|
Episode #2013
Medical Home
Bullock-Brown: Natalie Bullock-Brown, host
Earls: Dr. Marian Earls
Gerald: Dr. Laura Gerald
Morris: Dr. Peter Morris
Bullock-Brown: Is consistent, quality health care for African American children a luxury that can only be expected and afforded by well to do parents? A new federal concept in pediatric care says no. We'll learn more about it tonight on Black Issues Forum.
Voiceover: Funding for this program is made possible in part by UNC-TV members.
[THEME MUSIC]
Bullock-Brown: According to national statistics, tens of millions of American families currently live without health care due to lack of health insurance. This means that many children don't know what it means to see a family doctor, let alone a dentist or other specialist on a regular basis. How can the health of these children be adequately monitored if they don't have regular access to care, especially preventive care? And how can doctors and parents, those insured and uninsured, partner together to make sure that children from all socio-economic backgrounds enjoy quality, equitable access and care? Good evening. I'm Natalie Bullock-Brown and welcome to Black Issues Forum. A national movement spearheaded by the American Academy of Pediatrics is seeking to level the health care playing field for all children, especially those from disadvantaged and minority communities. And the movement comes from a concept called Medical Home. With us tonight are three medical professionals, all who serve on the Executive Committee of the North Carolina Pediatric Society, who will help us better understand not only the concept of Medical Home, but why it's so important to the African American population in North Carolina. One of our guests, Dr. Marian Earls, is the Medical Director for Guilford Child Health, a health care provider that has adopted the Medical Home concept and received recognition for its implementation. Guilford Child Health has a 13 minute CD that helps explain how their services work under the Medical Home concept. And we're going to take a look at some highlights of the CD but, first, please note that the information in this program is for informational purposes and is not intended for use as diagnosis, or treatment of a health problem, or as a substitute for consulting a licensed health care professional for medical advice, instruction, diagnosis, or treatment. If you have specific questions or concerns, please consult your physician or appropriate licensed health care professional. And now more on Medical Home.
[EXERPT FROM CD PLAYS]
To children of all ages across Guilford County, Guilford Child Health is committed to provide comprehensive services and a Medical Home to every child.
The menu of comprehensive health care services at GCH includes immunizations, endocrinology, neurology, even dental varnishing. These services are both for well children and those who require specialty services. GCH Medical Director, Dr. Marian Earls, says this type of wrap-around care for each child is carried out by community liaisons.
Our community liaisons work with every child, referring him or her to specialty services within Guilford Child Health or in the community. A liaison staff makes sure that a child's care is integrated with school and child care nurses.
GCH serves the needs of children form birth to adolescence. Their adolescent services address the physical, social, and emotional needs of teens.
For children with learning problems, attention deficit disorder, behavioral issues, autism, or other developmental delays, we provide developmental, evaluation, and follow up.
It's a nice facility. The people are very friendly and nice. You know, they treat them with a lot of respect and generosity.
[END OF EXCERPT]
Bullock-Brown: Once again, that was from the Guilford Child Health CD on their services. We're talking about one stop health care for kids tonight and a concept called Medical Home. With us to more clearly explain how this works are our guests: I'd like to introduce, once again, Dr. Marian Earls, who we saw and heard from on the CD. Dr. Earls is the Medical Director of Guilford Child Health Incorporated. We also have with us Dr. Laura Gerald, a Medical Consultant with Community Care of North Carolina which is administered out of the Office of Rural Health Resource Development and Demonstrations. And with us tonight is Dr. Peter Morris, Medical Director of Wake County Human Services, and President of the North Carolina Pediatric Society. Welcome to Black Issues Forum, all of you. Glad to have you. I'd like to start with just all of you giving a brief statement about why Medical Home is so important. Why don't we start with you, Dr. Earls?
Earls: I guess the key feature of Medical Home is the idea of continuity and the importance of that is really obvious for kids who might have a chronic illness like asthma or diabetes. But it's important for all kids that they're seeing somebody who knows them, who's seen them for their preventive care, who when they do have an illness or a crisis, they can be well taken care of. The provider knows very much about the family, knows about the child and their needs. It's important in terms of the parent as well because the parent then is able to be the expert on their child and be the partner with that physician in the care of that child and so we're really talking about relationships to a large degree.
Bullock-Brown: Relationship building with the doctor and the parents on behalf of the child. Dr. Gerald, what would you say?
Gerald: I would certainly agree with what Marian said, Dr. Earls has said. And I would add that we believe, or I believe, that the Medical Home is the place where you can get the best outcomes for a patient whether those outcomes are healthy patients or outcomes for patients with chronic illnesses. We just think that that's the best medical environment in which to deliver care.
Bullock-Brown: And Dr. Morris?
Morris: I think as parents become advocates for their children, they're more and more seeking a specific episode of care. They may be going to emergency rooms or urgent care centers and we would hope that they're actually going to a family physician or a pediatrician who knows them and knows them well because it's not just the visit that you're going for. It may be an ear infection or a fever that you're concerned about, but it's also perhaps some of the concerns you have that might not be articulated. Is my child speaking the way they ought to? Can they hear what I'm saying? And the urgent care center or emergency room might be more likely to simply treat the ear infection. The Medical Home would say, "How does this problem fit in with what I know about this child, how they've been growing, how they've been developing", and how this family has hopes and aspirations for what that child should be.
Bullock-Brown: Dr. Earls, let me come back to you and ask this: Medical Home; it seems like such an amorphous name for the concept that we're talking about. Why Medical Home? I mean, what's the significance of those two words in particular for this concept?
Earls: Well, home is an obvious one. We certainly want people to feel that it is sort of a home. Now when your child is sick, having been a parent with little kids, you're not thinking of it as home sometimes because you're nervous about what's going on with your child. But the idea that this is a place where I can go, where I'm familiar, where I know the service that I'm going to receive, and I know the persons that I'm going to be talking to about my child's care; so that the concept of home there is very critical. And as Dr. Morris suggested, you know, you can get technical medical care by going for episodic care but the difference is looking at the whole child over time. So we're talking about a longitudinal relationship where there's continuity, where care is comprehensive, where it's collaborated and where it's very family centered.
Bullock-Brown: Got you. Dr. Gerald, why is the concept of Medical Home particularly important for African Americans? What is it about our community that maybe requires and needs this sort of place?
Gerald: Well, for African Americans, regardless of your socio-economic status or your income, whether you're poor or whether you're affluent, regardless of that, if you are African American and you have a chronic condition like asthma or heart disease, you are still more likely to have a worse outcome than a majority person or a white person. So because of health disparity, we as African Americans particularly need Medical Homes or places where we can get comprehensive care to try to prevent, or at least decrease, health disparities.
Bullock-Brown: Got you. We've got some graphics that we want to direct our viewers to. The American Academy of Pediatrics has proposed a definition of Medical Home in a 1992 policy statement. And this new policy statement is actually a good guideline for knowing what you can and should expect and look for from your own personal doctor's office. Let's take a look at some of the main points: According to the APA, medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. Okay. Dr. Morris, that's a lot. It's a lot to try to absorb in one sitting. Can you just break that down a little bit for us?
Morris: Sure. I think what you're trying to seek as a doctor for your child is what you would seek for yourself. Is it someone who you're comfortable with? Is it someone who you can bring any concern, not just the obvious concern; my child has fever, my child is acting ill. But the concern that maybe you feel a little foolish about, "What's this bump on the arm?" "Is my child walking with a limp?" "Can I expect my child to speak at the same age as their sister spoke?" When you look at that, that's family centered, that's accessible. Is your practice available to you by day and by night? Can you make that phone call after hours and know that you'll get a skilled health professional to help guide you with the right advice for whether you should seek care now, seek care in the morning, what you can do between now and the time of that visit? I think.think of how you want to be treated and wonder if you have a relationship that allows you to be treated that way.
Bullock-Brown: So you're looking for a doctor that's going to basically make you feel comfortable enough to bring them into any situation that you might have concerns about.
Morris: Yes. And it's a challenge for the doctor as well, to be perfectly honest. We're challenged to look at how we run our offices, from the phone call that you make for that appointment, to the front desk and the way they greet you, to how we spend time with you in the examination room. Are we concentrating only on the problem at hand or are we looking at you and the other child in the room? Some of my best diagnoses, if you will, have been the sibling who's been in the room, who have been paying attention to the child you brought to me but I've been turning to the other one and saying, "Does he always talk like that? Does he always walk like that?" And I think to have that level of comfort on my part to say, "This visit isn't only about who you brought, it's about that look of concern on your face. Or the look of anxiety on your face. Or do I detect a note of depression?" How do I relate with you to make certain that I know the whole milieu of your child and child's care?
Bullock-Brown: Right. Got you. Dr. Earls, I know that you are the Medical Director for the practice that you work with and so a lot of what Dr. Morris is talking about, it seems you have been putting into-you've been implementing into your own practice. Tell us a little bit about that.
Earls: Well, in addition to the types of things that Peter is talking about; the relationship piece, there's also that coordination piece, collaborative piece. So in our practice we work very hard to make sure that families, even though there are a lot of doctors there, have one doctor who is named as their primary doctor. And that's the person who sees them most of the time, at least for their well child visits. We all know that when your child is sick on the spur of the moment you might see somebody else. But the other piece is putting systems in place so we can assist families to connect to other things in the community that they might need for their child's health, like connecting with the school nurse about the child who has asthma so at school there's good care available for their asthma as well as at home; being able to connect with Head Start for the mom who might be worried about her young child who seems not to be developing at the same pace as an older sibling. That sort of thing. That's a challenge for practices to have those connections but what we found is that our partners in the community are very interested in working with us and establishing those relationships has made things much more easy for families when they're looking for, "Well, gee, what can I do about this?" or "Where can I find a daycare that's good for my child's development?" That sort of thing.
Bullock-Brown: Okay. Dr. Gerald, I know that you work with parts of the local community who have Medicaid for insurance. Do you find that the resources that Dr. Earls is talking about are more difficult, more challenging to put into place for disadvantaged communities than they would be for other communities? And African American communities in particular?
Gerald: Absolutely, for disadvantaged populations oftentimes, you may not be accustomed to getting all of your services from one place or accessing services appropriately so it can be challenging. But one of the things that we try to do in the program that I work for, Community Care, is try to make sure that patients within the Medicaid population do have access to practices. They do have Medical Homes. They do have one stop or one place where they can go to make sure that they get all of their needs met. And what we're hoping is that in doing that for the Medicaid population, what you're actually doing is raising the bar for everyone because we try to help providers to establish Medical Home for Medicaid patients. These are still the same providers that are seeing uninsured patients and that are seeing patients with other forms of insurance so we're hoping that creating a Medical Home really raises the bar for everyone who is seeking care within our communities.
Bullock-Brown: Well, Dr. Morris, one thing that I know is kind of difficult for me to grasp in trying to understand Medical Home is, how do you apply this concept to both insured and uninsured because if you don't have insurance, most likely if you don't have the finances to go to the ER or to go to urgent care or to go to a doctor, you may not see a doctor at all. So how do you bring these people that don't have insurance into this concept?
Morris: One of the great successes of pediatric care in North Carolina has been the expansion of the Medicaid Program and the Health Choice Program so now more than ever more children are covered with insurance than before and we really encourage any family who is suffering from the problem of uninsurance to say, "Gosh, could I be eligible?" It's easy to pick up an application. You don't have to go to a Department of Social Services. You can mail it in. So first and foremost, see if you can get health insurance and see if you can get continuous health insurance.
Bullock-Brown: And that would be through Medicaid?
Morris: Well, through the Medicaid and the Health Choice Program are two programs that are specifically set for families who meet certain income guidelines and those income guidelines aren't only low income guidelines. Actually many working families are eligible for these programs. But the other side of it is if you're uninsured or if you have insurance that comes and goes and actually even the most affluent of us have seen insurance come and go as the economy changes. It's our experience and it's our recommendation that you try to establish that relationship with a practice, that you explain your circumstance and say, "Hey, this is where I am right now. My commitment is to bring my child to you for you to be able to deliver the best care possible. And my commitment is also to be responsible for my side of that which is to try to make payments towards my bill; to try to pay what I can, when I can, on a bill." And I think parents will find that most offices appreciate that honesty, appreciate that relationship, and appreciate the mutual responsibility that's there.
Bullock-Brown: So parents have to advocate for their children, just be proactive and aggressive about it even if they don't have the money, go and just see what you can arrange anyway.
Morris: The alternative is to go to even more expensive sources of care. The emergency room is far more expensive. Even urgent care centers are far more expensive than going to that primary care office and having that relationship. So when someone says, "I don't have insurance. I'd better go to the emergency room." they're actually making a very poor financial decision for their family because hospitals will try to collect that bill as well. So I think you're better off trying to establish that relationship with a provider and saying, "Hey, what can I do to work on this bill?"
Bullock-Brown: Very helpful. We've got another graphic. Medical care should be delivered or directed by well trained physicians who provide primary care and help manage essentially all aspects of pediatric care. Dr. Earls, can you break that down a little bit for us? What are we talking about?
Earls: Well, what you're talking about is really having a primary care physician who has experience and has been trained well to take care of children and in North Carolina, of course, that's family practice physicians and pediatricians. And that's usually fairly easy to identify in the community who is taking care of those kids. It's asking, the challenging thing that that statement is asking is, it's asking the pediatrician and the family practice physician to really be quite a generalist, able to work with a child who has school problems and talk to the school. Work with a child who might have behavioral difficulties and work with daycare teachers and other people who take care of the child. So it's really asking the physician to have expertise in helping the family also find other kind of community sources. One of the advantages of the program that Dr. Gerald works for is, as these community care networks develop around the state, very frequently the practices that comprise those networks, among themselves as a group, are able to really enhance their physician's abilities to do those things and to connect with community services.
Bullock-Brown: Great. Another point we want to make is that the physician should be known to the child and family and able to develop a partnership of mutual responsibility and trust with them which seems to kind of build on the last point. Dr. Gerald, how do you see that playing out in the practice that you're a part of?
Gerald: In terms of being mutually responsible that means to me that there are obligations on both parts, for the provider and the patient. For the provider, number one, you have to be available to the patient and able to provide the services that we've been talking about and you need to be able to do that in a way that is sensitive to the patient, to their culture, that respects the family, and their particular knowledge that they have with the patient that the provider may not have. On the other hand, we would also hope that patients are educated enough to take advantage of the services that a practice offers. If your practice has a nurse line or a phone number that you can call 24 hours, call it before you go to the emergency room. Ask your practice what they would want you to do about your fever or your earache. That's part of the patient's responsibility to take advantage of services. And also in this environment it's also one of the patient's responsibilities really to be an advocate for yourself or for your child whether your child is well or has a chronic illness. It's often on the parent to make sure that they're following through with appointments and that things are being done as they think would be appropriate for their child. So it really is both the provider and the patient that would have to work together to make sure that the best care is delivered, I think.
Bullock-Brown: Well, is it harder, do you find, for African American parents to actually ask the questions and demand the sort of care that their child deserves? Just to know how to do that, to know the protocol and the etiquette?
Gerald: Well, I think it's more challenging in several respects. In one instance, culturally, we may not be as accustomed to going to a doctor for advice. Maybe we're more accustomed to going to family members for advice. And so part of it may be re-working our norm or what we think is the source for medical information, if you will. By the same token, I think historically there have been injustices towards African Americans. There are health disparities, biases, and so perhaps we have come to believe that we're not going to get the best care once we go to a practice. Or maybe we've had experiences where we've been going to practices where there is no one that looks like us, whether that's behind the front desk or none of our providers look like us. So it can sometimes make you feel as a patient, or as an African American, somewhat less comfortable. So, hopefully what we would aspire to through education of patients and of providers is that we would start to eliminate some of that mistrust, if you will, or discomfort with the system so that, number one, we increase the number of African American providers who are able to give care to patients but that also we would help non-African American providers be culturally competent enough that they can deliver care.
Bullock-Brown: Dr. Morris, I want to ask this of Dr. Earls and Dr. Gerald as well, but any advice just in general for parents who are watching now and even people who don't have children; how can we all buy into the Medical Home concept?
Morris: I think most parents are bringing a single question to their doctor's office when they come and the question is, "Is this normal?" And certainly when it's a fever of 105, you kind of know the answer to that question is, "No, this isn't normal." Although, oddly enough, we could say, "Well, yes that's normal in the context of an ear infection or in the context of pneumonia and we can treat it. We can do this and it would be normal for the medicine to take this long to take effect." And you're actually building your competence and your building your advocacy skills by figuring out how to pursue that question, "Is this normal?" For ourselves, I think what we should be saying is, "Where can I be comfortable enough to ask the questions and where can I be confident enough that they'll not only answer the question at hand but say, "And here's somebody else I'd like you to see." Or "Here's another service that you should be connected to." Or "Yes, I can help with that school so that your child doesn't miss as much school and you don't miss as much work."
Bullock-Brown: And just to clarify. When you say parents should kind of think about where to go; they need to do their homework. They need to shop around and figure out what doctor or which providers, what practice is going to be the best for me and my family.
Morris: Certainly families who have insurance are often calling me and looking at their list and saying, "I need to go to so and so." And part of my question is, if that's true for your family, I'll try to help you choose the best physician for you from this list. There are large practices, small practices, practices that have more of a family sense to them, and practices that have more of a corporate sense. We can try to find something that meets your needs; closer to work, closer to home. You should be thinking about those types of questions and you should be asking for a certain type of care from that practice.
Bullock-Brown: Thank you. Dr. Earls, what would you say?
Earls: Well, I think the idea of a parent as an expert on their child is a very important one in all of this and we talk about that a lot particularly in our efforts to do good well child care with kids and look at how they're developing and learning. And I believe that that's a concept that needs to be promoted on both sides; helping parents feel like they're an expert and helping providers understand the expertise that parents bring about their child. They live with them. They know them. They may not know the medical, technical issues, but they certainly know their child. And I think if we could be comfortable with that concept and people could feel confident about that concept, that the care would be more of a partnership between the parent and the provider. And that's really what we're talking about because we're talking about a parent feeling comfortable asking difficult questions. Not being intimidated about asking a whole lot of questions and we're talking about the provider also being able to hear from the parent what their major concerns are.
Bullock-Brown: Got you. And Dr. Gerald, I'm going to give you the last word. A bigger challenge in finding, achieving Medical Home in rural communities since you also do work in Robeson County.
Gerald: It can be a challenge. Of course, we always think about access in rural communities. Do we have enough providers to provide services for the patients in our counties? And that answer may differ depending upon the community in which you work. I work in Robeson County that I think has pretty good access for patients in terms of coverage but I know that that is not necessarily the case around the state so one of our challenges is obviously to create more Medical Homes throughout the state and make sure patients have access wherever they may be located.
Bullock-Brown: Right. Well, there is so much to talk about Medical Home and I really appreciate you being here. We hope that we have provided some discussion that's been insightful and that you're inspired to do your part, to take advantage of the Medical Home concept for both your health and the health of our children. We thank you so much for joining us. Remember to watch Black Issues Forum at 9:30 p.m. every Friday evening. I'm Natalie Bullock-Brown reminding you to stay encouraged no matter what. Have a good night.
|
