The academic children's hospital primary care clinic: Responding to the challenges of a changing health care environment

Academic medical centers have encountered increasing fiscal challenges as the paradigm in health care has shifted from traditional fee-for-service reimbursement to systems of managed care. Most academic centers have maintained primary care clinics, which have served as "educational laboratories" for students and trainees, Largely providing care to underserved patients, academic primary care clinics have been heavily dependent on Medicaid reimbursement for support, Given the realities of a rapidly changing health care environment, academic primary care clinics have been challenged to respond with innovation and creativity in order to remain viable. The pediatric primary care clinic at Rainbow Babies & Children's Hospital of University Hospitals of Cleveland initiated a reorganization program with the goal of ensuring that patients receive quality, cost efficient care and that students and pediatric residents receive first-rate ambulatory education in a fiscally responsible setting, Fundamental was the setting of priorities for patient care and service while promoting an environment conducive to medical education. Educational programs were segregated into a well-defined educational "module," and various initiatives were advanced emphasizing patient access, consistency of care, efficient use of space and personnel resources, limitation of inappropriate use of costly after-hours resources, and identification and coordination of care for patients with chronic illness and/or at high risk for medical complications. Three years after the instituting of fundamental organizational change, objective measures of cost efficiency and selected quality measures compare quite favorably with a broad range of primary care providers throughout the region. If academic medical centers are to remain leaders in ambulatory pediatric education, energetic, proactive, and thoughtful responses to the rapidly changing global health care environment will be necessary.