After-hours care: What’s happened to the pediatric medical home?

A child becomes ill or injured and the pediatric office is closed. What does a parent do? Where does a parent turn for care? What matters most to parents? Do they choose where to go based on cost, convenience, or pediatric expertise?

These questions are top of mind for us in pediatric emergency medicine as we witness the evolution, or perhaps dissolution, of after-hours care for kids. The current after-hours marketplace offers more options, easier access, and inconsistent quality. I often wonder, what has happened to the inclusion of the pediatric medical home? What has happened to the value of a pediatrician?

Are pediatricians fully aware of the current landscape? Are we all doing enough to educate patients and families about where, when, and how to seek care? The referrals we see in the pediatric emergency department (ED) come less and less frequently from pediatricians and more and more from retail clinics, urgent cares, and local EDs. My perspective, from the pediatric ED, suggests that access is improving but the variation in quality of care is widening. We witness the variation in care and the challenge to the family as parents mistakenly choose convenient and low-cost care before they realize the need for expert pediatric care when their child needs it most.

These current fragmented offerings threaten the relationship of the pediatrician and his/her patients. It is also big business. Estimates suggest that nearly $30 billion is spent annually on after-hours’ pediatric care, which encompasses more than 24 million visits.¹ Visits to EDs, urgent cares, and retail clinics continue to grow exponentially. Direct-to-consumer telemedicine is the newest offering, which again disrupts the continuity of care.

Look at the current landscape

Emergency departments: Although we as pediatricians might think that all these patients go to the local children’s hospital ED, the data suggest that only 25% of pediatric ED visits are seen in academic children’s hospitals.¹ Seventy-five percent of children are seen in the close-by ED and by a variety of providers. Of course, visits to regional EDs often result in a transfer to the pediatric ED. Data would suggest that many of the children transferred even by ambulance are deemed unnecessary, and ED costs are very high.

Urgent care: The number of these offices is growing rapidly, and one just needs to drive around your town to see the inundation of these offerings. These centers are staffed with a wide variety of personnel and with a variety of pediatric experience, if any. Urgent cares are not created equal, but they do offer lower costs compared with an ED visit. Pediatric-specific urgent cares are a small percentage.

Retail clinics: You see them on virtually every corner. These centers offer a nurse practitioner and routine point-of-care testing, including an adenoviral test for pink eye. The clinics don’t have pediatricians and are found inside the retail pharmacy. These centers are convenient and are generally lower cost than urgent cares or EDs.

Telemedicine: New to the market is direct-to-consumer telemedicine. Many corporations and even some insurance companies are seeking to reduce ED visits by offering in-home video visits. The family logs onto a computer and requests a visit with a physician who is not their own doctor but one who is employed by the telemedicine service. The presence of a pediatrician is rare, and the providers have a variety of backgrounds and are generally licensed in many states.

What should pediatricians do for starters?

Encourage parents to call the pediatric office after hours. Whether you utilize a telephone nurse call center or your own service, Dr. Barton Schmitt’s standardized protocols offer parents triage advice. The nurse is able to handle 60% to 70% of after-hours calls for the families over the phone and keep the family connected to the medical home.

Investigate your area’s offerings and educate your families on best places to go in case of an urgent or emergent need. Pediatricians can’t see all patients at all times, but one should be able to help families prepare and understand where to go in time of need. Hopefully, parents can call the office and get the advice they need or be prepared prior to leaving the home.

Pediatricians should think outside the box

Identify and track your patients’ utilization data. Understand where your patients are going and ask them why and how you can innovate to provide better care and better access.

Partner with your nurse triage call center. A recent article in Contemporary Pediatrics suggested that fewer than 10% of pediatricians take calls from these after-hours centers, and, as mentioned, 30% of these calls are referred for additional evaluation before the office opens.² Taking these calls or ensuring your call center recommends quality pediatric care is an excellent way to save your families time and money and foster relationships. Of course, this call burden is not reimbursed and must be balanced with the added burden to your pediatricians.

Consider expanding after-hours or walk-in hours so to meet the ill child on demand. Families often report being unable to get an appointment with their primary care provider as a reason to visit the ED. The cost of an ED visit is incredibly high compared with an office visit. Of course, additional hours that add additional overhead costs are an added burden and a challenge for us all.

Finally, don’t ignore the presence or impact of direct-to-consumer telemedicine. Families are being encouraged to see other doctors by their employers and the same insurance companies that you contract with to provide care. Make sure you and your families are aware of the care being offered and by whom. Have you considered offering telemedicine? See the American Academy of Pediatrics (AAP) guidelines on after-hours care and telemedicine.³ Pediatricians need to innovate to stay connected to their patients and provide the pediatric care their patients need.

Kids deserve the best care when they are ill or injured. In my biased opinion, the best care comes from seeing a pediatrician and ensuring continuity with the medical home. We all need to foster the value of the pediatrician and the value of the relationship with the medical home to ensure that families seek expert pediatric care for their child.

The kids deserve it.

References:

1. Centers for Disease Control and Prevention. FastStats: Emergence department visits. Available at: https://www.cdc.gov/nchs/fastats/emergency-department.htm. Updated May 3, 2017. Accessed May 2, 2018.

2. Schmitt BD, Schuman AJ. Pediatric call centers fast-track urgent care. Contemp Pediatr. 2017;34(4):39-42.

3. Committee on Pediatric Workforce; Marcin JP, Rimsza ME, Moskowitz WB. The use of telemedicine to address access and physician workforce shortages. Pediatrics. 2015;136(1):202-209.