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Julia A. McMillan, MD, editor-in-chief of Contemporary Pediatrics, is professor of pediatrics, vice chair for pediatric education, and director of the residency training program, Johns Hopkins University School of Medicine, Baltimore.
The medical home is a familiar concept to pediatricians. In recent years its definition has been made more formal and more comprehensive, but it is nearly always linked to an environment of primary care in the outpatient setting.
After spending the month of July as attending pediatrician on a general inpatient service, I'm convinced that the medical home is an appropriate concept for the inpatient setting as well, and that inpatient facilities for pediatric patients-at least those in large academic medical centers-must begin to conceive of themselves as being responsible for creating an environment in which those same adjectives apply.
Children with complex, technology-dependent, chronic conditions increasingly occupy inpatient pediatric units in referral hospitals. They require surgical intervention, including cerebrospinal fluid shunts, gastrostomy and jejunostomy tube placement, debridement of decubitus ulcers, and insertion of central line catheters; their care involves coordination of multiple subspecialties meeting with each other and with family members.
Children who require extensive care coordination in the inpatient setting are often admitted repeatedly to one hospital. When this is the case, coordination of care among professionals who are familiar with the child and his or her family is possible. Such coordination is not likely to come from physicians, however. The rotating schedules of subspecialists, residents, fellows, and even hospitalists mean that families often have to become acquainted with an entirely new physician team with each admission.
Other professionals, including nurses, case managers, and social workers, sometimes provide continuity and a familiar face for families, but only if the child is admitted to a particular hospital and unit each time admission is required. One of the advantages of the electronic medical record is that it allows sharing of information among providers, and in some settings, even among institutions. As helpful as that can be, however, it does not replace the personal understanding of a family and a child's past medical and psychosocial history.
Coordination in the inpatient setting requires coordination with the professionals who will care for patients with complex, chronic needs when they return home. Communication with home care providers, subspecialists, pharmacists, primary care providers, and others who will resume their care of the patient after an inpatient stay involves more than sending copies of discharge summaries. Ensuring that communication occurs with each outpatient provider often is dependent on the conscientiousness of an individual resident or attending.
Extension of the medical home concept to the inpatient environment will not occur without conscious recognition of its importance by the institutions whose pediatric and surgical subspecialists attract patients with complex medical and surgical needs. Resources, including personnel who establish continuity with families and patients as well as communication with outpatient providers, will be needed. Pediatric hospitalists and nurse practitioners are possible candidates for assuming these responsibilities. The primary care medical home has provided a model; the inpatient medical home is the next logical step.