Bridging the gap
One pilot program demonstrates how hospitalized children can be connected to medical homes using a listening-based approach
Jamila, an 8-year old asthma patient, barely made it to the emergency department (ED) this time. This was the closest she had been to irreversible respiratory failure. In spite of multiple ED visits and hospitalizations, Jamila’s family still struggled to keep appointments with her primary care provider (PCP) in her medical home (MH) and to administer her prescribed controller medications. A PCP myself on inpatient service, I reflected on the staggering number of patients I saw who had no physician or whose only relationship to their physician was a name on an insurance card. Brainstorming with others on our medical team, we sought to bridge the gap between hospital and MH for our pediatric patients.
Through observation and literature review, we noticed that keeping the first follow-up appointment after hospital discharge was critical to connecting hospitalized patients to a PCP and, ideally, to a MH. The MH is defined as a model of care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective.1 Misky et al demonstrated that “patients lacking timely PCP follow-up were 10 times more likely to be readmitted.”2 Shakib et al reported that “newborns who have a first well child visit within the recommended time period after hospital discharge are substantially less likely to be readmitted.”3
Making the connection
Our team of pediatric healthcare professionals developed a hospital-based service at an inner-city hospital in Toledo, Ohio, to connect hospitalized children to MHs. The new service aims to: help families of hospitalized children know what a MH is; understand the benefits and their responsibilities as informed, shared decision-makers; identify a MH before discharge; make and keep a first appointment after discharge; and, a year later, report having kept appointments with that provider, sub-specialists, and community resources. The service was funded through grants from Healthy Tomorrows Partnership for Children – American Academy of Pediatrics & Health Resources and Services Administration of the Department of Health and Human Services, and the United Way of Greater Toledo.
The service provides a hospital-based medical home liaison (MHL), a nurse with pediatric experience (particularly with children with special healthcare needs), access to a counselor, listening tools for parents, a continuously curated list of practices in northwest Ohio that meet some or all of the MH definition, and a care notebook. The MHL works on a consultation team along with a primary care pediatrician providing palliative care and a licensed counselor.
Hospitalized children with various levels of severity are identified for the service by the nurses, social workers, or physicians caring for them. Patients in the neonatal intensive care unit (NICU), pediatric floor, pediatric intensive care unit, well-infant nursery, and subspecialty clinics that do not have a medical provider, or are underutilizing their current medical provider, or who have extenuating psychosocial co-morbidities are referred to the service.
After a patient is referred, the MHL meets with the patient’s family and builds a relationship using the Listening with Connection model.4 Listening with Connection focuses on respect, appreciation, connection, listening, warmth, and firmness. The MHL offers a safe environment in which to understand the child’s medical history and current needs with respect to a MH. In “listening time,” the MHL listens to the family’s upsets and the emotional overload that accompany having a hospitalized child. During listening time, the MHL does not judge, criticize, tell the family what to do, or how to feel or act — he or she listens. The concept, and our experience, is that as families offload these emotions, they think more clearly and function more responsibly so they are better able to make decisions and follow through with care for their child and themselves.