A Pilot Exploring Integration of a Home Visiting Public Health Nurse into a Pediatric Medical Home Team

Introduction/Background: Mounting evidence shows that home visiting programs can decrease health disparities; reduce hospitalizations and emergency care visits; and increase access to health care services. Furthermore, experts in pediatrics, public health and early childhood development have discussed the integration of home visiting nurses and the medical home and how the new model of care can optimize communication, and collaboration improving continuity of care for pediatric clients and their families.

Public Health Seattle and King County (PHSKC) has a robust Public Health Nurse (PHN) home visiting service as well as pediatric clinics that have achieved medical home designation. PHSKC serves a diverse population with over 100 languages spoken in the area which increases the complexity of providing comprehensive patient care. Formalizing the relationship between home visiting PHN’s and the Pediatric Medical Home team could serve to strengthen the care coordination and health resources available to the pediatric clients.

Aim/Goal/Purpose Sentence: The aim of the pilot project is to explore a new model of care that enhances the Pediatric Medical Home model by incorporating a home visiting Public Health Nurse (PHN) into the existing medical home team. The goal is to improve client access to medical care and the continuity of care  between the clinic and the home.

Methods: A Public Health Center site, Columbia Public Health Center, was identified as having a Pediatric Medical Home team as well as a home visiting PHN department, which operated separately. The leadership fellow facilitated the formation of the pilot project team consisting of an MD, office RN, MA, PHN, and nurse supervisor. The team identified a pilot group of seven clients to follow over 9 months who met the criteria of being under 6 months of age and a high risk client. The newly developed team met for regular team meetings for case conferencing and evaluation of pilot strategies and problems with communication.  Team guidelines were set regarding preferred methods of communication for care coordination activities and patient education strategies. Family interviews and a medical home staff focus group were conducted after the pilot’s completion. Chart reviews provide additional descriptive data for activities and family data. 

Results: Themes from interviews of the Medical Home team are presented exploring the benefits and barriers for the communication, timing and health care encounters of patients involved in the pilot.  Care perceptions of family members and recommendations for future team care will be analyzed and reported. Impact of the project, next steps and recommendations for continuation and/or expansion of the project will be presented.

Conclusion: This pilot project explores an enhanced model of care incorporating a home visiting Public Health Nurse (PHN) into the existing Medical Home team. This project provides data about the viability and impact of expanding the Pediatric Medical Home team to provide improved services and access to care for high risk children in the community.