The Future Pediatric Subspecialty Physician Workforce Meeting the Needs of Infants, Children, and Adolescents (2023) / Chapter Skim
Currently Skimming:
7 Innovations at the Pediatric PrimarySpecialty Care Interface
7 Innovations at the Pediatric PrimarySpecialty Care Interface
Pages 261-312
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 261... ...
. Ideally, general primary care clinicians and pediatric subspecialty physicians work collaboratively at the interface of primary and specialty care to provide the full spectrum of care for children with more complicated and unusual acute and chronic disorders.
|
From page 262... ...
. This chapter examines the interaction of primary care and pediatric subspecialty care with a focus on the efficient use of both primary care and subspecialty care clinicians and innovative models at the interface of primary and specialty care so as to ensure the delivery of high-quality subspecialty care.
|
From page 263... ...
. A meta-analysis of integrated primary care–behavioral health models for children and adolescents demonstrated superior outcomes for the integrated care model when compared with conventional care, and collaborative care models with a team-based approach that included primary care clinicians, care managers, and mental health specialists showed the strongest effects (Asarnow et al., 2015; NASEM, 2021b)
|
From page 264... ...
For example, pediatric subspecialty care has become more sophisticated in the use of therapeutics for chronic conditions that require expertise and facilities not typically available to primary care clinicians. The use of biologic pharmaceuticals for immunemediated conditions such as inflammatory bowel disease, juvenile inflammatory arthritis, and even severe eczema often requires access to an infusion center for administration and carries the risk of serious side effects that must be closely monitored.
|
From page 265... ...
But doing so is often difficult, and we have found ourselves being passed back and forth between specialists many times. The second problem in coordinating care is a lack of communication effort between subspecialists and primary care clinicians.
|
From page 266... ...
transition from pediatrics to adult GI was a little bit of a challenge… eventually when I did transition, we were able to form this partnership between my physician and my specialist, so now they kind of work hand in hand with trying to make sure that the records are up to date on both sides…it works well, primarily if it's kind of in the same network or same area where the specialist might be.3 Adult subspecialists have found the transition of care for children with special health care needs to be more complex compared with assuming care of adult chronic care patients (Kobussen et al., 2021)
|
From page 267... ...
. According to the report, primary care clinicians, specialists, patients, and schedulers are involved in nine overall steps, each of which can experience barriers that contribute to suboptimal access to pediatric subspecialty 4 The webinar recording can be accessed at https://www.nationalacademies.org/event/ 11-09-2022/the-pediatric-subspecialty-workforce-and-its-impact-on-child-health-and-well-beingwebinar-4.
|
From page 268... ...
care. At the initial step of referral decision, primary care clinicians may be uncertain regarding whether to refer, where to refer, and the degree of work to be completed before referral.
|
From page 269... ...
According to the 2020–2021 National Survey of Children's Health,5 26 percent of families in need of subspecialty care encountered difficulty in obtaining specialty care (NSCH, n.d.) .6 This percentage increased to 32 percent for families with a primary household language other than English, 32 percent for children receiving public insurance, and 40 percent for children who are uninsured, thereby contributing to inequities in access and use (NSCH, n.d.)
|
From page 270... ...
I think their scope of practice has expanded."8 PROMISING PRIMARY–SPECIALTY CARE MODELS Appropriate primary care management and referral to subspecialists are important factors that affect demand for subspecialty care. Many diagnoses for which patients are referred may be addressable to some extent in primary care, and many specialist-induced follow-up visits for a referred health problem could be done in primary care settings.
|
From page 271... ...
. To achieve seamless integration of primary care and subspecialty care, innovations in workforce, processes, technology, payment, and setting of
|
From page 272... ...
Appropriately financing the primary–specialty care interface. Integrating Primary Care and Subspecialty Care Promising models that integrate primary care and subspecialty care include models for co-management and co-location of primary care clinicians and subspecialists, educational activities to encourage expanded primary care clinician scope of practice, and the determination of appropriate management and referral guidelines.
|
From page 273... ...
. Co-Location of Primary and Subspecialty Care Co-location, where clinicians work together in the same physical space, is another potential element of integration (Richman et al., 2018)
|
From page 274... ...
. According to a scoping review, integrated care programs have been found to increase the likelihood of families attending an initial appointment, complying with recommended treatment, and receiving specialty mental health care when needed, as compared with referrals to usual specialty care (Platt et al., 2018)
|
From page 275... ...
. A variation on this model involves a general pediatrician embedded in the same physical spaces with subspecialists, but without their direct involvement, to evaluate uncomplicated potential referrals and escalate them to subspecialty care as needed, also called "access clinics." Matt Di Guglielmo, director of the Division of General Academic Pediatrics at Nemours Children's Hospital, described the access clinics at Nemours Children's Health in his presentation at one of the committee's public webinars.10 Given that wait times for specific pediatric subspecialties ranged from weeks to months, Nemours developed access clinics to improve 5-day access for new pediatric patients by embedding a general pediatrician, assisted by a nurse navigator into subspecialty clinics (Di Guglielmo et al., 2013, 2016)
|
From page 276... ...
. The REACH model for patient-centered mental health care in primary care, which supports clinicians in developing skills to diagnose and treat a spectrum of pediatric mental health conditions, is one example of how condition-focused education can expand the capacity of primary care to the most needed subspecialty care (Green et al., 2019; The REACH Institute, 2022)
|
From page 277... ...
. Referral guidelines also support primary care clinicians in the ongoing management of patients who need and are awaiting subspecialty care, help to address discrepancies in opinion, and build buy-in and receptivity for subspecialty care by patients and families (Children's National, 2023; Cornell et al., 2015; Kwok et al., 2018; Seattle Children's, 2023)
|
From page 278... ...
. Even before the COVID-19 pandemic, telehealth technologies were recognized as an important mechanism for increasing access to pediatric subspecialty care and reducing urban/rural disparities (Marcin et al., 2016; Ray et al., 2017)
|
From page 279... ...
are defined as "directed communication between providers over a secure electronic medium that involves sharing of patient-specific information and discussing clarification or guidance regarding clinical care" and have been touted as a mechanism to improve access to subspecialty care, in addition to improved collaborations among clinicians. One Milbank report declared e-consults a "triple win for 11 Store-and-forward telehealth is a type of asynchronous telemedicine service that allows patients to submit clinical information for evaluation without an in-person visit.
|
From page 280... ...
. Effective use of these types of technologies assists the primary care clinicians in managing the family experience during referral along with expectations of subspecialty care (Ray et al., 2016; Ray and Kahn, 2020)
|
From page 281... ...
Providers overwhelmingly believed that the program affects patients positively, and 80 to 85 percent of primary care clinicians voluntarily used e-consults (CHA, 2021; McCulloch et al., 2023)
|
From page 282... ...
A key example is the availability of behavioral health consultation with child psychiatrists and mental health specialists. The Massachusetts Child Psychiatry Access Project (MCPAP)
|
From page 283... ...
Telementoring An important example of remote integration of primary and subspecialty care is Project Extension for Community Healthcare Outcomes (ECHO)
|
From page 284... ...
These interactions may occur between the patient and family and the medical home or between the medical home and specialty care providers (Price et al., 2020)
|
From page 285... ...
Unless specifically required by regulation or policy, states can cover such services without submitting a state plan amendment if they reimburse telehealth in the same way and amount as face-to-face services. If states want to reimburse telehealth services differently from face to face, they must submit and receive approval for a state plan amendment if that is not already specified in the state plan (CMS, 2023b)
|
From page 286... ...
. The expansion of this compact could help to break down regulatory barriers to accessing subspecialty care for children in states with few pediatric subspecialists via telehealth.
|
From page 287... ...
. 287 SOURCE: Adapted from Augenstein and Marks Smith, 2023.
|
From page 288... ...
. One study that examined telehealth use among patients requiring pediatric subspecialty management before and after the COVID-19 pandemic at a single academic health system found that the nature and scale of pandemic effects were complex and varied by pediatric subspecialty type, social demographics, and established patient status (Cahan et al., 2022)
|
From page 289... ...
. Nurses in both primary and subspecialty care settings can assume responsibilities that allow them to increase the availability of subspecialty care clinicians to meet the most critical or complex pediatric health care needs.
|
From page 290... ...
Adolescents with Ambulatory care Support to teach self-management of chronic complex health needs disease, facilitate transitions of care to adult (e.g., spina bifida, type clinicians, care coordination (Campbell et al., 1 diabetes mellitus)
|
From page 291... ...
In some cases, multispecialty groups that combined primary care and specialty care jointly entered risk contracts, creating incentives for joint, efficient patient management, but these arrangements did not account for most patient care and often did not include pediatric care (Mechanic and Zinner, 2016)
|
From page 292... ...
(Bachman et al., 2017) ; complexity of pediatric patients who receive subspecialty care and the need to consider individual and familyspecific circumstances (Kevill et al., 2019)
|
From page 293... ...
. Notably for the pediatric primary–specialty care interface, current ACO models for children focus mainly on primary care, and often still "carve out" subspecialty care into a fee-for-service model.
|
From page 294... ...
; the implementation of many of the 2021 report's recommendations will support the innovative care and delivery models discussed in this chapter. Additionally, while this chapter's recommendations are focused on improving the delivery of subspecialty care through innovations at the primary–specialty care interface, many recommendations will also help to support primary care clinicians.
|
From page 295... ...
Finding #7-6: Many innovative, collaborative primary–subspecialty care models exist to improve children's access to care and outcomes. Finding #7-7: Beneficial policies developed during the COVID-19 pan demic to promote telehealth and access to care across state lines are threatened as the public health emergency ends.
|
From page 296... ...
rural and urban areas will require removal of regulatory barriers to the delivery of pediatric subspecialty care, both in-person and virtual, to ensure timely and equitable access to care for all children who need pediatric subspecialty care. RECOMMENDATIONS Pediatric subspecialists need to focus on their essential role in the care of children with complex, severe, and rare disorders or those requiring technical procedures, while collaborating with primary care clinicians.
|
From page 297... ...
Enhanced communication at the primary–subspecialty care interface is essential within these models. Therefore, to achieve a goal of promoting collaboration and effective use of services between pediatric primary care clinicians and subspecialty physicians, the committee provides the following recommendations: RECOMMENDATION 7-1 The American Academy of Pediatrics, the Council of Pediatric Subspecialties, and other pediatric professional societies should collaboratively develop, disseminate, and implement testing, management, and referral guidelines for health conditions com monly managed by subspecialists.
|
From page 298... ...
2023. Entrustable professional activities for general pediatrics https://www.abp.org/ content/entrustable-professional-activities-general-pediatrics (accessed April 30, 2023)
|
From page 299... ...
2019. Unscheduled referrals and unattended appointments after pediatric subspecialty referral.
|
From page 300... ...
2022. The impact of telehealth adoption during COVID-19 pandemic on patterns of pediatric subspecialty care utilization.
|
From page 301... ...
https://www.childrenshospitals.org/news/childrens-hospi tals-today/2021/02/improving-communication-between-primary-care-providers-and-spe cialists#.YiZ_TXrMKUk (accessed April 14, 2023)
|
From page 302... ...
2015. Implementation of referral guidelines at the interface between pediatric primary and subspecialty care.
|
From page 303... ...
1999. The pediatric primary-specialty care interface: How pediatricians refer children and adoles cents to specialty care.
|
From page 304... ...
2017. Comparing two models of integrated behavioral health programs in pediatric primary care.
|
From page 305... ...
https://www.kff. org/medicaid/issue-brief/state-delivery-system-and-payment-strategies-aimed-at-improv ing-outcomes-and-lowering-costs-in-medicaid/ (accessed April 19, 2023)
|
From page 306... ...
2018. Pediatric nurse practitioners' perspectives on health care transition from pediatric to adult care.
|
From page 307... ...
2022. Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured.
|
From page 308... ...
https://www.ncbi.nlm.nih.gov/books/ NBK7232/pdf/Bookshelf_NBK7232.pdf (accessed April 27, 2023)
|
From page 309... ...
2017. Family perspec tives on telemedicine for pediatric subspecialty care.
|
From page 310... ...
2005. Training behavioral health and primary care providers for integrated care: A core competencies approach.
|
From page 311... ...
capability at an academic medical center to improve efficiencies in delivering specialty care. Journal of Primary Care and Community Health 12:21501327211005303.
|
From page 312... ...
2021. Enablers, barriers, and contributions of pediatric nurse practitioners to ambulatory specialty care.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.