- ACGME —
- Accreditation Council for Graduate Medical Education
- CSHCN —
- children with special health care needs
- HCH —
- home-centered health
After a short ride from resident clinic, we drove into 1 of the city’s low-income housing complexes. Walking up to the third floor of a dilapidated building and noticing the flimsy railing, we realized our anticipatory guidance on child proofing the home must also include outdoor areas. In fact, it was the motivation to see just how appropriate our recommendations were for families living in urban poverty that led us to join a community outreach worker on a routine home visit.
When we arrived at apartment 3A, Janelle and her daughter Mia were warmly awaiting us. We followed them into a small living room where Mia, the fearless 2-year-old, quickly went back to her favorite game of jumping off the furniture. The sight of an easily accessible open window with no screen gave us pause, and we suggested several ways to prevent Mia from accidently falling out. Janelle, a first-time mom, thanked us for the advice. She soon became more relaxed and began speaking candidly about the importance of supporting her daughter. In the less personal atmosphere of a clinic examination room, the interaction with a young mother might not reveal the parent’s strengths, but by visiting Janelle in her home environment and watching her interactions with Mia, we could appreciate just how committed she was.
Just over half a century ago, 40% of physician–patient encounters were in the home.1 It was in this era that Sir Luke Fildes’ painting, “The Doctor” (which depicts a committed physician sitting in a family’s humble kitchen, watching in anguish as a child fights infection) came to embody the ideal pediatrician as a healer serving patients in their natural environment. By the end of the 20th century, however, this once ubiquitous scene no longer carried relevance for families or physicians. A higher volume of patients accessing the medical system, the increasing role of third-party payers, and rising liability concerns all contributed to a shift toward clinic- and hospital-based care. Currently, only 0.6% of physician–patient encounters occur in the home.1
With the dwindling number of home visits, trainees have lost a unique learning opportunity. Studies reveal pediatric residents participating in a home-visiting curriculum become more empathetic regarding their patients’ communities, barriers to care, and family dynamics.2 For children with special health care needs (CSHCN), home visits can positively impact family satisfaction, resident attitudes toward CSHCN, and trainees’ ability to set patient-centered goals.3 Furthermore, the knowledge gained by stepping into patients’ homes lasts throughout residency,2 and may also help young attending physicians better connect with their patients regardless of their specialty.
Patients and families may also greatly benefit from home visitation. During visits, families receive undivided attention in their place of residence, leading to stronger connections with their primary care physician and pediatric practice.4 Programs offering regular home visitation to low-income, first-time mothers until the child’s second birthday led to higher intellectual functioning and fewer behavioral problems in the children, with sustained benefits demonstrated years after completion.5 Asthma-focused interventions in the home improved caregiver quality of life while reducing patients’ asthma symptoms and the need for urgent care services.6 Home visits are also shown to be associated with fewer hospitalizations in CSHCN.7 Most recently, the United States Congress highlighted the importance of home visits by establishing and renewing funding for the Maternal, Infant, and Early Childhood Home Visiting program.
Home visits provide invaluable resident learning and improve patient care, but are they essential for trainees? With the expansion of biomedical knowledge and technology over the last half century,1 health care systems have become excellent at diagnosing and treating diseases, but may be lacking in addressing patients’ social determinants of health. Recognizing this imbalance, the Accreditation Council for Graduate Medical Education (ACGME) recently challenged pediatric programs to formally introduce social determinants of health in graduate medical education through advocacy rotations. The hope is for residents to gain first-hand knowledge of community resources and social services, which can become powerful adjuncts to treatment plans.8 By mobilizing young physicians into the home and community, there is an opportunity to revolutionize the current model for treating and preventing illness in children. Home visitation is an ideal way to incorporate these advocacy experiences into residency curricula.
The ACGME requires Family Medicine residents to participate in at least 2 home visits. Because many elderly and nonambulatory patients may prefer home-based rather than clinic-based care, the home visiting experience appears crucial for trainees planning to care for these populations postgraduation. It is surprising that an equivalent requirement does not exist for pediatric trainees, despite the profound effects of poverty on patients’ development and the growing number of households with CSHCN (increased from 20% in 2001 to 23% in 2009-2010) who face significant challenges getting to clinic.9 Even with strong evidence that home visitation benefits trainees, patients, and families, only 35% of pediatric residencies offered formalized experiences as of 2012.10 If training programs embrace the home visit as a powerful adjuvant to existing advocacy and community-based tools, both trainees and at-risk pediatric patients stand to benefit from this more personalized approach.
Beyond its importance to resident education, home-centered health (HCH) is gaining traction as an innovative alternative to current delivery systems. From the field of pediatrics, where academic centers are exploring the benefits of managing chronic conditions at home,11 to geriatrics, where a home care delivery program is actively saving Medicare millions of dollars,12 HCH is quickly becoming an evidence-based substitute for attaining the triple aim of improving population health, reducing costs, and improving the patient experience. Yet, creating home visiting curricula specific to the pediatric resident will not be easy. First, current reimbursement structures prevent home visits from being a financially viable alternative to high-volume clinic schedules. To overcome this barrier, residency programs would have to create the space for nontraditional outpatient experiences while more research is conducted to evaluate the types of home visits that can result in cost savings. Additionally, advocacy for higher reimbursement rates for a specific subset of home visits, those with children at high risk, would be needed.
Second, the paucity of pediatric faculty skilled in HCH is a significant barrier. The intricacies of a home visit differ from a clinic visit, making it difficult to lead residents without previous experience. Interdisciplinary collaboration is an excellent alternative and could lead to comprehensive visits that address patients’ social, nutritional, behavioral, and medical needs. By combining home visit education with interdisciplinary education, trainees would benefit from the extensive experience of community health workers, social workers, early intervention therapists, nurses, and dieticians. These medical professionals regularly visit the home, are familiar with important policies, and are enthusiastic to share the type of knowledge that trainees rarely encounter in residency. With an innovative, multidisciplinary curriculum, pediatric programs can offer high-level experiential learning for trainees.
The 21st century pediatrician faces a complex medical environment. The clinical characteristics of the pediatric patient population are ever changing, and a more integrated health care system is emerging. Home visits improve health outcomes, alleviate barriers to accessing care, and positively affect CSHCN. By expanding the traditions of home visitation to include trainees, the field of pediatrics will foster a new generation of innovative, socially minded pediatricians. Thus, “The Doctor” could be repainted to encompass the model of in-home care delivery used in previous eras along with the advanced, multidisciplinary approach of the current century. If implemented successfully, home visits can help to equip pediatric trainees with the skills to better advocate for home safety and the health of children like Mia.
Thank you to Kristin Schwarz, MD, Mark Kissler, MD, Bryan Sisk, MD, and Lydia Furman, MD, for their thorough review and guidance in editing this article.
- Accepted June 16, 2016.
- Address correspondence to Igor Shumskiy, MD, Boston Medical Center, 720 Harrison Ave, Boston, MA 02118. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- ↵U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2009–2010. 2013. Available at: http://mchb.hrsa.gov/cshcn0910/more/pdf/nscshcn0910.pdf. Accessed July 19, 2016
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- ↵Affordable Care Act Payment Model Saves More than $25 Million in First Performance Year. 2015. Available at: https://www.cms.gov/newsroom/mediareleasedatabase/press-releases/2015-press-releases-items/2015-06-18.html. Accessed January 10, 2016
- Copyright © 2016 by the American Academy of Pediatrics