August 1, 2017
For many years, children in Connecticut who needed to see medical specialists often had to wait. An increase in referrals from pediatricians had outpaced the availability of subspecialists to meet the demand. This created long waiting lists and access problems for children needing specialty care, especially in the areas of neurology, endocrinology, urology, and psychiatry.
To address this problem, Connecticut Children’s Medical Center began exploring co-management strategies. Co-management, also referred to as "shared care," is a health system innovation that helps children receive the care they need, when they need it, and in a familiar place. In co-managed care, pediatric primary care providers work collaboratively with subspecialty providers to diagnose and treat patients for relatively common and mild conditions traditionally managed by specialists. Some pediatric subspecialty practices estimate that up to 30% of the children they see have needs that could be addressed by their primary care provider. In co-managed care, the primary care provider only refers patients who need more extensive care that cannot be managed using guidelines (algorithms) in the primary care site that are jointly developed by the primary care and specialty providers.
In addition to improving access, co-management responds to concerns about rising health care costs. Diverting care from subspecialty services to primary care saves money. It also allows children to receive more of their care from providers with whom they have an established relationship. This supports the implementation of primary care medical homes, which are increasingly considered the gold standard for primary care service delivery. Co-management is also in line with payment models designed to utilize the least costly provider and discourage use of more expensive subspecialists.
From 2009-2013, the Children’s Fund of Connecticut (CFC) funded Connecticut Children’s efforts to develop and test co-management of several common pediatric conditions including: migraines, Lyme disease, concussion and obesity. CFC also funded CHDI to create co-management algorithms for pediatric anxiety and depression. An evaluation of these programs found co-management improved the efficiency and coordination of patient care.
Since that time, Connecticut Children’s developed and implemented additional co-management protocols in asthma, cardiology, and other high volume specialties. They also have seen impressive results using co-management in neurology and endocrinology, two high volume specialties with a history of long wait times for new patient visits. For example, over the past year during which co-management was in place, 163 new patient appointments were freed up for children referred to endocrinology for weight issues and 682 new patient appointments were freed up for patients referred to neurology for headaches. Follow-up with primary care providers who co-managed patients with headaches indicated that nearly 90% of those patients got better without a subspecialty consult or referral.
CHDI’s co-management work in anxiety and depression is being implemented as part of Connecticut Children’s work with The Village for Families and Children. In this project, two primary care practices will detect, assess, and manage anxiety and depression in their patients using CHDI’s co-management of anxiety and depression algorithms, in collaboration with a psychologist in each practice. The approach specifies the roles and responsibilities of each provider type, ensures shared communication about patient status and outcomes, and emphasizes patient and family-centered care. In addition, these primary care practices will be encouraged to adopt co-management plans for additional conditions and help develop new co-management plans relating to behavioral health and primary care.
Connecticut Children’s is also working to expand the use of co-management in primary care through a partnership with Community Health Center Inc. (CHCI), a medical home provider recognized by the National Committee for Quality Assurance. In this partnership, co-management protocols for commonly referred conditions in endocrinology, neurology, and pulmonary medicine will be integrated into CHCI’s Community e-Consult Network. E-consult requests will inform the topics of future co-management algorithms to expand the scope of primary care in the medical home and preserve subspecialty services for those patients who truly need them.
As Connecticut and other states across the nation struggle to address rising health care costs and disparities in access to services, especially subspecialty services, co-management is a promising strategy for statewide system level reform.
The steps to further the adoption of co-management include:
For more information on co-management between pediatric primary care and subspecialty providers, visit www.chdi.org/co-management, www.connecticutchildrens.org/co-management, or contact Lisa Honigfeld at honigfeld@uchc.edu. Related publications include Issue Brief 29: Co-Management: Improving Care for Children (2/29/14), Issue Brief 21: Addressing Child & Adolescent Depression & Anxiety in Pediatric Primary Care: A Co-Management Approach (4/30/13), and IMPACT: Working Together to Meet Children's Health Needs: Primary and Specialty Care Co-Management (January 2014).
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