A home care program for children with chronic illness.

Pediatric Home Care (PHC) of Albert Einstein College of Medicine was designed as a special ambulatory care unit for children who are seriously or chronically ill and whose needs were not being met successfully through conventional programming. Services include: monitoring the patient's care: delivering direct services in the home, clinic, and hospital; teaching therapeutic programs to the family and patient; coordinating services; patient advocacy; health education; and supportive counseling. Each patient has a core team consisting of a generalist pediatrician, a PNP, and the patient's family. Visits are provided in the patient's home as needed, as well as in the traditional locations of the clinic, the inpatient units, and the PHC office. The program accepts patients with serious medical problems and who face any of a series of other difficulties, including: especially complex management problems that cannot be handled well in the customary outpatient settings; unstable family settings; or extended hospitalizations. Because it is not restricted to any single type of disease, the PHC provides a model that is applicable in a wide range of medical and community settings. Results of a program evaluation show that PHC is an effective intervention that has positive mental health outcomes and improves satisfaction with care.