Health Policy$ense

Ten Years Back and Ten Years Ahead: Innovation in Pediatric Primary Care

A post from PolicyLab's 10th anniversary blog series

On October 22, policymakers, researchers, advocacy group representatives, physicians, and other experts will convene for CHOP PolicyLab's 10th anniversary forum: Charting New Frontiers in Children's Health Policy & Practice. Attendees will discuss the most pressing health issues facing children, adolescents, and families across the country. The post below from PolicyLab Faculty Member and LDI Senior Fellow Alexander Fiks is part of a series leading up to the event.

[Reposted from CHOP PolicyLab Blog]

Recognizing that nations with strong primary care systems achieve better health outcomes, we have made important gains in the U.S. pediatric primary care over the past 10 years. In fact, primary care pediatricians are delivering more care to more children and adolescents than ever before. Importantly, we are not just providing more care, but improving access for minorities and impoverished children and addressing a growing range of complex chronic conditions and social problems, such as adverse childhood experiences. Even with these advances, we need continued innovation in pediatric primary care to deliver the best possible outcomes to children.

Ten Years Back: Innovation in Pediatric Primary Care
Over the last 10 years, we’ve witnessed improvements in where children receive care, who provides that care and how care is delivered. Children are increasingly served by primary care practices certified as “medical homes.” As defined by the American Academy of Pediatrics, medical homes are sites where patients establish a relationship with a personal physician and are cared for by a team that takes collective responsibility for their ongoing care—both inside and outside the health system. To better patient health outcomes, the medical home measures and improves upon quality as part of its daily workflow and enhances access to care and communication where possible. In addition, pediatric practices are increasingly implementing electronic health records (EHR) and registries of children needing care to support the clinical decision-making process.

This evolution occurs in the context of a shift in the population being cared for and the pediatric workforce providing the care. Underscoring the need for cultural sensitivity, immigrants represent a growing proportion of U.S. children with 21 percent of U.S. households speaking a language other than English. And although reducing poverty could bolster child health, children in America remain almost twice as likely to live in poverty as adults, a problem that highlights the importance for programs within pediatric medical homes that are especially responsive to issues like hunger.

The pediatrician workforce is also changing. The proportion of pediatricians working in solo or two-physician private practices has declined from nearly 40 percent to under 15 percent with nearly all (88 percent) ‘new’ pediatricians under 39 years of age working as employees of larger, consolidated health systems. At the same time, women, previously a minority of the primary care workforce, now represent well over half of primary care pediatricians. Recent trends also suggest more pediatricians are working part-time—more than any other medical specialty.

Finally, 10 years ago, when deciding where to go for care families often only had two choices—their primary care office or the emergency department. Now, the variety of consumer-focused options has increased with a growing number of urgent care centers, retail-based clinics and telehealth services. While these options may sometimes be more convenient for patients, they have the potential to fragment the integrated care that is the foundation of the medical home.

Changes in My Practice
In response to these general trends, my own primary care practice has evolved. New vaccines have decreased the burden of infectious disease in primary care, but the care of children with behavioral health problems has escalated. While I once recorded all visit notes by hand in sometimes hard-to-find charts and wrote all prescriptions on paper, that process has now been automated. The use of EHRs is now routine at all of my primary care visits, allowing for automated vaccine reminders and assisting with the long-term management of chronic conditions like ADHD and asthma. This work has proven benefit based on research from PolicyLab and CHOP’s Department of Biomedical and Health Informatics.

Furthermore, medical interpreters—both in person and over the phone—are regularly available and my most complex patients now benefit from care coordinators, who provide supports to families by negotiating challenges inside and outside the health system.

Ten Years Ahead: Innovation in Pediatric Primary Care
The “Possibilities Project,” a group that I direct along with CHOP’s Dr. Lisa Biggs, has been focusing on re-imagining primary care delivery to better the patient and provider experience of pediatric primary care and improve child health outcomes. Over the coming years here at CHOP, we will (1) update the model of care (e.g., better use teams) to create more flexibility in how care is delivered and (2) implement innovative programs that take advantage of that flexibility to improve outcomes, for example by better addressing wellness. Several catalysts will be key to these efforts including leveraging technology, better using behavioral and communication strategies and bolstering collaboration.

  • Technology: Technology is well-recognized as a “disruptor” of industries, and health care is not immune. For example, we expect that pediatric care will increasingly involve a mix of office-based and virtual-video visits with families at home or in school. In addition, parents and older children will increasingly use technological advances such as texting, mobile health applications (“apps”) and wired devices (e.g., smart watches), encouraging physicians to more frequently recommended their use as technology advances and these interventions become better able to motivate behaviors associated with wellness.
  • Behavioral Strategies: Concurrently, clinicians will need to become even more effective communicators, using evidence-based strategies like motivational interviewing, an approach to foster behavior change, and shared decision making, a strategy to ensure that clinical decisions reflect both patient’s values and the best medical evidence. We’ll also look to approaches from behavioral economics, less well studied in pediatrics than in adult care, which may help align incentives with desired outcomes, further supporting child health.
  • Collaboration: Finally, primary care pediatricians, at one time the center of all care delivery, will increasingly partner with teams of individuals with varied skills—including those in subspecialties like child psychiatry and psychology—to improve clinical effectiveness and access to care. Since child health is tied so closely to school performance, we will need programs at the school or community levels, sometimes encouraged by the medical home, to bolster wellness. Programs at CHOP like the Community Asthma Prevention Program (CAPP) are already demonstrating the effectiveness of community engagement.

We still have much to learn. Health services and informatics research and quality improvement within primary care will help to address key unanswered questions in order to create a future of better child health care and, ultimately, health. Personally, I look forward to implementing and testing innovative approaches in my own practice and research. I hope you can join me and other national leaders as we continue this discussion at PolicyLab’s 10th Anniversary Forum: “Charting New Frontiers in Children’s Health Policy & Practice.

Katya Nekrasova, MPH, and Andrew Johnson contributed to this piece.