The aforementioned medical home principles can be further illustrated by the following clinical examples of asthma management:
Personal physician: During urgent care hours, 7-year old, Jackson, comes in to see your on-call partner with a chief complaint of cough. Since he is listed in your registry of Children with Special Health Care Needs (CSHCN), your scheduling staff and care providers are aware that he is a known asthmatic and had a gastric duplication repaired at birth, therefore, he needs and is given a longer appointment. He has just spent the weekend in his paternal grandmother’s home; mom sent his “puffers” but they were not used during his visit. Your colleague accesses his problem list and current asthma plan from his medical record, stabilizes him and arranges for him to return to see you the next day for follow-up, sending an email to you and your care coordinator.
Physician-directed medical practice team: Having recently completed his kindergarten check-up, you know that Jackson’s parents are not together and his dad is only peripherally and episodically involved in his care. His mother, maternal grandmother and uncle are his usual care providers. You and your care coordinator have worked with a Medicaid case manager to assist in the home by providing education about medicines and compliance.
Whole-person orientation: Prior to receiving care in your medical home system, Jackson was hospitalized twice for asthma exacerbations, once with a complicating pneumonia. You discovered that he sleeps on the floor on a very old mattress and the family claims that they do have “lots of” cockroaches in the home. You and your care coordinator have arranged for dust-mite covers for his bedding and have contacted his school’s social worker to assure his medications are given at school, when necessary. You also updated his asthma plan at his recent check-up.
Care is coordinated and integrated: After Jackson’s second hospitalization, he had quantitative IGE allergy testing with you and saw the pulmonologist to consider what role GER might play in his exacerbations. Your review of his pulmonology consult in his medical record confirms your recollection that studies for reflux were negative, but his allergy testing showed marked reactivity to cockroaches and dust mites. You place a reminder on his chart to arrange asthma education for Jackson’s father when he is stable; you plan to do spirometry to assess control at that visit.
Quality and safety: Using NHLBI guidelines, you and your partner move Jackson’s medications up to the “yellow zone” in his asthma plan and arrange for him to return for his flu shot and follow-up in the two weeks. You remind his uncle of the importance of using his controller medicines daily. His uncle says “he does much better with his nebulizer when he’s sick”, but they have lost their tubing. You replace his tubing and mask and adapt his asthma plan for nebulizer use until his return visit. An electronic reminder for his flu shot is placed in his chart, along with a reminder that his father needs an asthma education session and an asthma care plan for his home.
Enhanced access: Jackson arrives with his uncle at 1 pm on Sunday to be seen during urgent care hours. A consent by proxy is on the chart which permits his uncle to seek care for him. A “same-day” appointment is available and scheduled for follow-up by you the next day. An ED visit is unnecessary.
Payment: Your partner charges an “after-hours” code (code 99051) for Sunday care and captures charges for oximetry (94760) and nebulization (94640), and nebulizer tubing (A7003). Your visit the following day is moderately complex (99214), sorting out the exacerbation and assuring that Jackson is clinically improved. Your nurse reviews inhaler use with his local family (code 94664) and makes an appointment in 2 weeks for spirometry to assess control (94060) and for this father’s asthma education visit.