Capital Region's Family Medicine physician, Dr. Douglas Dreffer began his interest in the medical home early on in his career. Dr. Dreffer was called upon to care for a child with particularly complex special health care needs. Adam, then a four-year-old, presented to him with a Mitochondrial disorder - electron transport chain defects complex II and II, myopathy and congestive heart failure. For Dr. Dreffer, 3 weeks out of residency, a call for "help" to his nearby pediatric colleagues was his first and immediate course of action. He needed reliable information, handouts, and websites. "At first I was just trying very hard to help the family to get stuff, to assist them with their understanding, to understand myself.

As a four year old, this child's world was:

  • His family, his friends
  • His yard, his school, his town

His medical community: primary care physician, multiple specialists, the hospital, and the tertiary care center.

Adam and his family needed a medical home - people they can trust, family centered care processes, and dependable information helping them to pull everything together. This was a learning process for both the family and the team at the medical home. Adam's first illness episode required multiple phone calls from the medical home to the on-call team of 24 residents and 12 part-time providers. Later, when Adam transitioned to kindergarten his needs continued to change with him. His teachers needed to understand his needs, they required a clear sickness and emergency response plan, and needed help understanding how changes in his condition would impact his school experience. So, an emergency plan needed to be established. Care planning and care coordination also emerged as critical services to meet this child and family's needs.

Early on, Dr. Dreffer approached care planning with a focus on immediate needs such as medications, doctors, and equipment. He began to understand that the family was also focused on their hopes and dreams for Adam's future. Over time, these two perspectives meshed. Now care planning and coordination involve medical concerns, school and social implications, as well as long term life planning. Today, Adams family has a strong relationship with their medical home. They are known by a staff who are ready to help with urgent medical and broader needs. Adam has not had a hospital admission in over 3 years; most of his care can be handled locally with the support of distant specialists. The school and medical community are increasingly more comfortable with his medical condition and issues are predicted and approached proactively rather than reactively.

Dr. Doug Dreffer, with a very busy primary care practice, has seen positive observable and measurable benefits for all of the children and families whom he cares for. Many of the changes his team has made related to the medical home (ease of access, registries, care plans, etc) are now applied across the lifespan with all children, youth and adults in their practice.

By James – James occasionally writes for ABC Contracting Solutions – The best home remodeling contractors in Long Island.