title: Medical Homes for Children With Special Health Care Needs: Primary Care or Subspecialty Service?
abstract: To examine primary care pediatricians' (PCPs) beliefs about whether the family-centered medical home (FCMH) should be in primary or subspecialty care for children with different degrees of complexity; and to examine practice characteristics associated with these beliefs.
  
  
  
  Data from the American Academy of Pediatrics Periodic Survey (PS 79) conducted in 2012 were analyzed. Outcomes were agreement/strong agreement that 1) primary care should be the FCMH locus for most children with special health care needs (CSHCN) and 2) subspecialty care is the best FCMH locus for children with rare or complex conditions. In multivariate models, we tested associations between outcomes and practice barriers (eg, work culture, time, cost) and facilitators (eg, having a care coordinator) to FCMH implementation.
  
  
  
  Among 572 PCPs, 65% agreed/strongly agreed primary care is the best FCMH setting for most CSHCN, and 43% agreed/strongly agreed subspecialty care is the best setting for children with complexity. Cost and time as barriers to FCMH implementation were oppositely associated with the belief that primary care was best for most CSHCN (cost: adjusted odds ratio [AOR] 2.31, 1.36-3.90; time: AOR 0.48, 0.29-0.81). Lack of skills to communicate and coordinate care was associated with the belief that specialty care was the best FCMH for children with complexity (AOR 1.99, 1.05-3.79).
  
  
  
  A substantial minority endorsed specialty care as the best FCMH locus for children with medical complexity. Several barriers were associated with believing primary care to be the best FCMH for most CSHCN. Addressing medical complexity in FCMH implementation may enhance perceived value by pediatricians.
authors.affiliation: Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, Mass; Harvard Medical School, Boston, Mass. Electronic address: jvancleave@partners.org.
authors.forename: Jeanne
authors.initials: J
authors.lastname: Van Cleave
authors.affiliation: Department of Pediatrics and Internal Medicine, University of California San Francisco School of Medicine, San Francisco, Calif.
authors.forename: Megumi J
authors.initials: MJ
authors.lastname: Okumura
authors.affiliation: Children's Health Services Research, University of Indiana, Indianapolis, Ind.
authors.forename: Nancy
authors.initials: N
authors.lastname: Swigonski
authors.affiliation: Department of Research, American Academy of Pediatrics, Elk Grove Village, Ill.
authors.forename: Karen G
authors.initials: KG
authors.lastname: O'Connor
authors.affiliation: HRSA/Maternal and Child Health Bureau, US Department of Health and Human Services, Rockville, Md.
authors.forename: Marie
authors.initials: M
authors.lastname: Mann
authors.affiliation: James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Lail
mesh_terms: D001291:Attitude of Health Personnel; D002648:Child; D019988:Children with Disabilities; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care / Q000458:organization & administration*; D000072143:Pediatricians; D058007:Physicians, Primary Care; D011320:Primary Health Care / Q000458:organization & administration*; D063128:Tertiary Health Care / Q000458:organization & administration*
keywords: children with special health care needs; medical home; primary care; subspecialty care