Pedis report it is more than medical knowledge one needs to be comfortable

Pediatricians uniformly agree that the medical home for children with special health care needs should be in primary pediatrics, but few studies have actually looked if primary pediatricians feel comfortable providing this care.
This study surveyed Californian pediatricians about their comfort for caring for complex children using 2 cases, both which would requiring consultations- one with medical needs and the other with developmental and behavioral needs. This study found that primary care providers were much more comfortable providing the medical home, no matter the patient’s condition, compared to specialists. The pedi was more comfortable caring for the case patient if they were part of a Title V practice. Surprisingly, having a support staff (SW, case manager) did not increase provider comfort.
Finally, this study also made each case have either high or low level of social resources. Pedis were more comfortable in cases with higher amount of resources.


This article highlights that caring for children with complexity extends far beyond the office visit. Seasoned clinicians know that time is required for adequate care coordination. Also, the amount of information flowing during the visit requires more time than typical patient. And thirdly communication about the patient to various agencies does not need to be performed by the physician.

Higher functioning families, practices with resources designed to care for children with complexity either within the practice, the community or the family will increase the likelihood that the practice will accept these families.

Care coordination resources by itself does not predict acceptance. This may also be explain why the children with purely developmental issues are less accepted by primary care practices, as they can be more disruptive and require extra time for examination. Community resources for this population may not be readily available for general pediatrics. The title V certified practices have staffs with extra training so they are more able to care for these families.

This study adds several things
1.       Help for this specialized population needs to be targeted and specialized.
2.        Care coordination is not generic, it must be accompanied by knowledge of local resources.
3.       Strategies that increases in time, reimbursement and knowledgeable support will  improve access to care in a medical home for these families.

Matthew Sadof, MD
Complex Care, Baystate Children’s Hospital

As a newer practitioner to the field of complex care, I found my largest learning curve to be about the resources in my community for my patients. I agree with Dr. Sadof that medical care in addition to care coordination needs to be targeted, and often the best way to develop the skill to efficiently target care is through experience. I appreciate this article for addressing the reality that often we are all uncomfortable at times caring for complex patients (no group was 100% comfortable with any case) and that it is more than just having resources- it is about having highly trained resources.
In addition, I like how this article references that there may not be a perfect medical home but regardless “specialty trained providers would need to exercise their generalist training and generalist pediatricians acquire some specialized knowledge and skills to provide primary care services for CSHCN.”

Kristie Malik, MD
Complex Care, Children’s Hospital at Montefiore

Okumura MJ et al. Pediatricians’ Comfort Level in Caring for Children with Special Health Care Needs. Acad Pediatr. 2017 Feb 25, epub ahead of print. PMID: 28246025