Pediatric Home Health: The Need for Physician Education

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928 PEDIATRICS Vol. 95 No. 6 June 1995

COMMENTARIES

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American

Academy of Pediatrics or its Committees.

Pediatric

Home

Health:

The

Need

for

Physician

Education

ABBREVIATIONS. HCFA, Health Care Finance Administration;

AAP, American Academy of Pediatrics.

Home health represents a spectrum of exciting

practice possibilities for the pediatrician. Care in the

home can be provided for acute, intermediate, or

long-term health conditions. An acute infection can

be treated at home with physician or nurse visits; a

relapse of leukemia or chronic infection

(osteomyeli-tis) can be managed at home with intermittent drug

therapy. Home care can involve high technology

(mechanical ventilators), low technology (assistive

mobility aids), or no technology. Home care can be

provided only by family members or with

supple-mental support from neighbors, friends, personal

at-tendants, or professionals on an intermittent or

con-tinuous care basis. For the physician, home care may

involve discharge planning, postdischarge care

over-sight (telephone, documentation), or just “an

old-fashioned house call.”

Home health care may become a major practice

opportunity for pediatricians.1 In the future,

pediat-ric generalists and specialists should consider the

home as an appropriate alternate care setting to the

hospital, office, or ambulatory care center. The

pedi-atrician would choose home care after considering

the clinical needs, family preference, home situation,

funding mechanisms, and availability of appropriate

community resources. According to surveyed

pedi-atricians involved with high technology home care, a

primary care physician must directly participate in

clinical management.2 To assume their appropriate

roles and responsibilities, physicians need more

awareness and education about this new dimension

in practice. Current home health information and

experiences must be integrated into medical school

curricula, residency training, and postgraduate

education.

Home health has experienced explosive growth

with development of: 1) community-based services,

2)

home technology, and 3) cost-containment.

Ac-cording to the Health Care Finance Administration

(HCFA), home health is the fastest expanding

com-ponent of personal health care costs.3 Expenditures

increased from $2.1 billion in 1988 to $10.5 billion in

Received for publication Sep 10, 1993; accepted Sep 22, 1994.

Reprint request to (A.I.G.) Loyola University Medical Center, 2160 S First Aye, Maywood, IL 60153.

Acad-emy of Pediatrics.

1993; HCFA anticipates them to reach $22.3 billion by

1999. HCFA Director Bruce Vladeck stated that

pe-diatrics is now the fastest growing segment of home

care.5

PHYSICIAN PARTICIPATION IN HOME CARE

In the past, home care was developed by industry

without sufficient physician involvement and was not

designed to encourage direct physician participation.

Although some community-based home health

agen-cies have medical directors and advisors, they are not

required by the government or accreditation

authori-ties.6 It has been less difficult for the pediatrician to take

care of patients in the office, clinic, or hospital than to

deal with clinical management at home. Furthermore,

physician reimbursement for home care activities has

been limited.7

Recent changes in organization and physician

pay-ment have made participation more feasible. The

health industry now provides services and products

that allow direct medical management and

monitor-ing at home for a variety of situations. A pediatrician

can order equipment, supplies, and health care

per-sonnel to meet the technological, developmental, and

clinical needs of children with disabling or chronic

conditions requiring prolonged mechanical

life-sup-port, drug and blood product infusion, and nutrition.

Home health agencies and equipment vendors

ded-icated to pediatrics understand and meet the special

home care needs of children including family

sup-port and growth and development. Current

Proce-dural Terminology codes for physician

reimburse-ment for Medicare home visits have been available

since 1991.8 In 1991, payment ranged from $15 to $60

per visit; by 1993, $42 to $90 per visit.9’10

In the future, home care physician activity may be

encouraged. Paradoxically, this is due in part to the

explosive increase in home care costs. Conventional

thought attributes increased health care

expendi-tunes to physician involvement. Federal authorities

have also expressed concerns that home care services

may be abused and medically inappropriate.”

How-ever, HCFA Director Vladeck considers home care

cost escalation partly due to lack of physician

under-standing about home care and inadequate direct

physician participation in determination of medical

necessity, timely decision-making, and care

over-sight.4 As a result, HCFA’s home care initiative is

underway inviting direct physician participation to

decide the medical necessity of home care.4 Codes for

physician care oversight services may result from

this initiative in 1995.12

Besides proposed reimbursement changes,

physi-cian home care activity may be encouraged by political

reform, market changes, and consumer preference.

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COMMENTARIES 929

Nearly every health care reform proposal includes an

acute and/or long-term home care benefit.13 The

mar-ketplace may encourage pediatric care delivery via

in-tegrated community networks that will be directed

by

primary care physicians. To be competitive, these

pro-vider networks might offer comprehensive services

in-duding office, hospital, and home care packaged for

contracting with managed care organizations. Home

care would become economically appealing to the

pe-diatrician as a cost-saving alternative to facility-based

care and physician home care activities should make

financial sense especially in capitated arrangements.

Furthermore, pediatrician house calls would be

favor-ably considered by families when choosing a health

plan. Parents appreciate pediatricians’ seeing firsthand

the multiple factors that affect the health of their child

and family. Pediatric home health offers ideal

oppor-tunities for parents to discuss growth and development

and habilitation/education needs of their child.

THE ROLE OF THE AMERICAN ACADEMY OF

PEDIATRICS (AAP) IN PHYSICIAN EDUCATION

Pediatricians need education about home care.

Pe-diatric home health education is not included in most

medical school experience, pediatric residency

train-ing, or continuing education. Due to the expected

increased activity in home care by pediatricians, the

AAP established a Provisional Section on Home

Health in 1994. This Section may evolve into a

na-tional clearinghouse to collect, generate, and

distrib-ute information to help pediatricians understand

practical aspects of home care. In collaboration with

other AAP sections, educational programs will

present clinical and management issues for

special-ists and generalists, community and hospital-based

pediatricians. Section members will participate in

initiatives to generate practice parameters, develop

continuous quality improvement processes, and

de-termine policies and procedures for pediatric home

care. They will also consider standards for home

health care including clinical, psychosocial,

environ-mental, technological, organizational, and cost

ap-propniateness criteria that are not currently available.

To accomplish this mission, the AAP Provisional

Section on Home Health has three goals:

1. Provide Section members access to current

infor-mation and a forum for dialogue about medical,

financial, organizational, educational, and

re-search issues concerning pediatric home health

management.

2. Enhance the understanding of AAP members

about clinical aspects of home care to encourage

them to integrate home care into their current

clinical practice.

3. Serve the AAP as a primary resource by

partici-pation in activities within the Academy and by

representation of the Academy when pediatric

home care expertise is required.

MEDICAL EDUCATION FOR STUDENTS AND

RESIDENTS

To implement a pediatric home health care

curnic-ulum for medical students and residents-in-training,

an academic program in home health is

recom-mended. Physician education in home care has been

addressed and advocated by the AMA Council on

Scientific Affairs.14 Based on experiences with an

existing family practice curriculum,15 educational

programs

should enable students and residents to:

I. Understand required community resources and

how to contact and use them;

2. Become familiar with current home care cost

re-imbursement policies;

3. Know available home care technology: devices

designed/adapted for home use;

4. Appropriately apply home care principles,

guidelines, and protocols;

5. Play active/major role as a home care team

member;

6. Integrate patient home, ambulatory, and hospital

care;

7. Evaluate the adequacy of family and other care

providers;

8. Evaluate the efficacy of home care by

contnibut-ing to continuous quality improvement;

9. Prove the value of home care by its appropriate

utilization; and

10. Show appropriate home care assessment skills.

Home health education including house calls

dun-ing medical school and residency training is not new.

Excellent pediatric model programs over the last 50

years were successful but may not have been

univer-sally adopted due to lack of funding.1618 Home visits

have been recommended for medical students as an

ideal introduction to clinical medicine, community

pediatrics, and comprehensive primary cane.19’2#{176}

They have been incorporated into medical education

in the first year as a pre-clinical experience and later

during the clinical years to enhance the

understand-ing of psychological, social, cultural, and

environ-mental influences on chronic illness.227 Evaluation

of medical student home care experiences confirm

benefits including better appreciation of the

interac-tion of multiple factors contributing to illness,

build-ing skills in communication and teamwork, and

de-veloping interest in home cane for future practice.1927

Similarly, home health experiences enhance pediatric

residency training.’29 However, recent surveys of

pediatric training experiences failed to mention the

home as an educational setting.#{176}’31

Residency training is determined by financial

re-alities that are about to change.32 Insurance

compa-nies and the federal government recognize that

res-idents educated in a high-technology specialized

tertiary

care center will not choose a career that

enhances the health of the general public.32 HCFA’s

Director Vladeck raised concerns about the focus of

graduate medical education on acute care and

inpa-tient care settings. He recommended physician

training with other health care professionals in

non-hospital based community settings to encourage

in-terdisciplinary team approach, specifically citing

home

health as one option. Interdisciplinary

edu-cation in community pediatrics focusing on primary

care in the home would provide teachers necessary

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930 COMMENTARIES

for medical students and faculty to understand the

team concept of delivering home health.20’

Pediatric home health represents a new dimension

of care and a way of thinking about the role of

patients and families in their own health

manage-ment and other factors that impact the health of the

child. The required attitudes, skills, and knowledge

should be offered early in medical education as an

ideal way to introduce primary care. During

pediat-nc residency training, home health should be

inte-grated into all program components during the

en-tire training period. Home health could be

demonstrated during inpatient rotations (discharge

planning) and on ambulatory services with home

visits conducted as an extension to clinic-based care

(resident follow-up clinics). Residents should be

in-vited to attend all home visits and be included in all

care oversight activities related to patients for whom

they have rendered care. If possible, an elective

should be made available to residents to introduce

them to the operation of programs relevant to home

care (nursing agencies, equipment vendors,

man-aged care organizations). Residents should learn

di-rectly from home care team members and parents

who can serve as important role models in whom the

resident will hopefully observe appropriate

interac-tions between professional team members, patients,

and families. These learning experiences would be

useful preparation for the pediatrician’s primary care

role in the community.

ALLEN I. GOLDBERG, MD, MM, FAAP

Loyola University Medical Center

Maywood, IL 60153

REFERENCES

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2. Goldberg Al, Monahan CA. Home health care for children assisted by

mechanical ventilation. The physician’s perspective. IPediatr. 1989;1 14: 378-383

3. Letsch SW, Lazemby HC, Levit KR, Cowan CA. National health

expen-ditures. Health Care Finan Rev. 1992;14:1-30

4. Vladeck BC. From the Health Care Financing Administration: Medicare home health initiative. JAMA. 1994;271:1566

5. Vladeck BC. Keynote Address. Home-Based Care for a New Century. Arden

House, Harriman, NY: Milbank Memorial Fund and Visiting Nurse

Service of New York; 1993

6. Joint Commission for Accreditation of Healthcare Organizations. Accreditation Manualfor Home Care. Oakbrook Terrace, II: Joint

Commis-sion for Accreditation of Healthcare Organizations; 1993

7. Schwartzberg JG. New CPT codes for physician reimbursement for home care activities. Am Aced Houw Care Physicians Newsletter. 1990;2:1, 7

8. American Academy of Home Care Physicians. Comments re: Medicare Payment Schedule for Physicians’ Services. Am Acad Home Care Physicians Newsletter. 199L3:1, 3-5

9. American Academy of Home Care Physicians. Significant increase in reimbursement by Medicare for physician house calls. Am Acad Home Care Physicians Newsletter. 1992;4:1

10. National Association for Home Care. Physicians to see increase in Medicare reimbursements for home visits. Am Acad Home Care Phsi-cians Newsletter. 19935:4

11. Fraud/abuse concerns play big role in review of home care benefit. Home Health Line. 1994;19:2-5

12. Health Care Financing Administration. Medicare Program: refinements to geographic adjustment factor values and other policies under the physician fee schedule. Federal Register. June 24, 1994;59:32754

13. National Association for Home Care. Key congressional health care

reform bills compared. Health Care Reform Update. 1994;2(84):1-4

14. American Medical Association Council on Scientific Affairs. Educating

physicians in home health care. JAMA. 1991;265:769-771

15. Keenan JM, Bland CJ, Webster L. Home Care Curriculum. Minneapolis,

MN: Department of Family Practice and Community Health, University

of Minnesota; 3988

16. Bergman AB, Shrand H, Oppe TE. A pediatric home care program in London: ten years’ experience. Pediatrics. 1965;36:314-321

17. Shrand H. Medical students and pediatrics in the community. Pediatrics. 1971 ;47:751-757

18. Stein RE. Pediatric home care: An ambulatory ‘special care unit.’

IPediatr. 1978;92:495-499

19. Shrand H. The teaching potential of a home-care unit. faucet. 1966: i(452):1416-1417

20. Wallgren-Pettersson C, Donner M, Holmberg C. Wasz-Hockert 0.

Interdisciplinary teaching of community pediatrics. IMed Educ. 1982; 16:290-295

21. Lewis CE. A study of the effects of a multidisciplinary home-care training program on the attitudes of first-year students. I Med Educ. 1966;41:195-201

22. Tomich J.Home care: a technique for generating professional identity.

IMed Educ. 1966;41 :202-208

23. Billings JA, Colas, Reiser SJ, Stoeckle JD. A seminar in ‘plain doctoring’.

IMed Educ. 1985;60:855-859

24. McCahan JF, Bissennette AM, DiRusso BA. A house call teaching

program for fourth-year medical students. IMed Educ. 1983;58:349-351

25. Sankar A, Becker SL. The home as a site for teaching gerontology and chronic illness. IMed Educ. 1985;60:308-313

26. Reuler JB, Gardner EM. An inner-city clinic and house call experience

for medical students. JMed Educ. 1987;62:183-185

27. Page AEK, Walker-Bartnick L, Taler GA, Snow DA, Wertheimer OS,

Al-Ibrahim MS. A program to teach house calls for the elderly to fourth-year medical students. IMed Educ. 1988;63:51-58

28. Berger LR, Samet KP. Home visits. Extending the boundaries of

com-prehensive pediatric care. AJDC. 1981 ;135:812-814

29. Stemkuller JS. Home visits by pediatric residents. A valuable

educa-tional tool. ADJC. 1992;146:1064-1067

30. American Academy of Pediatrics Committee on Community Health

Services. A survey of community (out-of-hospital) sites used in

pediat-nc training. Pediatrics. 1991 ;87:719-721

31. Liebelt EL, Daniels SR. Farrell MK, Myers MG. Evaluation of pediatric

training by the alumni of a residency program. Pediatrics. 1993;91: 360-3M

32. McMillan JA. Pediatric residency training in the 1990s. Conte;np Pediatr.

1994;1 I:31-32

33. Vladeck BC. Graduate medical education: reorienting for the future. Acad Med. 1994;69:32-33

34. Zungolo E. Interdisciplinary education in primary care: the challenge. Nurs Health rare. 1994;15:288-292

The

Pediatric

Report

Card

for

Preventive

Services

ABBREVIATIONS. AAP, American Academy of Pediatrics; SIDS,

sudden infant death syndrome.

Health cane reform and consolidation within the

health cane industry has led to greater interest in

measuring the quality of care that children receive.

Remarkably little is known about measuring the

quality of ambulatory services in pediatrics, but

nev-ertheless there is growing interest in “grading” the

services provided by health delivery systems. Health

care “report cards” are a cornerstone of managed

competition-a set of quality indicators that will

al-Received for publication Jun 27, 1994; accepted Sep 16, 1994.

Reprint request to (H.B.) Boston City Hospital, Talbott 103, 818 Harrison Ave. Boston, MA 02118.

Acad-emy of Pediatrics.

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1995;95;928

Pediatrics

Allen I. Goldberg