Application of the Medical Neighborhood to Children with Severe Obesity

Abstract

Background:

Growth in the prevalence of severe pediatric obesity and tertiary care pediatric weight management programs supports the application of chronic disease management models to the care of children with severe obesity. One such model, the medical neighborhood, aims to optimize care coordination between primary and tertiary care by applying principles of the Patient-Centered Medical Home to all providers.

Methods:

An exploration of the literature was performed describing effective programs, approaches, and coordinated care models applied to pediatric weight management and other chronic conditions.

Results:

Though there was a paucity of literature discovered with applications specific to pediatric weight management, relevant disease management and care coordination approaches were found. Proposed applications to the care of children with severe obesity can be made.

Conclusion:

The application of the medical neighborhood framework, with its inclusion of healthcare and community partners, may optimize the management of children with severe obesity.

Introduction

Obesity affects 18.5% of children¹ in the United States and 6.3% of children have severe obesity (class 2 and 3).² Obesity in young children tracks into later childhood,³ and severe obesity in later childhood tracks into adulthood.⁴ The unremitting nature of this condition supports the rationale for chronic disease management.^5,6 In response, tertiary care children's hospitals have developed treatment programs for children with severe obesity. Of 118 children's hospitals responding to the Children's Hospital Association's 2013 Obesity Services survey, 85 (72%) had a stage 3 treatment program, representing exponential growth since the year 2000.⁷ These programs are ideally positioned to be referral resources after stage 1 (Prevention Plus) and 2 (Structured Weight Management) treatment by primary care providers (PCPs).⁸ To enhance treatment outcomes, coordination between stage 3 programs and the PCP office, which often serves as the patient-centered medical home (PCMH), is critical.^8,9 Few publications describe effective strategies for coordinated care of children with severe obesity.

Care Coordination in the Medical Neighborhood

Multiple consensus articles and policy statements recommend frameworks for optimal interaction between tertiary and PCPs in patient management,^10–12 including examples of promising models. Although pediatric obesity models are not often included, many recommended elements can be applied to the management of children with severe obesity to strengthen coordinated care (the deliberate organization of patient care activities between ≥2 participants [including the patient] involved in a patient's care to facilitate the appropriate delivery of healthcare services).¹⁰ Since the 2007 release of PMCH joint principles,¹³ the concept of provider partnerships, along with emerging literature on the development and functioning of the PCMH, has broadened to include the “medical neighborhood,” a framework where both primary care and specialists provide coordinated care.^11,14 The Affordable Care Act and Accountable Care Organizations have reinforced the importance of the PCMH, medical neighborhoods, and care coordination.¹⁰

Pediatric studies¹⁰ demonstrate that care coordination facilitates the achievement of the Institute for Healthcare Improvement's Quadruple Aim (better care, better health, lower cost, provider satisfaction).¹⁵ Treatment recommendations are based on the chronic care model,⁸ which focuses on the child's needs first, are family centered and team based. This process stimulates improvements in systems of care by promoting value of the PCMH and decreasing care fragmentation (or misalignment of care).¹⁶ Expansion of the chronic care model to include the broader medical neighborhood applies coordinated care principles, where predetermined responsibilities are shared among the specialty practice, the patient/family, and the PCMH.¹⁷

Care coordination within the medical neighborhood includes the core elements of access to primary and tertiary care, communication between families, PCPs and specialists, coordination of providers with defined roles sharing the care of the patient and patient/family inclusion in care planning, and delivery.¹² Elements of care coordination, which could reduce fragmentation for children with severe obesity include (1) assisting child/family with communicating clinical issues, (2) PCP considering consultant recommendations and implementing them when appropriate, (3) facilitating communication among all healthcare- and community-based treatment team members, (4) supporting self-management, (5) supporting and revising care plans (longitudinal plans toward transition from specialty back to primary care and pediatric to adult care), and (6) ensuring successful linkages with community-based resources.^9,10,12

Actualization of an effective medical neighborhood for children is hampered by several factors, including an inadequate number of pediatric subspecialists, increasing demand for subspecialty care, lack of primary care capacity, fragmentation between primary and subspecialty care, and inadequate third-party payment for care coordination.^12,15 Despite these challenges, establishing a medical neighborhood for children with severe obesity is well aligned with many treatment goals. This article will feature elements of care coordination among medical neighborhood members and proposed applications to severe childhood obesity management. These examples will be from literature describing (1) coordination of chronic disease care among providers, (2) care coordination in the community, (3) transition of care between pediatric and adult specialists, and (4) facilitators and barriers associated with effective care coordination.

Chronic Disease Care Coordination, Access, and Communication among Healthcare Providers

Employing care coordination in the management of children with severe obesity can improve resource utilization and communication, build capacity for care (increasing capabilities to meet treatment needs), and enhance patient outcomes and experience.^5,10,12,18 Pediatric weight management (PWM) lends itself to varied levels of comanagement (shared responsibility) of associated morbidities, including hypertension, diabetes, or dyslipidemia, which require clearly defined management roles. The degree of comanagement should be collaboratively agreed upon and clearly communicated between tertiary and PCPs in the medical neighborhood, and may take the form of (1) preconsultation exchange, (2) formal consultation, and (3) comanagement, which may be shared or grant a higher level of specialty responsibility for a limited period, and/or (4) transfer of patient to specialist for the entirety of care.^8,12 Use of Care Coordination Agreements (CCAs) should be considered to delineate expectations of these clinical interactions for both the referring provider and the consultant. (Table 1) Since access to specialty care can be limited, these expectations may include tools to assist PCPs in performing sufficient assessments and initial care within the PCMH.¹² In addition, care coordination should utilize care plans, the components of which include (1) actionable plans with assigned tasks/roles for tertiary and PCPs, staff, and parents; (2) emergency information and/or medical summary; (3) input from members of the team; (4) explicit statement of goals to maximize outcomes and support transition to adult systems of care; and (4) updates and maintenance with timely and salient information.^10,12,19,20 (Table 1)

Table 1.

Templates and Tools for Coordinated Care

Resource	Weblink
Care Coordination Agreement samples⁴⁶	American College of Physicians Accessed December 8, 2017
Care Plan Templates⁴⁷	National Center for Medical Home Accessed December 3, 2017
Transition Care Resources⁴⁸	Got Transition.Org Accessed February 3, 2018

Literature supports parents/caregivers' and patients' involvement in shared decision making (a collaborative process to arrive at a plan) about consultation and ensuing medical management roles.¹² A survey of parents and providers reported that diverging perspectives on referral necessity and seriousness of the child's health problems led to not keeping the appointment.²¹ Parents of children with special healthcare needs reported desire for inclusion in shared decision making in the referral process.²⁰ Use of an electronic patient portal for shared decision making in children with asthma increased family engagement and patient outcomes.²² Promoting clear communication about reasons for referral for severe obesity with agreement from the patient/family, and agreed-upon division of care between the PCMH and the PWM specialist is recommended.

An example of how care coordination successfully met the quadruple aim was through Improving Pediatric Access through Coordinated Care (IMPACC), a five-hospital learning collaborative, designed to improve the transition from tertiary care to medical homes for over 1500 enrolled pediatric patients in North Carolina. IMPACC reduced emergency department and hospital utilization, saving over $6 million in 2 years by increasing communication between PCPs and endocrinologists and between case managers from children's hospitals and PCP clinic case managers. Toolkits outlining guidelines for common conditions with red flag indicators for immediate referrals built capacity within primary care settings while utilizing specialist care more efficiently.²³ A care coordination process which improves communication among the team (PCP to PWM specialist and PCMH to PWM coordinators) aided by shared guidelines for management and referral indicators could apply to obesity care. This approach could potentially increase primary care capacity by increasing primary care-based PWM services followed by referral of patients unresponsive to treatment or with significant comorbidity. This could improve efficiency by delivering the right care at the right time.

Referral and consultation approaches have demonstrated improved efficiency, access, and communication between pediatric PCPs and specialists. A Connecticut study evaluated paper- and computer-assisted clinical care algorithms for anxiety and depression in children seen by PCPs. Shared tools for history taking, next-level actions and referrals improved PCP management of mental health concerns.²⁴ The same group field tested relationship-building activities, including in-person meetings, mini-trainings, listservs, and agreed-upon communication tools and processes. These strategies improved communication quality and quantity and interprofessional collaboration between PCPs and mental health specialists.²⁵ Another study, Targeted Child Psychiatric Services employed a collaborative treatment model in which referring providers called the psychiatrist on-call about a nonemergent consultation. Recommended management was discussed and formal consultation was offered as necessary. After stabilization by the psychiatrist, the patient was referred back to the PCP or to a community mental health system for continued care. Forty-three percent of consultations occurred by phone within 20 minutes of the request and patient consultations were seen within 4 weeks.²⁶ Relevant to weight management is the application of agreed-upon screening and care algorithms, uniform referral content and process, quicker communication and patient referral access, and short-term management followed by transition for continued care.

HopSCOTCH was a randomized Australian trial involving pediatric patients with obesity, which aimed to improve weight status using a shared care model (employing joint participation) across tertiary and primary care settings. General practitioners received brief obesity education and managed their patients after an initial encounter in an obesity clinic and shared electronic health record (EHR) designed to (1) allow communication between PCP and specialists about patient care, (2) provide EHR tailored to PWM, (3) share patient tracking, and (4) interface with established PCP software. BMI z-score did not change, possibly because intervention patients only received an average of 3.5 of 5–11 recommended visits. Additionally, one visit to the weight management center may not have been adequate to impact weight status. Challenges to implementation of this model included technical problems with the EHR and need for more intensified PCP training and connection with specialists. Further testing of more robust PCP training and treatment and designing and implementing facile shared EHR is needed for this model.^27,28

Some challenges to autism management mirror those in obesity care, with limited access to specialty care and limited capacity and efficacy for care within the medical home.^19,29,30 The Extension for Community Healthcare Outcome (ECHO) model aims to address specialty care capacity building in primary care through telehealth learning collaboratives.³¹ Project ECHO was applied to autism care by University of Missouri researchers using the Missouri Telehealth Network. Biweekly 90-minute sessions combined 15 minutes of high-value didactics with case discussion presented by learners and facilitated by an expert panel. Outcomes are pending, but the hope is that this approach increases high-quality care for patients with autism in their own primary care settings.³²

The ECHO model has potential to address some of the limitations of the HopSCOTCH trial by continual capacity building in primary care through this learning collaborative approach. The Pediatric Overweight Quality Improvement (QI) project, part of ENVISION, a New Mexico initiative to improve pediatric care, aimed to improve pediatric obesity management by training rural PCPs and staff through twice monthly telehealth didactic sessions and case consultations with specialists to improve communication and increase capacity for care. Patient-level outcomes were not reported, but providers improved BMI documentation, weight diagnosis, and nutrition and physical activity counseling after participation.³³

Care Coordination in the Community

The medical neighborhood for children with chronic diseases ideally provides comprehensive care that facilitates partnerships among patients, the healthcare team, and community. Successful care coordination in this broader medical neighborhood should include consideration of health, education, early childcare, early intervention, nutrition, mental/behavioral/emotional health, community partnerships, and social services needed to improve equity and quality of care.^6,10

A new model of chronic care management (CCM) for prevention and treatment of obesity has been proposed by Dietz et al.⁶ Revisions to previous iterations of CCM, which were health organization centric include a focus on patient/family engagement and empowerment and a complete integration with the community, which is no longer in the background but positioned as a key partner in care. Beyond a care coordinator, a trusted integrator can build and sustain key relationships, infrastructure, and policy changes within a complementary community ecosystem comprising sectors, which can improve nutrition and physical activity environments. Case studies demonstrating components of this new model show promise of improving linkages and integration with the community for prevention and treatment.⁶ To address known socioecological contributors to severe childhood obesity, identifying partners within the community as “neighbors” in the medical neighborhood to coordinate the delivery of care and services and using a trusted integrator to build and sustain relationships with these services could also hold promise.

A literature review of studies evaluating the intersection between PCPs and community programs for weight management reported that referral relationships from PCPs were viewed as valuable partnerships. Providers valued the added services offered not available in the office setting and community partners reported improved health behaviors in provider-referred participants. Parents viewed the program as an extension of the office since the program had a close partnership with the office and was recommended, and there was follow-up after program ended.³⁴

An example of an integrated model between tertiary PWM clinic services and community-based programming is Bull City Fit, a partnership between a local park and recreation facility and Duke University's Healthy Lifestyles Clinic. Patients and families seeking care at the clinic were randomized to PWM and park district family-based wellness programming or to PWM alone. The study demonstrated improvement in contact hours, quality of life, and physical activity for patients in the enhanced program and feasibility of integration between the two partners. Components of integration included (1) creation of a formalized shared use agreement, (2) collaborative creation and implementation of the program, (3) connection between park district and PWM site through on-site sign-in software tracking attendance and duration, and (4) connection between PWM and patients using text messaging reminders about sessions.³⁵

Optimal care coordination among schools, PCPs, and specialists ensures that treatment for disease is incorporated throughout a child's day in a manner that facilitates achievement of their educational goals. Features of communication models for the care of children with other chronic conditions could be applied to the management of children with severe obesity. Written care plans outlining school-based management of childhood conditions is agreed upon within an Individual Education Plan or 504 plan.³⁶ Clear delineation of roles and the process of communication among students, school staff, PCPs, and parents within these care plans have demonstrated improved management support, specifically in asthma and diabetes care.^36,37

School-based health centers (SBHC) offer a multidisciplinary team structure, enabling partnerships between healthcare and educational staff to support students in preventative healthcare, acute and chronic disease care, and mental healthcare.³⁷ The aforementioned Envision QI Initiative implemented obesity prevention through improved clinical practices in periodic exam and behavioral health screenings in SBHC. The Envision initiative concluded that SBHC could serve as a medical home or comanage a child/teen's healthcare with the PCP or specialty provider.³⁸

Transition of Care between Pediatric and Adult Specialists

Longitudinal care plans may include the transition of adolescents with severe obesity from pediatric to adult obesity specialists. The Society for Adolescent Medicine defines transition as “the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from a child-centered to adult-oriented healthcare system.”³⁹

Certain recurrent themes in transition literature can facilitate this process and thus extend the capacity for pediatric obesity care within the medical neighborhood.

American Academy of Pediatrics Guidelines recommend a discussion of the practice medical transition policy with families and patients at 12 years of age. A written policy detailing the practice policy and rationale is helpful.⁴⁰ This discussion is the first of several core elements needed to facilitate a successful transition to an adult provider. After a discussion of the practice policy, tracking and monitoring adolescents ready for transition as well as those in the process of transitioning is critical. The provider, patient, and family must plan the transition, execute, and then follow-up in several months to ensure success. (Table 1 for examples) Barriers to transition include distrust of a new provider and limited patient autonomy, which is essential in preparation for an adult-care management style.⁴¹

Discussion of care transition should be a part of the initial encounter in an obesity management visit if possible, as the goal is an eventual transition to the PCP or an adult bariatrician. Discussing transition early also informs the patient and family that this therapeutic relationship is not intended to be long term or one that replaces the PCP. Starting this process entails patient education and communication with the referring provider.^40,42 Both components are crucial for children with chronic medical conditions such as severe obesity.

Although there is a dearth of outcome studies related to transition of care for adolescents with obesity to adult providers,⁴³ outcomes have been reported on three disease-specific transition programs. Transition coordinators among patients with juvenile idiopathic arthritis improved quality of life in contrast to those patients who did not have this additional management. Transition clinics designed specifically for the adolescents and young adults significantly improved the clinical outcome of kidney transplant recipients in contrast to controls. Lastly, adolescent transition programs, where patients met their adult and pediatric providers in one setting, demonstrated better glycemic control in Type 1 diabetics.⁴² These practices are applicable to the transition of obesity management.

Facilitators and Barriers in Medical Neighborhood Care Coordination

Factors facilitating and challenging improvement of patient care in the medical neighborhood have been identified but not published within the context of obesity care. One such factor includes provider-to-provider communication. Facilitators of communication include receiving information before the first consult, clear identification of referring provider and all specialists involved, timely receipt of specialist communication, computer access to chart notes, and lack of delays on receipt of information. Desired content of specialist communication includes a patient history, suggestions for future care, follow-up arrangement, and plans for management or comanagement in the form of letter or phone call. Reported challenges include a lack of infrastructure and processes to facilitate timely and relevant communication by phone, EHR, e-mail or fax, delayed phone and transcription availability, and failure to keep all providers informed when multiple team members are involved.¹²

Easily accessible EHR can also facilitate access to care, communication, and care coordination by successfully creating four core functions: (1) provide a standard means to refer a patient, (2) facilitate preconsult communications, (3) track referrals to ensure prompt scheduling and notify PCP of patient appointment incompletion, and (4) measure performance with appropriate metrics.¹¹ Lack of standardized transfer of data from acute care hospital to PCP and interoperability between EHRs continue to be barriers.⁴⁴

Finally, allocation of healthcare system resources^44,45 and payment for staff effort and infrastructure associated with care coordination are not regularly implemented, despite evidence of improved efficient care delivery. Though current American Medical Association Current Procedural Terminology (CPT) codes have been developed for care coordination activities,¹⁰ reimbursement in a “fee-for-service” system does not include pre-consultative exchange or care coordination. Barriers to establishment and implementation of CCAs among providers can be fiscal- and infrastructure-related. Compensation schemes have not been created for time to develop CCAs, including administrative support, consensus-building among providers for master service agreements, and electronic support to provide rapid access to CCA details and identify patients covered by CCAs.¹⁶ Either simultaneous payment reform or agreements between providers and payers are needed to support these services and justify healthcare system investment.¹¹

Specific to PWM, facilitators of coordinated care include: (1) provider-to-provider communication with agreed-upon content and information exchange process (e.g., referral template shared electronically), (2) a process that facilitates efficient communication among providers during the treatment (e.g., e-mail, fax, EHR messaging), (3) useable electronic health information exchanges to access patient information (e.g., providers who do not share the same EHR can access relevant patient clinical information tracking weight status, comorbidities, and lifestyle goals), and (4) infrastructure support to develop and sustain CCAs and care coordination efforts (e.g., CCAs which implement primary care capacity building, shared care or comanagement of PWM processes, and staff to facilitate communication and delivery of services among the care team members).

Summary

Many principles from the emerging field of chronic disease care coordination can be applied to optimize management of children with severe obesity. The more recent concept of the medical neighborhood provides a helpful framework in which primary and tertiary care providers, community partners, and families can communicate. The medical neighborhood principles of access, communication, coordination and patient/family inclusion may be met using telephonic consultations, unified referral and screening processes, automated referral management systems, and shared decision making for intensity of interventions. Increased access and capacity building for comanagement can be enhanced with the use of learning collaboratives or multidisciplinary care teams, including those in community settings. Transition of patients with severe obesity from pediatric to adult care should begin in early adolescence and be facilitated with a transition plan. Infrastructure support is necessary to establish interoperable EHRs, which standardize the referral and transition process, support provider communication, track referrals, and enable outcomes measurement. Finally, payment for care coordination is essential for this healthcare innovation to be fully realized.

Footnotes

Acknowledgments

The authors acknowledge the Children's Hospital Association and the American Academy of Pediatrics as the primary project sponsors for the Expert Exchange.

Author Disclosure Statement

The study sponsors had no role in study design or the collection of reviewed articles. Editors supplied by the sponsors reviewed the final draft of the article. The sponsors hosted study group meetings. The views expressed are those of the authors and do not necessarily reflect those of the Children's Hospital Association or the American Academy of Pediatrics. The authors have no conflicts of interest to disclose.

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