The Patient-Centered Medical Home is Not Always the Primary Care Provider’s Office :

As I reflect on the critical factors that lead to the successful diagnosis and treatment of a young child with a solid tumor, I come up with a list of factors similar to the characteristics often used to describe the patient-centered medical home (PCMH). According to the Agency for Healthcare Research and Quality (AHRQ), the five functions and attributes of the PCMH are comprehensive care, patient-centered care, coordinated care across all elements of the broader health care system, accessible services, and a commitment to quality improvement¹.

In the February issue’s Visual Diagnosis presentation of an infant with a malignant rhabdoid tumor by Drs. League-Pascual and Hartman², one can see the critical importance of collaboration between the disciplines of radiology, surgery, pathology and oncology in arriving at the correct diagnosis. When reading Drs. Allen-Rhoades, Whittle, and Rainusso’s³ overview of the most common solid tumors that occur in infancy, one can appreciate the unique combination of medical and surgical experts that must come together to deliver the optimal treatment to children with these rare and complex disorders.  For example, a pediatric oncologist works closely with ophthalmology when treating a child with retinoblastoma; then coordinates care delivered by surgery, radiation oncology, and the hematopoietic stem cell transplant teams to a child with neuroblastoma; and consults with surgery, radiation oncology, and, at times, the liver transplant teams when treating a child with hepatoblastoma.  Also, of great importance to successful outcomes is the collaboration with nursing, pharmacy, social work, psychology, child life therapy, the primary care physician, and other support services to ensure that all the needs of the patients and families are being met and that all necessary services are accessible.

PCMH model of healthcare delivery is a topic of frequent discussion among healthcare administrators, payers and general pediatricians and is being implemented in general pediatric practices throughout the country with the goal of improving the quality of care while reducing costs.  Up to this point, pediatric oncologists and other pediatric subspecialists who care for children with rare and complex diseases have generally not been part of PCMH discussions.  The PCMH model is more mature in adult medicine, and it has been recognized that specialists, such as oncologists, play an important role in providing a PCMH for oncology patients during active treatment.  This has resulted in the development of the Oncology Medical Home (OMH) model by the National Committee for Quality Assurance⁴ and the American College of Surgeons Commission on Cancer⁵. 

Pediatric oncologists and other pediatric subspecialists should be brought into the conversation about PCMH for children to 1) take advantage of their significant experience in coordinating care across disciplines for patients with rare disorders, and 2) establish the role of pediatric subspecialists as the primary coordinators of care for their patients with unique and complex needs. 

References

1. AHRQ- PCMH Resource Center.  https://pcmh.ahrq.gov/page/defining-pcmh, accessed 03-01-2018.
2. League-Pascual JC, Hartman KR.  Visual-Diagnosis:  A Rapidly Progressive Soft Tissue Shoulder Mass in a 3-month-old Infant. Pediatr Rev. 2018 Feb;39(2):e5-e8. doi: 10.1542/pir.2016-0174.
3. Allen-Rhoades W, Whittle SB, Rainusso N.  Pediatric Solid Tumors of Infancy: An Overview.  Pediatr Rev. 2018 Feb;39(2):57-67. doi: 10.1542/pir.2017-0057.
4. Oncology Medical Home Recognition- NCQA.  http://www.ncqa.org/programs/recognition/practices/oncology-medical-home, accessed 03-01-2018.
5. McKellar DP.  Commission on Cancer and the Oncology Medical Home.  Evidence Based Oncology.  February 2015.  http://www.ajmc.com/journals/evidence-based-oncology/2015/february-2015/commission-on-cancer-and-the-oncology-medical-home, accessed 3/1/2018.