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    Bridging the gap

    One pilot program demonstrates how hospitalized children can be connected to medical homes using a listening-based approach


    Heather had no doctor for Cindy, so the MHL shared the list of potential providers in her geographic area that could manage the outpatient methadone wean.  The MHL gave Heather a list of appropriate questions to ask when choosing a MH.  She also educated her on responsibilities, such as coming to appointments informed, complying with treatment plans and keeping appointments.  She gave her a medical care notebook and empowered Heather to make an appointment with the MH she had selected before discharge.

    Next: Maternal substance abuse tied to risk of sudden neonatal death

    Heather kept her first appointment with Cindy’s MH.  Later, the MHL contacted that MH to follow-up on the baby’s progress. Cindy was weaned off the methadone 4 weeks after discharge.  Heather kept Cindy’s appointments with the pulmonologist, ophthalmologist and with the NICU follow-up clinic. In addition, Heather kept Cindy’s medical care notebook updated and took it to all appointments.

    Implications for practice

    Our data suggest dramatic success is possible with our hospital-to-MH service model involving a listening, strength-based approach of educating and coaching parents how to identify and utilize a MH for their hospitalized child.  In our experience, the face-to-face interaction between the MHL and family is critical to the success of this service.  If a hospital is unable to assign an individual specifically as the MHL, then the practice’s rounding pediatrician, nurse practitioner, or one of the hospital-based team can listen, appreciate, inform, and coach families in the hospital.  Before discharge, it is vital that someone on the healthcare team ensures that the family has made a follow-up appointment with a MH or PCP, and that the family is empowered to know and carry out their responsibilities.


    1. American Academy of Pediatrics, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The medical home.  Pediatrics. 2002; 110:184-186.

    2. Misky GJ, Wald HL, Coleman EA.  Post-hospitalization transitions: examining the effects of timing of primary care provider follow-up.  Journal of Hospital Medicine. 2010; 5(7):392-397.

    3. Shakib J, Buchi K, Smith E, Korgenski K, Young PC.  Timing of initial well-child visit and readmissions of newborns.  Pediatrics. 2015; 135(3):469-474.

    4. Wipfler, P. Listening to Parents: Listening Partnerships for Parents.  http://www.handinhandparenting.org/wp-content/uploads/2013/10/Listening_Partnerships_for_Parents1.pdf.  Published 2006.  Accessed September 17, 2015.

    Pamela Oatis, MD
    Dr. Oatis is a pediatrician and the medical director of Mercy Children's Hospital Family Care Team at Mercy St. Vincent Medical Center ...
    Nancy Buderer, MS
    Ms. Buderer is an independent biostatistician, research consultant, and program evaluator in Oak Harbor, Ohio.
    Estil Canterbury
    Ms. Canterbury is a licensed counselor for CPPL Counseling in Toledo, Ohio.


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