Medical Home: Introduction
Review sample policies, procedures and competency guidelines that align with JCIH Guidelines.
Assure follow-up with a few key data-collection and communication tools.
See how the collaboratives used improvement tools to test steps of change within their organizations.
Closing the follow-up gap: Medical Home
Visiting the Medical Home
Two Week Visit
Julia has come to the First Street Clinic with her two-week old infant, Samuel for the first time. Samuel was born with a cleft lip and Julia is very concerned he is not getting enough milk. He has been wakeful and crying much of the night.
Samuel did not pass his hearing screening in his left ear. The birthing unit reviewed this information with Julia, along with a wealth of other information about Samuel’s condition. The birth hospital also made a follow-up appointment for a diagnostic hearing evaluation because the craniofacial anomaly put Samuel in a high-risk category for hearing loss. Because of her struggles with Samuel’s feeding, Julia forgot about the appointment.
At this two-week check up, Dr. Wu attended to Julia’s immediate feeding concerns and also connected her with Parent to Parent, so she could get support from a parent with a child with a cleft lip. However, Dr. Wu was not aware of Samuel’s failed hearing screening or missed follow-up appointment.
Eight Week Visit
Julia returned to First Street Clinic for her eight-week visit. This time she is able to see Samuel’s primary care provider, Dr. Westby. Samuel is now thriving and gaining weight. In the interim period Julia had rescheduled Samuel’s hearing evaluation after receiving a follow-up call from the audiology department. Julia informs the doctor that Samuel woke up in the middle of the hearing evaluation and therefore his hearing results were inconclusive. The audiologist indicated that there was a hearing loss, likely caused by fluid that would resolve on its own. Julia expresses concern and frustration about not knowing if the hearing loss would be correctible. Dr. Westby attends to Julia’s concerns by scheduling a visit with ENT to determine if there is fluid present. He also takes steps to arrange an ABR test and possible tube placement while Samuel is sedated for his cleft lip repair, which is coming up in three weeks.
- How is care coordinated and communicated?
- Were there missed opportunities?
- Which improvement strategies would have assisted the family in getting to follow-up?
- How does Samuel's care differ as a result of his craniofacial anomaly? Are you familiar with the other high risk categories for hearing loss?
- Does your practice know the results of each infant's hearing screening?
- Has your practice established a protocol for evaluation of children at risk of hearing loss?
- How does your practice help families coordinate follow-up appointments and procedures?