Bridging the gap
One pilot program demonstrates how hospitalized children can be connected to medical homes using a listening-based approach
The MHL educates the family about MH’s qualities and benefits. He or she empowers the family to come to appointments informed, respectful, on time, and with relevant information. Every family in the program is offered a care notebook to organize and track their child’s relevant information (eg, test results, appointments, consultations, diet input/output, medications, observed signs and symptoms). The MHL provides a list of qualified MHs that matches the family’s insurance coverage and geography. Not all of the PCPs on the list are certified MHs, but they contain most or all of the qualities of a MH. Families are also given a set of questions they can ask prospective MHs in order to find a practice that fits their needs.
The MHL helps establish and maintain the family’s connection with a MH before and after discharge. He or she ensures the family schedules their first outpatient appointment with the MH before hospital discharge. After discharge, the MHL calls the family to confirm that they are ready for their child’s first MH appointment. He or she calls after the appointment to ensure that the family kept the appointment and discuss how it went. If the family didn’t keep the appointment or if it didn’t go well, then the MHL works with them to reschedule or find a new provider. The MHL maintains contact with the family after discharge to ensure they are well-connected. If the patient is rehospitalized, the MHL reassesses the patient and family, re-educates, and reinforces the MH concepts.
The MHL refers families to other resources as needed. Some families may require a social worker. When families and children need listening time beyond what the MHL can offer to offload emotional upsets, the MHL refers them to a part-time, on-site licensed counselor hired specifically for the program and, if appropriate, to the hospital’s bereavement service.
Keeping their appointments
Between February 2009 and January 13, 2014, the program served 809 hospitalized children: 57% Caucasian, 25% African American, 74% Medicaid, 49% aged less than 1 week. Thirty-nine percent had had no MH. Follow-up data was available for 617 patients; 97% kept their initial appointment with their MH. One year follow-up data was available for 406 patients; 95% were able to identify their MH and 87% had kept “all or almost all” of their appointments with their MH, subspecialists, and community resources.
It’s important to consider some limitations to the evaluation data. The program was designed as a consultation service, not research; therefore, the level of evidence is limited. Our positive results may not generalize to other institutions or with other MHLs. Data are self-reported. Follow-up data were missing due to patient death, transfer to another MH or institution, lost contact, still in the hospital, or too recently discharged. The 1-year show-rate could be inflated due to missing data. Finally, a baseline rate of first appointments kept is not available.
One success story
The MHL met in the NICU with Heather at the bedside of her newborn baby, Cindy. The MHL introduced herself and explained her role as a non-judgmental listener who was able to help Heather connect with a MH that could best serve her and her baby. Open and willing to answer questions, Heather described her long-term medical and emotional issues that led to prescriptions for Norco (acetaminophen and hydrocodone), Vicodin (acetaminophen and hydrocodone), Percocet (oxycodone and Acetaminophen), and Xanax (alprazolam) throughout her pregnancy. Heather’s newborn, Cindy, required methadone to treat the withdrawal. Heather cried during many visits with the MHL knowing that withdrawal from opiates would be miserable and she dreaded watching her little baby girl suffer through it. She felt guilt and shame. The MHL listened without judgment and assured Heather that she would continue listening and supporting her through the hospitalization and after she was home.