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O‘ahu's primary care physicians are in the process of implementing the Patient-Centered Medical Home (PCMH) model. The Medical Home Task Force recommends the implementation of the Children with Special Health Care Needs (CSHCN) Screener© as one of the two quality improvement programs that must be completed by each participating physician. This study sought to find how many pediatricians practice population health management and to determine barriers for incorporating population health management and care registries into practices.
An online survey of 55 pediatricians in Hawai‘i was conducted between January 10, 2012 and March 10, 2012. The survey contained questions regarding knowledge and use of population health management and investigated the utilization rate of the Screener©. This survey provides baseline data on the implementation of this recommended screener, and informs the process that will be necessary to ensure maximal adoption of recommendations.
Sixty percent of the survey participants have not incorporated population health management into their routine practice. Twenty three percent did not have knowledge of population health management and 85% did not use a chronic disease registry. As of August 2011, 95% had not screened their patients with the Screener©. Reasons included not having heard of the Screener© and never having considered using a systematic process to ask patients to assess their health.
Based on results, there are important educational goals that need to be accomplished in order for Hawai‘i's physicians to transform their practices into effective PCMHs. Physicians will likely need instructional and monetary support to effectively change their practices into PCMHs.
Population health is a conceptual approach to identifying the determinants of health status affecting a particular group.1,2 To utilize population health concepts is to take a step beyond the individual-level focus of mainstream medicine by addressing a broad range of factors that impact the health of an entire population group.3 A good population health management program is cognizant of the many elements which affect the wellbeing of a particular population and has access to programs that target health needs of that population.
According to the American Academy of Pediatrics,4 the medical home is “a partnership approach with families to provide primary health care that is accessible, family centered, coordinated, comprehensive, continuous, compassionate, and culturally effective.” In order to perform the functions of a medical home, physicians would do well to understand and use population health management concepts. With use of these concepts, for example through disease management, individuals with complex medical needs would have better access to health care, increased satisfaction with care, and ultimately improved health of a specific population.5,6
Children with Special Health Care Needs (CSHCN) are one particularly important pediatric population that can benefit from application of population health management concepts. The Health Resources and Services Administration, Maternal and Child Health Bureau defines children with special health care needs as “those who have a chronic physical, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”7 The 2009/10 National Survey of Children with Special Health Care Needs (NS-CSHCN) conducted by the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics showed that Hawai‘i's prevalence of CSHCN is 45,700 (12.3%), while the national prevalence is 11.2 million (15.1%).8 Additionally, nationwide over 1 in 5 households with children have at least one child with a special health care need.8 This statistic translates into almost 9 million households. The 2009/10 survey also showed that in Hawai‘i, 29.0% of CSHCN did not receive care coordination within a medical home, 33.2% did not receive family-centered care, and 22.4% of CSHCN families were not partners in care decision making at all levels.8
The Child and Adolescent Health Measurement Initiative, in collaboration with the National Committee for Quality Assurance, has developed a questionnaire called the Children with Special Health Care Needs (CSHCN) Screener©, hence forth referred to as “screener.” The screener helps a family identify their child's need for extra services due to existing chronic conditions.9 Children's health care needs status is assessed by asking questions about prescription medications, need or use of services, functional limitations, specialized therapies, and counseling. (A copy of the screening instrument is provided in Appendix A.) The screener is used in several surveys, including the Medical Expenditure Panel Survey, the National Survey of Children's Health, and the National Survey of Children with Special Health Care Needs (NS-CSHCN).8,10 This tool gives physicians the opportunity to engage in a more comprehensive needs assessment based on a family's perception. The screener enables physicians to identify CSHCN in their practice as a population and to examine whether comprehensive care is provided for the CSHCN population.
The screener is important because the overall health of a child is influenced by multiple factors and it may be difficult to identify all of these factors during a single office visit with their health care provider. The CSHCN population shares many common health-related needs and issues. In addition, they often experience more than one condition at a time. Focusing on single conditions is both limiting and often impractical due to the large number of relatively low prevalence childhood chronic conditions.10 Population health management programs begin with the identification of the population at risk. The screener is recommended by the American Academy of Pediatrics as one of three screening tools that can be used to identify CSHCN.11 The screener was selected as the screening tool in this study because the screener is the only nationwide tool that allows comparison of Hawai‘i's profile with NS-CSHCN's data. Results from a study in 2002 indicate that the screener requires minimal time to administer, is acceptable for use as both an interview-based and self-administered survey, and provides a comprehensive yet simple method for identifying CSHCN.12 Thus, it would appear that the screener would be an ideal tool for pediatricians to begin that identification process which could then lead them to improve population health management skills.
The 2009/10 NS-CSHCN8 showing that 29% of Hawai‘i's CSHCN do not receive comprehensive, coordinated care in a medical home setting has room for improvement. Possible reasons for this issue include: physicians lacking an understanding of population health management, and/or physicians not having a mechanism to identify their children with special health care needs. To elucidate these questions, a survey was administered to a select group of pediatricians in Hawai‘i to find out how many of them had knowledge of population health management, how many practiced population health management, and how many utilized the screener in their office.
A baseline survey with twelve questions (Appendix B) was designed and created in Survey Monkey© and then emailed on January 10, 2012 to 55 O‘ahu physicians participating in the Patient-Centered Medical Home (PCMH) project. To participate in the PCMH project, physicians had to be primary care, general pediatricians practicing in Hawai‘i, with email access and have a minimum patient panel size of 150 members covered under one of the Hawai‘i Medical Service Association (HMSA)'s commercial plans, ie, the Preferred Provider Plan (PPP) and the Health Plan Hawai‘i, a health maintenance organization (HMO). In addition, participating pediatricians have opted to work with the Hawai‘i Chapter of the American Academy of Pediatrics (HAAP) to facilitate transformation through HMSA's PCMH project. Participants did not receive any monetary incentives. All participating physicians had a signed agreement with an Independent Practice Association to participate in the PCMH project. (For a more detailed explanation of the selected group size, refer to Appendix C.) Participants' age, gender, race, and practice location varied.
The survey, conducted between January 10, 2012 and March 10, 2012, consisted of 12 multiple-choice questions in total, 8 of which had comment boxes. The questions had a “skip logic” sequence and the questions presented to each respondent depended on the respondents' preceding answers. Thus, respondents were not presented with all 12 questions, but were required to answer all presented questions. The survey questions were grouped by categories which asked general questions about population health, the use of population health in the physician's practice, and the use of the screener for detection of children with special health care needs. Expected completion time was 5 to10 minutes. On January 23, 2012, there were 26 non-respondents and all were sent a reminder email.
Forty out of the fifty-five (73 %) PCMH physicians completed the survey. Survey responses are highlighted in Table 1.
Sixteen participants said they incorporated population health management in their practice. Descriptions of their methods vary and include a pilot of the CSHCN Screener©, Electronic Medical Record data tracking and warnings, Body Mass Index (BMI) lists, advising patients on better eating habits and exercising more, and assessing patient wellness, prevention, and needs. Six participants said they used a chronic disease management system in their office. Descriptions of their methods also varied and included the use of a BMI registry, a problem list attached to the front of the patients' charts, and the CSHCH Screener©. The top five reasons why physicians did not use the screener are included Table 2.
Effective medical homes are accessible, family-centered, comprehensive, coordinated, and culturally competent.4,6 Hawai‘i performs above the national average in health measures such as preventive health care, health care service needs and access, and the minimal quality of care index.8 However, CSHCNs have a lower average in health care measures than non-CSHCN.7,8,10 If CSHCNs are less likely to receive services consistent with medical home criteria than the general pediatric population, this could be partly explained by pediatricians not using a standard method of identification of the CSHCN population.
Data from our baseline survey show that 95% of surveyed pediatricians did not screen patients with the screener and 85% of physicians did not use a chronic disease registry to identify specific populations in their practice. When given a list of characteristics of population health management, 23% of physicians said they did not know what population health management is. The survey indicates that the top reasons why physicians do not implement the screener may be that physicians lack knowledge about the screener, have not considered incorporating a systematic process to ask patients to assess their own health, and do not get paid for using the screener.
Based on reports from parents in the 2007 National Survey of Children's Health (NSCH),13 collected by the CDC, 60.2% of all children in Hawai‘i below the age of 18 have a medical home that meets all medical home criteria. The 2007 NSCH indicates that families receive comprehensive, ongoing, and coordinated care only 47.6% of the time.13 In this study, 60% of physicians indicated that they do not incorporate population health management in their practice. Population health management is a crucial component of ability to deliver comprehensive, coordinated care for an entire practice. To improve the care of our children with special health care needs, physicians need to understand population health management and have a process to identify their children with chronic conditions that require special health care.
There are limitations to this study that need to be considered. A primary limitation is the lack of survey validation because the survey was created for this project. The survey was designed to support a quality improvement effort by providing baseline data on the implementation of this recommended screener. Also, the number of participants was limited to 55 physicians on O‘ahu. Pediatricians from Kaua‘i, Maui, Moloka‘i, and the Big Island were not represented in the survey. The size of the patient panel varied and the extent of the physicians' training on PCMH was not queried. Family practitioners did not participate in the survey. Potential biases of the baseline survey include selection bias and response bias. The group of physicians who received the survey was not selected at random and had to have chosen to participate in this PCMH project. Therefore, one would expect them to be more likely to use a screener. In addition, each physician had to have a minimum of 150 patients covered under the HMSA PPP/HMO health plan in order to qualify for this program. That requirement may have excluded recent graduates and younger physicians who might have received training and education on population health management. Although the response rate was satisfactory at 73%, the survey was not anonymous so there also could have been some response bias. Demographic comparison between respondents and non-respondents from collected data was not possible so generalizability of the data was not determined.
Nevertheless, the results from the survey are valuable because they clearly illustrate that pediatricians are not using chronic disease registries and do not have a standardized approach to identify CSHCN. The survey responses showed a lack of knowledge and utilization of population health management concepts. This lack of knowledge and utilization should be addressed because of the potential social and economic savings that could arise if population health management, use of chronic disease registries, and screening for children with special health care needs were routinely employed by physicians.7
Based on the survey responses, the two major reasons physicians cite for not using the screener are not considering to routinely query families about their perceptions of their child's health and not being familiar with the screener. Increasing awareness about the concepts of population health management and means to identify children with special care needs will benefit our community. With support from the health care system, physicians can become fully engaged in the medical home concept and PCMH techniques. If all providers who care for children in Hawai‘i uniformly screened their patients for special health care needs and had a process in conjunction with a health plan to aggregate and examine their population data, the quality of patient care would improve and would likely lead to an overall reduction in the cost of medical care.
The future of primary care relies on transforming physician practices into patient-family centered medical homes where patient health is seen holistically and in the context of the larger population. To accomplish this transformation, primary care physicians need to incorporate population health management into their practices.
Barriers towards implementation of routine screening of all children with the screener include:
These barriers can be overcome if the physician can gain an understanding and commit to transforming their practice into PCMHs, incorporate population health management concepts into their practice, and receive support from the health plan. The health plan can use this data generated from wide spread use of the screener to allocate appropriate resources to CSCHN and the practices that serve them.
For providers who care for children, using the screener appears to be a simple patient-centered tool that can help primary care pediatricians identify their patients with chronic health conditions and needs as identified by their families. This survey reveals there are many work, education, and system changes that are needed in Hawai‘i in order for pediatricians to transform their practices. To effectively manage population health, practices will need to restructure their workflow and adopt health tools such as the screener, which will enable them to reach out to patients who need services and track their population. Use of the screener in conjunction with PCMH transformation may lead physicians and the health system toward identifying patient population characteristics and building a more sustainable health care system that provides quality care at an affordable cost.
Hawai‘i Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association, set a minimum panel size of 150 Preferred Provider Plan (PPP)/Health Management Organization (HMO) patients in order for the primary care pediatrician to participate. The Hawai‘i Chapter of the American Academy of Pediatrics has an agreement with HMSA to partner with other Independent Physician Associations (IPAs) to facilitate the transformation of primary care pediatric offices into Patient-Centered Medical Homes. HMSA set the group size to 55 pediatricians.
None of the authors identity any conflict of interest.