PROVIDENCE – More than four years ago, on May 22, 2012, Dr. Patricia Flanagan, a pediatrician, sat behind ConvergenceRI at a presentation at the Alpert Medical School at Brown University, listening to a number of national experts talk about the best way to grow patient-centered medical homes, or PCMHs, as a way to transform the business of health care delivery.


The star-studded cast included: Dr. Douglas Eby, vice president of Medical Services for South-Central Foundation, Alaska Native Medical Center; Dr. Craig Jones, director of the Vermont Blueprint for Health, Dr. Paul Grundy, global director of IBM’s Healthcare Transformation; and Dr. Frank Basile, an internist with University Medicine, an early adopter of patient-centered medical homes in Rhode Island.

Just before the session began, Flanagan had wondered out loud to ConvergenceRI: why hadn’t pediatrics been integrated into the PCMH framework? Why had all of the investments gone to identify potential cost reductions in the chronic care of adult population, with little focus on children? Good questions.

Three years later, on May 21, 2015, Flanagan would turn around and answer her own questions with a plan of action: the launch of PCMH-Kids in Rhode Island, where she serves as co-director, which now includes nine pediatric practices serving some 30,000 Rhode Island children.

ConvergenceRI recently caught up with Flanagan at Olga’s Cup + Saucer to talk about the ongoing evolution of PCMH-Kids and the learning curve involved in developing an all-payer medical home for children and their parents.

For many of the nine participating pediatric practices, Flanagan said, it was a steep learning curve. “We are all learning,” she explained, saying that there were major differences between primary care patient-centered medical homes that take care of adults and the new model for kids.

“Practice transformation is hard,” Flanagan continued. “It’s really about taking people and systems that have done things one way for a long time and standing it on its head.”

And, unlike the counterparts under the umbrella of the Care Transformation Collaborative network that are providing primary care for adults within the patient-centered medical home model, the return on investment is much more long-term.

“Children don’t cost a lot of money [in health care costs],” Flanagan explained. “So, the idea that the outcome of PCMH-Kids is going to [result] in reduced costs for children’s health [is not the major focus]. We can, no doubt, make some inroads in reducing emergency room use costs for children.”

But for PCMH-Kids, in particular, Flanagan continued, the emphasis has to be more than about short-term dollar gain. “It has to be about a belief that we’re investing in the health of the population.”

Here is the ConvergenceRI interview with Dr. Patricia Flanagan, a pediatrician who is co-chair of PCMH-Kids.

ConvergenceRI: What is the current status of PCMH-Kids?
FLANAGAN: We launched in May of 2015. Before the launch, [there were] 18 months of very large stakeholder group meetings.

The stakeholder meetings were really important, although it was frustrating for those of us who just wanted to get started.

It was important to have a large stakeholder group that involved not just the payers and the providers, but included people from DCYF, from the schools, from mental health providers and from parent associations – a really wide range of stakeholders.

It was important to be sitting with each other and talking about what becoming patient-centered medical homes really meant and how it was different from adult [primary care] practices.

We could have simply joined the Care Transformation Collaborative, but I think we would have missed some really important distinctions of what is different [in health care] for kids and families.

It was a frustratingly long process; it took 18 months before we could put out an application for practices to join and start contracting.

In many ways, it gives us a better understanding of what we’re about and how we’re not the same as other CTC PCMH practices.

ConvergenceRI: How many practices are participating in PCMH-Kids?
FLANAGAN: We have nine practices right now.

Intentionally, the nine practices represent a wide variation in both size, the percent of Medicaid kids that they care for, and differences in medical-homeness, if you will.

Out of the nine practices, four of them were already connected with adult CTC patient-centered medical home practices, so that they had some infrastructure built in. Because we wanted to learn from each other, so that some of the newer practices could learn from practices that have been [caring for adults] within the PCMH model.

But even the practices that are CTC-experienced, if you will, with adults, are learning a lot about behavioral health integration.

We are all learning. Changing the way we practice; practice transformation is hard.

It is exciting, but it’s a steep learning curve. It’s really about taking people and systems that have done things one way for a long time and turning it on its head.

ConvergenceRI: Can you explain what that means, turning a practice on its head?
FLANAGAN: In a traditional pediatric practice, you have the pediatrician, and the people who work for her.

It is a somewhat hierarchical structure: the pediatrician is in charge, the nurse does certain things, the secretary does certain things, and overall, the pediatrician is responsible for the quality of the care of the patient.

In the new model of care, there is certainly leadership from the pediatrician, but there is a much more efficient and effective model for who does what within the practice, and for accountability.

I think it has really increased job satisfaction; it gives the nurses much more [responsibility to be] a part of the care [team], with many more things to do other than just give shots at the doctor’s orders.

It recognizes that the nurses are well-versed in educating families about asthma, in following up on an ER visit to find out what went on, how the care was for your child, and kind of follow-up is needed.

And, in the future, if the [child] has that problem again, maybe you can give us a call and we can see them for an office visit.

It’s a very different model and it takes a lot of infrastructure [to make it work].

ConvergenceRI: When you’re a pediatrician, you’re not just dealing with a child, you’re often dealing with parents. How does that factor in the design of the model of care for PCMH-Kids?
FLANAGAN: I think the relationship with parents, depending on the age of a child, evolves.

When you bring a newborn to me, my relationship is with you, the parents. I think the baby’s cute, but if the baby’s two months old, my relationship isn’t with the baby; my relationship is with you, as a parent.

As the baby grows up, the baby becomes more and more involved in a relationship with me. By the time the baby is five years old, I’m talking with the child. I want to [understand] from the kids what they think about their own health.

By the time the kid is 12, part of the visit is without mom or dad.

In adolescence, it’s the kid and me who have the relationship. Mom and dad are very important, but my primary relationship is with the adolescent.

It’s the dynamic of being a pediatrician, and it’s pretty cool. But it does mean that the practice always has to include the parent as part of the conversation.

The child’s engagement with their own health and health care obviously changes as they grow to adolescence and become adults.

I mean, mom can’t tell me what your mood is; mom can’t tell me how you’re feeling. You can tell me.

ConvergenceRI: How has the revolution in personal digital devices and apps changed the dynamics within the pediatric practice, such as the popularity of apps that track menstrual cycles?
FLANAGAN: Apps to track menstrual cycles are very popular. On a simpler level, we have been using kids’ phones to remind them to take their birth control pills every morning for years.

The notion that you can set your alarm, and it will go off every night at 7 p.m., and you can take your pill. We’ve been using devices like that for a long time.

I think that tracking sleep is another really important function.

I think we are beginning to use neat gadgets that will provide us with great opportunities. Have you read Eric Topol, [author of The Patient Will See You Now, exploring how smartphones, big data, and technology are disrupting and democratizing health care]?

I personally have not started using [such devices] in any organized way. But I do ask my teens, what gadgets they have and what apps they’re using.

ConvergenceRI: With the all-payer model of patient-centered medical homes through the Care Transformation Collaborative, I have heard rumors that there has been some pushback from payers, asking that the practices work harder to achieve reductions in medical costs. Is that something that PCMH-Kids has experienced?
FLANAGAN: Not for us. Once again, we’ve only had one cohort of nine practices that have contracts with us.

I know that there are payers who are not convinced that the patient-centered medical home was saving them money in the adult practices.

I would say that lately, there has been some data coming out that there is an anticipated lag time between transforming practices and seeing the costs decrease.

This is something for PCMH-Kids, for pediatrics, that is particularly important, and it was a big part of the conversation in laying the groundwork.

In part, because, children’s [health care] doesn’t cost a lot of money.

For PCMH-Kids, in particular, keeping the payers on board has to be more about than short-term dollar gains. It has to be about a belief that we’re investing in the health of the population.

Rhode Island tends to have a stable population. So, if payers can invest in good quality, coordinated health care for children and their families, including mental health, the [return on investment] in outcomes is really going to be what happens when these kids turn 18 and become adults.

The impact is going to be in other systems: it’s going to be in schools, in DCYF, in juvenile justice, where hopefully you can improve the health of children and families and show impacts.

It’s very different than the adult world [of primary health care], with high rates of chronic illness and expensive use of health care for patients, where you can, through better care coordination, keep patients healthier [and reduces costs].

ConvergenceRI: Can you state the value proposition for PCMH-Kids, in your own words?
FLANAGAN: By investing in PCMH-Kids, I’m hopeful that we will be able to show cost savings. But it’s not about cost savings for [the delivery of] kids health care; kids don’t cost a lot of money. It’s about better quality, better coordinated care and integrated behavioral health – that can catch social and emotional problems before they become diagnosed mental illnesses.

These are the kinds of investments that are going to pay off when children grow up and join the workforce [and raise their own families]. That’s why you invest in children.

But that can be a hard argument to make with insurers, and I understand, they have short-term goals, they have to show that they are being responsible.

I don’t think anyone is going into PCMH-Kids thinking that there are going to be short-term economic savings.

ConvergenceRI: What about factors that are outside the delivery of health care? Is there a need to figure out ways to reduce toxic stress in Rhode Island?
FLANAGAN: How about reducing poverty? We can tinker at the edges, and we can help build resilience in young children, in stressed families, and I think we should do that.

But I think all of these efforts sort of beg the question: Why is it that we have people who are working 40 hours plus a week and they are making less than $20,000 a year. What’s going on? Why is this allowable?

Poverty doesn’t equal stress. But it’s very difficult to raise a child in extreme poverty and not be stressed.

ConvergenceRI: How does affordable housing fit into the equation?
FLANAGAN: Affordable housing is huge. And so is a living wage. You can’t raise a family on $8 an hour. It doesn’t work.

The frustration is that we know what will help families with young children. If you look at the British model, when they had the political will, which was short-lived, but in 10 years, they had made huge inroads in the rate of poverty. It was done through housing policy, it was done through high quality day care and child care, it was done through creating a living wage. It worked.

You just really want to have to do it.

ConvergenceRI: Is there a need to look at how investments are spent in new technology and health IT?
FLANAGAN: I think medical technology is wonderous. I think the technologies that can save early preterm babies are tremendous.

We don’t question investing millions of dollars in that. But if we ask for help with parenting support, or for the minimum wage to be raised a little bit, these are off the table.

It may be a different pocket that the money comes out of, maybe. That’s part of the problem.

And, don’t get me started with Big Pharma, and how they can drive up prices, so that it costs $100,000 for a course of medicine, and get it. Why do we not question that?

Do you know how many families could be pulled out of poverty if they were just given a subsidy?

There is a really interesting article in Pediatrics that came out in June [“Can society buy a better infant?”] which reported on the results of a study of low-income Canadian women, who were given less than $100 months for six months of their pregnancies, and it resulted in a significant decrease in the rates of premature births and low birth weight babies.

ConvergenceRI: Will PCMH-Kids become involved with any research related to the microbiome and its relationship with things such as asthma and obesity?
FLANAGAN: I am not in touch with a lot of the microbiome work, but it’s fascinating, what we don’t know, for instance, looking at breast feeding and the microbiome.

An exclusively breast-fed baby will have a totally different microbiome in its first year of life. It’s astonishing how productive and protective breastfeeding is for a child.

So, where are our breastfeeding initiatives? They could be stronger.

ConvergenceRI: Are there particular elements of research that PCMH-Kids may consider becoming involved with, moving forward?
FLANAGAN: There is something called PCORI, which is the Patient Centered Outcomes Research Institute.

And it’s something that we’re just starting to look at, about a research agency that’s driven by the community.

The West End and South End communities in Providence, after a four-year process, have decided that they want to focus on the early social and emotional health of children as a health need. The work is being done as part of a Health Equity Zone, I believe.

To me, that’s the research entry point: can we have the neighborhood agenda drive what research we are going to be doing with PCMH-Kids practices?