Systems Integrating Home Visitation and the Family-Centered Medical

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent132Supplement_2S74including high resolution figures can be found at

References

BIBLhttppediatricsaappublicationsorgcontent132Supplement_2S74This article cites 35 articles 16 of which you can access for free at

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on June 8 2018wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2013-1021E2013132S74Pediatrics

Megan M Tschudy Sara L Toomey and Tina L ChengHome

Merging Systems Integrating Home Visitation and the Family-Centered Medical

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DOI 101542peds2013-1021E2013132S74Pediatrics

Megan M Tschudy Sara L Toomey and Tina L ChengHome

Merging Systems Integrating Home Visitation and the Family-Centered Medical

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ISSN 1073-0397 60007 Copyright copy 2013 by the American Academy of Pediatrics All rights reserved Print the American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village Illinoishas been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

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