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    A medical home far away from home

    If the medical home concept of team-based healthcare works for kids and their families in Peru, it will work in your community, too.


    What puzzled us most when we started working in these economically impoverished areas was the fact that reasonable-quality, appropriate care was often available at low or no cost within the government system, within just a few kilometers of where the children we aimed to serve were living. We found ourselves asking, “Where is the breakdown? What can we do?” Duplication of services and resources was not the answer. This would neither improve efficiency nor enhance coordination with the local system. Reproduction of services was simply an unsustainable solution.

    We realized that an unfortunate combination of poor (or no) care coordination, logistical barriers such as transportation, and lack of family education was creating an unhealthy synergy. This, in turn, was excluding some patients with complex illness from badly needed, government-subsidized care. Because of the lack of a few pieces of the puzzle, these patients were losing out on the whole package of meaningful care. Whether it was the child with cerebral palsy who could not access her tuberculosis care because of a lack of appropriate transportation, or a child with complex congenital heart disease who was not receiving care because of a lack of maternal job security, these kids were missing out. In almost every case, the missing pieces cost a fraction of the children’s overall state-subsidized care. Families lacking the small resources that would allow them to coordinate transportation, procure supplies, or gain support were missing out on many of the free services the state had to offer.

    The fact that children with complicated illness have increased care utilization is well established in the literature.2 What is lacking are well-defined models that can be applied in complex, resource-limited environments to better coordinate care for vulnerable children. The medical home model in North America has shown promise in improving overall care of medically complex children.3 The nurse case management model also has been shown to be effective in improving care and reducing costs.4 Community health promoter models have been used to improve the health of communities in a variety of ways and in both urban and rural settings.5,6 Few of these models, however, have been tested in environments with such complex need and limited resources.

    Our solution to the problem

    In response to what we saw as a tragic and frustrating problem, we combined the medical home, the nurse case management, and the community health promoter approaches into a combined care-delivery model that we call the Seguimiento Y Coordinación Inter-profesional para Niños con Casos Complejos (SYNC) Project. We created a team-based model comprised of health "ambassadors," a social worker, and a supervising nurse care coordinator.

    Our health ambassadors are members of the local communities, well versed in microculture, available resources, and the varied logistical challenges of the individual communities across the city. They are the backbone of the SYNC project, providing consistent interaction with the medically fragile patients and their families. A social worker helps with legal and system-level issues. The driving engine of the project is the nurse care coordinator. She provides targeted education, advocacy, and guidance for each patient and family. With her broad system knowledge and cultural competence, the nurse coordinator is able to target and fill the specific gaps in care delivery.


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