Pediatrician Jim Rice notes that the members of Annapolis Pediatrics didn’t decide to sit down one day and draw out a plan to develop a medical home practice for their most medically complex patients. But changing dynamics in pediatric medicine like decreased hospital stays and increased community services made the need for a medical home model even more essential. Consequently, in a step-by-step and somewhat serendipitous approach, they’ve created the components of a medical home. 

“The hospital was really the center of the medical home 30 years ago for kids with special healthcare needs,” Rice says. “Today there’s much more being done in the outpatient realm, which had certainly posed a challenge for us community pediatricians.” 

Those challenges also include today’s typically busy, high-volume practice. While the majority of Rice’s patients come with bread-and-butter pediatric issues like the flu, summer injuries and swimmer’s ear, mixed in with that caseload is the recent heart surgery patient dealing with a G-tube, a tracheostomy and a dozen meds daily. 

“The challenge for me and most pediatricians,” Rice explains, “is how do we handle that at 3 in the afternoon when the waiting room is full?” 

Among the steps Annapolis Pediatrics took was creating a new staff position to coordinate follow-up services for the more medically complex cases, like the patient who needs a referral to pediatric pulmonary or scheduling for an upper GI. The practice also purchased a faster, more accurate and more efficient electronic patient record system, which helps track medications and labs. Citing a recent hypoplastic left heart syndrome patient who needed prescriptions filled for an upcoming trip, Rice notes, “With a few clicks I was able to pull up his doses and quickly fax them at the end of the visit with less chance of errors.” 

Another challenge for the pediatrician is sustaining the role of central coordinator of care for the patient and family. With so many entry points for healthcare services for the recently discharged hospital patient with special needs—home care and rehab, multiple subspecialists and the local hospital—what can the primary care pediatrician do to act as the hub? 

“The availability of home care and other services has allowed a lot of these patients to go home, which is good, but we run the risk for some of these patients not having a home,” Rice says. “Are they interacting with their specialist from Hopkins? Are we the point of contact? Sometimes patients can become somewhat triangulated between our office, the subspecialist and home care.” 

Electronic communication helps, says Rice, though for him and others the practice of emailing personal health information raises flags about patient confidentiality. Rice still relies mostly on the traditional mode of communication with patients—the telephone—though the office encourages face-to-face visits whenever possible. Being a group practice open seven days a week with some 16 pediatricians and nurse practitioners at four locations, Annapolis Pediatrics makes itself as accessible as possible to patients, especially those with special healthcare needs. 

“If I was in solo practice I wouldn’t be here until 9 p.m. every night and working Saturdays and Sundays, so my patients would have to go somewhere else,” Rice says. “This way they’re still in their medical home.” 

In another step Rice reaches out to families and specialists in the community and places like Hopkins to collaboratively develop ways to manage complex patients. In spring 2011, for example, Rice participated in a panel of pediatric cardiologists and parents of children with congenital heart disease at Hopkins Children's annual Pediatric Trends conference. 

“For us,” Rice says, “it’s mostly getting more comfortable with managing these complex patients, knowing what we can handle and when to defer to the specialist, and improving communication to deal with those areas in between.” 

Developing a medical home is a tedious, painstaking process, Rice concludes, with myriad medical issues, not to mention reimbursement codes for coordination of care. A good business office, he quips, helps. Perhaps new technologies and strategy meetings with easels lining the walls would help in developing a medical home model, he concedes, but at the end of the day best practices still come down to dedicated care. 

“The idea of a commitment, that this is my patient and I’m going to see this through,” Rice says, “is still the most important thing. Technology is never going to replace that.”