The first nurse practitioner program owes much to Henry K. Silver, MD, a pediatrician, an endocrinologist, and a pioneer who was influential in the development of innovative educational programs for advanced pediatric health care providers. Dr. Silver, then a professor at the University of Colorado School of Medicine in Aurora, with Loretta Ford, EdD, a pediatric nurse and professor at the same university’s School of Nursing, developed that program in 1967 ( Pediatrics. 1967;39[5]:756-60 ). They were responding to a serious shortage of pediatric providers, especially in rural and low socioeconomic areas. Pediatric nurses learned about primary care, office-based practice that included evaluating children with hearing and speech deficits, nutritional needs, vision impairment, and other congenital and acute problems. They made home visits and participated in follow-up of children with medical, surgical, and mental health concerns.
Dr. Silver made a case for nurses and physicians to integrate their work, and together determine who is best suited to meet the therapeutic needs for a specific aspect of care. This initial endeavor became the foundation for many other advanced nurse provider programs, including neonatal, adult, women’s health, and psychiatric/mental health programs.
Now, more than 50 years later, an era when health care for children is at the forefront of policy and financial concerns, children are surviving longer with chronic and complex illness, and receive sophisticated therapies for medical and surgical problems. The definition of family is very different from that used in the 1960s, and challenges in health care provision begin with identification of basic needs such as food and shelter. In light of the risks for children today, there are many more opportunities for pediatricians and pediatric nurse practitioners (PNPs) to collaborate, especially in planning complex care strategies.
One example for collaboration is within the pediatric health care/medical home model (PHC/MHM). Practices, whether primary or subspecialty, can benefit patients and their families by providing a coordinated model of comprehensive care, especially for children who are at greatest identified risk. In addition, the PHC/MHM practice can receive insurance reimbursement benefits, and demonstrate a decrease in hospitalization rates, improved health care quality, and increased patient satisfaction ( JAMA. 2014 Dec 24-31;312[24]:2640-8 ).
The American Academy of Pediatrics defines the medical home as “a model of delivering primary care that is accessible, continuous, family centered, coordinated, compassionate, and culturally effective to every child and adolescent” ( Pediatrics. 2002. doi: 10.1542/peds.110.1.184) . The National Association of Pediatric Nurse Practitioners (NAPNAP) describes the pediatric health care/medical home as a “model of care that promotes holistic care of children and their families where each patient/family has an ongoing relationship with a health care professional” ( J Pediatr Health Care. 2015. doi: 10.1016/j.pedhc.2015.10.010 ). This is an approach to providing comprehensive pediatric care that facilitates partnerships between patients, providers, and families, which is not contained within the walls of the office or building.
By virtue of their designation and training, nurses provide care for the patient in a holistic fashion, including physical care, therapeutic treatments, education, and coordination of services. Primary care nurse practitioners are trained in health promotion and prevention. They receive advanced level education in pharmacology, pathophysiology, and physical assessment, diagnosis, and management. The combination of skills between the PNP and the pediatrician are complementary and, as history suggests, can result in improved patient care. In 1967, Dr. Silver and Ms. Ford reported: “It is becoming increasingly clear that competent professional nurses working cooperatively with physicians can make greater contributions to patient care.” The PHC/MHM is an excellent opportunity for collaboration between pediatricians and NPs.
Examples of collaboration in the PHC/MHM
Building the PHC/MHM requires an evidence base, with data obtained from EHRs and current research, but also founded on individual practice culture, type of practice, and patients served. Physician and NP collaboration in collecting, reviewing, and applying this evidence can result in the development of unique guidelines for that specific practice. Patients who are considered at risk for frequent illness and hospitalizations, or who have multisystem problems, including mental health or social issues, are primary candidates who can benefit from the medical home model. The NP, by virtue of leadership training, can assist in coordinating care teams, procedures, and office staff.
Cheryl Samuels, PNP, works at the University of Texas Health Science Center at Houston, McGovern Medical School in the UT Physicians High Risk Clinic, along with two other PNPs and two pediatricians. Their collaboration has resulted in the development of a certified health care home for children with complex illness. This practice has continued to collect data and publish research to document the effectiveness of their program. One recent study was a randomized controlled trial demonstrating cost efficiency and decreased serious illness when children with complex needs are cared for in a medical home ( JAMA. 2014 Dec 24-31;312[24]:2640-8 ). Ms. Samuels and her colleagues published, “Case for the use of a nurse practitioner in the care of children with medical complexity,” in which they described the role of the NP and benefits in utilizing these skills in the multifaceted care of children with chronic and complex illness ( Children [Basel]. 2017 Apr. doi: 10.3390/children4040024 ).
I practice at Beacon Pediatrics, a large, busy primary care practice in Rehoboth Beach, Del., which is a rural area with limited local pediatric subspecialists and resources. We have been working with a state consultant to apply changes to the practice with the intention of moving toward a PHC/MHM. The pediatricians, myself, the nurses, and office staff are involved in changing structure and practices to adapt to the needs of patients and their families. Identifying children with higher medical risk, creating systems like walk-in sick hours, offering an open office 7 days a week, as well as the ability for parents to communicate via EHR email, are some of the changes that have evolved as the practice has become more patient and family focused. I serve as the liaison between the consultant and the practice, and there are plans to document quality, patient satisfaction, and perhaps some financial savings in applying a PHC/MHM to primary care.
At the University of California, Los Angeles, Mattel Children’s Hospital, the pediatric medical home program provides primary care services and care coordination for more than 300 children, adolescents, and young adults with medical complexity. Nurse practitioner Siem Ia oversees the coordination of care for these patients, and collaborates with a team of four attending physicians, resident physicians, care coordinators, and an administrative assistant. These children have multisystem problems requiring multiple specialty services, and frequent hospitalizations. Ms. La works with her colleagues to ensure patients and families are provided with care that is aligned with the AAP and NAPNAP medical home principles. This team is now involved in a national collaborative project that aims to improve health outcomes for children with medical complexity, and enhance family partnerships to support the health of the child and promote family well being. She also has provided clinical expertise for the recently completed randomized, controlled trial aimed at reducing utilization for children with medical complexity through care coordination and health education.
These are just a few examples of the possibilities when pediatricians and NPs collaborate to influence and change models of primary patient care. The medical care of any child can be multifaceted, with increasing complexity, and require vigilance and thoughtful planning to be successful. Outcomes from these attempts documented in the literature include opportunities for certification and accreditation, insurance reimbursement at incentive levels, and, most importantly, patient and family satisfaction.
Dr. Haut is a PNP at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She also works part time for Pediatrix Medical Group, serving the pediatric intensive care unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore and as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore.
