1. University of Hawai’i Integrated Pediatric Residency Program Continuity Care Program Medical Home Module Case 2

2. You are seeing a new 3 year old child in your clinic for a routine WCC. The findings on history and physical exam are normal, except you discover severely delayed expressive language. He has not been seen for a WCC since 18 months old. The parents don’t agree with you about the child’s development, and actually feel that their child is developing appropriately and is more advanced than expected for his age.

3. What are the problems in this case? New patient New patient Severe expressive language delay Severe expressive language delay Parents don’t agree with your assessment Parents don’t agree with your assessment Parents think the child is advanced for age Parents think the child is advanced for age

4. How would you communicate your diagnosis to this family? Before answering….

5. Think of a personal situation where you needed to be given sensitive information… 1. Identify and list for yourself elements of that situation that you appreciated. 2. Identify and list for yourself elements of that situation that you did not appreciate. 3. Keep these lists in mind when trying to provide compassionate care for your patients…

6. When delivering sensitive information… Set a non-intimidating environment: Set a non-intimidating environment: Do not appear rushed or preoccupied – sit down! Do not appear rushed or preoccupied – sit down! Watch your body language – use good eye contact. Watch your body language – use good eye contact. Allow parents time to absorb information and think of questions Allow parents time to absorb information and think of questions Use clear and understandable language Use clear and understandable language Involve the patient and family in the discussion Involve the patient and family in the discussion Allow for a follow-up discussion Allow for a follow-up discussion General Principles

7. What medical home principles can you apply to this case? Compassionate care Compassionate care Family Centered care Family Centered care Comprehensive care Comprehensive care Coordinated care Coordinated care Accessibility Accessibility

8. How would you use family centered care in this situation? 1. Ask open ended questions to assess for other underlying parental concerns 2. Assess why parents are not concerned about this child’s development 3. Ask if anyone else is involved in the care of this child – and if they have concerns 4. Involve all key caretakers in the discussion of this patient’s management plan to assess feasibility and follow through

9. How would you provide comprehensive care in this case? 1. Obtain thorough history and physical: -assess for underlying medical conditions -assess for underlying social concerns: -assess for underlying social concerns: child abuse, neglect, barriers to care child abuse, neglect, barriers to care -obtain family history for inherited causes -obtain family history for inherited causes -assess medications or home remedies -assess medications or home remedies -include thorough review of systems -include thorough review of systems

10. How would you provide comprehensive care in this case? 2. Provide routine anticipatory guidance 3. Educate about developmental screening and interventions for developmental speech delay 4. Update immunizations 5. Update medical records, including problems lists, chronic medications, allergies, etc

11. How would you provide coordinated care for this patient? 1. Obtain medical information from past PCP 2. Communicate concerns with appropriate family members 3. Communicate concerns with referring agencies or consultants 4. Request follow-up information to be sent to you following referrals 5. Review findings with family at follow-up visit

12. How would you provide accessible care for this family? 1. Discuss potential barriers to care: financial, cultural, transportation, etc 2. Identify yourself as this child’s new PCP 3. Inform parents how to access you easily 4. Offer plan for after hours care to ensure healthcare needs are being met

13. What would you recommend for this child’s management plan? 1. Obtain information from past PCP 2. Obtain hearing test 3. Initiate early intervention services 4. Recommend comprehensive developmental testing from Developmental-Behavioral Specialist 5. Communicate your concerns to consultant (fax chart notes or call directly)

14. Medical Home Elements: 1. Family centered 2. Accessibility 3. Coordinated 4. Continuous 5. Compassion 6. Comprehensive 7. Culturally Effective

15. When delivering sensitive information to families, which is LEAST appropriate for providing compassionate care? a. position yourself to allow as much space between you and the patient as possible b. sit down during the conversation c. use silence to allow patient and parents time to absorb information and think d. involve the patient in the discussion e. allow for a follow-up discussion Answer: a

16. You are seeing a newborn in your clinic and learn that the baby is both breast and bottle feeding. Which of the following LEAST demonstrates family centered care? a. ask parents how long they would like to breastfeed this infant b. ask parents why they are currently using both breastmilk and formula c. ask parents if they are concerned about feeding both breastmilk and formula d. ask parents to decide if exclusive breastfeeding would be the best plan for feeding this infant e. educate and recommend breastfeeding as the best choice for feeding this infant Answer: e