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Issue Brief #29

February 28, 2014

Co-Management:  Improving Care for Children


Challenges Accessing Specialty Care

Children who are referred to a specialist by their primary care doctor often encounter two challenges: long waits and disjointed coordination of care between the two providers. A rising demand for specialty pediatric care coupled with a declining supply of specialists results in long waits for appointments and decreased access to needed services. Children’s care is also compromised by inadequate communication between all of their providers.i Lack of communication and collaboration puts the burden of coordinating care onto families. It can result in duplication of services, inconvenience for families who need to visit multiple sites for care and confusion about instructions.

Co-Management: An Innovative Solution

Co-management or "shared care" enables primary care providers to treat patients for certain conditions that traditionally are referred to a subspecialist. Equipping primary care providers to treat a broader range of conditions means that more children will receive the care they need, when they need it, and in a familiar place (their primary care medical home). Medical home, a promising model that can improve quality and outcomes, ensures that children receive services from their primary care site that is accessible, coordinated, comprehensive, family-centered and culturally competent.ii Co-management facilitates the primary care site’s ability to meet medical home ideals.

In co-managed care, pediatric primary and subspecialty providers collaborate on the development of step-by-step algorithms for shared care for specific conditions. Algorithms include tools for obtaining medical history information, ordering and performing diagnostic tests, developing and implementing care plans, ensuring family engagement in care and assessing progress in treatment. The tools allow primary care providers to more independently detect and effectively treat some relatively high-volume, lower-acuity conditions traditionally managed by subspecialists.

Testing Co-Management in Connecticut

A recent report in the Child Health and Development Institute's (CHDI) IMPACT series reviewed three pilot studies of co-management in Connecticut. Connecticut Children’s Medical Center researchers completed two of the studies, and CHDI staff directed the third. Across all three studies, which included more than 10 pediatric practices, pediatric primary care providers collaborated with orthopedic, infectious disease, urology, neurology and mental health specialists to develop and test co-management algorithms for the following conditions: anxiety, chronic fatigue syndrome, concussion, depression, fibromyalgia, hematuria, migraine and voiding dysfunction.

Pilot study results showed that:

  • Pediatric primary care providers adhered to the jointly developed algorithms for between 84% (migraine) to 100% (hematuria) of patients who came to them with symptoms of one of the co- managed conditions.

  • Patients who received co-managed care for concussion compared to patients from the same practice before it adopted the co-management algorithms, were more likely to receive their follow-up services in the medical home (84% versus 66%).

  • Participating in co-management encouraged pediatric primary care providers to more frequently screen for mental health concerns at well-child visits. Ninety-nine percent of well child visits included formal screening for mental health issues, and 95% of charts reviewed contained information about family mental health issues.

  • Providers participating in these studies reported high rates of satisfaction with co-managed care. All 17 participating providers agreed that co-management allowed them to provide more care for their patients and to participate in a new model of care. 

The pilot studies also highlighted some challenges that practices experienced in co-managing care.

  • Practices reported that they could not easily use co-management algorithms with electronic heath records. This often created extra work in documentation.

  • Pediatric well-child visits include so much that it was often difficult to address mental health issues (when initial screening results showed concerns) within the allotted time. Practices developed protocols for completion of some parts of the assessments during the initial visit and put other actions on hold for follow-up visits.

Overall, the three pilot studies conducted in Connecticut supported co-management as a promising approach to: 1) improving children’s access to subspecialty services, 2) increasing collaboration between pediatric primary care and subspecialty providers, and 3) expanding the role of the pediatric medical home in meeting children’s needs. Necessary next steps for moving the co-management model forward include:

  • Engagement of parents in selection of conditions for co-managed care
  • Documentation of patients’ experiences with co-managed care
  • Development and testing of business models that support pediatric primary care and subspecialists to participate in co-management arrangements
  • Pre-professional and continuing medical education that supports the delivery of co-managed care
  • Exploration of how technology can better connect families, primary care providers and subspecialists to enhance information sharing

For more information on co-management between pediatric primary care and subspecialty providers, see CHDI’s recent report, "Working Together to Meet Children's Health Needs: Primary and Specialty Care Co-Management" and Issue Brief 21: Addressing Child & Adolescent Depression & Anxiety in Pediatric Primary Care: A Co-Management Approach (4/30/13). CHDI also offers free training for providers on collaborative health care and other topics through Educating Practices in the Community (EPIC).

i Stille CJ, Primack WA, Savageau, JA. (2003) Generalist subspecialist communication for children with chronic conditions: A regional physician survey. Pediatrics.112(6):1314-1320.

ii American Academy of Pediatrics Medical Home Initiatives for Children with Special Healthcare Needs Advisory Committee. (2002) Policy statement: The medical home. Pediatrics. 110:184–186.