Medical Home

AAP Medical Home Resources

The American Academy of Pediatrics is the originator of the medical home model, which refers to delivery of advanced primary care with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated, and family-centered manner.

AAP Advocacy and Policy

The Medical Home

The American Academy of Pediatrics proposed a definition of the medical home in a 1992 policy statement. Efforts to establish medical homes for all children have encountered many challenges, including the existence of multiple interpretations of the “medical home” concept and the lack of adequate reimbursement for services provided by physicians caring for children in a medical home. This new policy statement contains an expanded and more comprehensive interpretation of the concept and an operational definition of the medical home. This statement was re-affirmed in 2008.

AAP Preamble to the Patient-Centered Medical Home Joint Principles (March 2007)

The preamble introduces four critical pediatric medical home principles identified in the Patient-Centered Medical Home Joint Principles statement: family-centered partnership, community-based system, transitions and value.

AAP Issue Brief: Implementing the Medical Home in Medicaid, CHIP, and Multistakeholder Demonstration Programs

This issue brief from the AAP Division of State Government Affairs provides guidance to AAP chapters working with states to implement medical home projects in Medicaid and CHIP as well as multipayer demonstration programs, either through legislation or through administrative changes. It also addresses a number of the policy questions that frequently arise in creating state supports for the medical home

General Medical Home Resources

National Center for Medical Home Implementation

Medical Home Initiatives and Resources by State
The National Center for Medical Home Implementation serves as a clearinghouse of practical implementation tools and updated information on medical home activities across the country.

AAP Periodic Survey of Fellows

The Periodic Survey of Fellows gathers data on current topics in pediatrics for the purpose of informing policy, developing new initiatives, or modifying or evaluating existing projects. Several recent surveys queried AAP fellows about the medical home.

AAP Graduating Residents Survey

Since 1997, the AAP has conducted an annual survey with a random sample of third-year pediatric residents, which asks residents about their experiences with residency training and job searching, career intentions, and questions related to a certain theme. The 2014 Annual Survey included questions related to training on medical home principles and preparedness to operationalize such principles in practice.

Are Graduating Pediatric Residents Trained and Prepared to Utilize Medical Home Principles?

Pediatric Medical Home Outcomes and Evaluation

There is growing data supporting the positive benefits of the medical home model of care. This summary outlines recent data specific to the pediatric population, and is organized by 2 main constructs (1) children and youth with special health care needs (CYSHCN) vs. non-CYSHCN, and (2) the Triple Aim (improved patient experience, increased quality, and decreased costs).

Healthychildren.org

HealthyChildren.org is the only parenting Web site backed by 62,000 pediatricians committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. Here, parents and families can find information regarding the American Academy of Pediatrics many programs and activities, policies and guidelines, publications and other child health resources plus much, much more.

Practice Transformation and Implementation Resources

Bright Futures

Bright Futures is a national health care promotion and disease prevention initiative that uses a developmentally based approach to address children's health care needs in the context of family and community. Its purpose is to promote and improve infant, child, and adolescent health within the context of family and community. Bright Futures offers many different resources for health care or public health professional, a parent, a child advocate and others to use in improving and maintaining the health of all children and adolescents.

Building Your Medical Home: An Introduction to Pediatric Primary Care Transformation

The National Center for Medical Home Implementation presents a brand new resource that provides direction, resources, and tools to pediatric medical home clinicians and practices seeking to advance their knowledge and understanding of the medical home concept as it relates to practice transformation.

Clinical Practice Guidelines and Policy Implementation

See here for more information about the Partnership for Policy Implementation and the AAP’s approach to developing Clinical Practice Guidelines.

Practice Transformation Web pages
AAP members seeking guidance on transforming their practices to face the rapidly changing healthcare environment can access free resources on the newly revised Practice Transformation Web pages at www.aap.org/practicetransformation. The site includes a practice transformation implementation guide, as well as resources and guidance on coding and getting paid, re-engineering pediatric practice, managing patients, and advancing your career in the new healthcare system. For additional information, contact practicemanagement@aap.org.

The site features a wealth of resources for pediatricians and pediatric subspecialists, including:

A practice transformation implementation guide, which includes 5 modules on leading practice change, team-based care, population health, quality improvement and alternative payment models. These 5 modules contain step-by-step strategies, practical tools and training materials to advance your practice's staffing and operations for the future.
Resources on Managing Your Career, which includes extensive content for all career stages, from pediatric trainees making early career decisions, to those who are interested in opening a new private practice, to those who are making career transitions or retiring from practice.
Practice management resources, such as for Managing the Practice, Coding and Getting Paid.
Content to help members understand and respond to the changing demands of the health care system, such as the implementation of telehealth care, value-based payment, and population health.
Resources on managing patient care, which includes partnering with youth and families, addressing low health literacy and care coordination.

Quality Improvement in the Practice

See here for information about the AAP Quality Agenda along with information about opportunities to engage in quality improvement activities, Maintenance of Certification and clinical practice guidelines and policy implementation.

Solutions for Maintenance of Certification (MOC)
The American Academy of Pediatrics (AAP) provides a number of options to meet Maintenance of Certification (MOC) requirements, as defined by the American Board of Pediatrics. The AAP provides various activities approved for MOC Part 2 and Part 4 credits, and can help AAP groups develop MOC activities through the AAP MOC Portfolio Program. For more information about AAP activities to support members’ MOC needs, visit the AAP MOC Web page.

Medical Home Financing and Payment Resources

Getting Paid
Visit this section of the AAP Practice Transformation Web pages to review methodologies and tools to advocate for appropriate payment. This section includes resources on value based payment methodologies, including accountable care organizations (ACOs) and alternative payment models (APMs).

Hassle Factor Form: Concerns with Payers
The AAP developed an online Hassle Factor Form for use in reporting issues and concerns related to health plans and carriers.

Understanding the Economics of Health Care
This section of the AAP Practice Transformation Web pages describes the main components of health care economics: health care expenditure, insurance coverage for children, cost and utilization of health services by pediatric patients, and access to health care for children.

Youth and Family Engagement

FamilY Partnership Network
The FamilY Partnerships Network (FPN) is an advisory group to the American Academy of Pediatrics (AAP) Board of Directors, which has a goal of developing and implementing a strategy to expand the opportunity for parent/family/youth input and participation in AAP activities and programs.

Special Projects

Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis

The Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis serves to meet an identified need for the development of a high-impact, national initiative focused on improved quality care of pediatric patients with asthma, allergy and/or anaphylaxis issues within medical homes.

Florida Pediatric Medical Home Demonstration Project

This quality improvement project coached primary care practice teams through medical home transformation. Using resources, tools and quality improvement strategies and measures, practice teams worked to enhance access to care; provide family-centered care; provide and document planned, proactive, comprehensive care; and coordinate care across all settings.

Subspecialists and the Medical Home

Breaking Barriers to Improve Communication and Co-Management
In the AAP News article entitled “Breaking barriers to improve communication between primary, specialty care” appearing in the October 2014 issue, members of the AAP Specialists and Medical Home Leadership Team provide their perspectives on the importance of communication and co-management between primary care pediatricians and subspecialists, plus the challenges and strategies for improvement related to same.

AAP website on Subspecialty Pediatrics

This Web site is specifically designed for pediatric subspecialists and surgical specialists and provides resources to enhance subspecialty care of children, professional development, networking and interaction with peers, and work-life balance.

Pediatric Subspecialists Fact Sheets

This section of the healthychildren.org Web site provides a series of informative articles about a variety of pediatric medical subspecialties.

AAP Guidelines for Referral to Pediatric Surgical Specialists

Created by the Surgical Advisory Panel of the AAP, these referral guidelines serve as voluntary practice parameters to assist general pediatricians in determining when and where to refer their patients to pediatric surgical specialists.

Co-management Resources

Building Your Medical Home: An Introduction to Pediatric Primary Care Transformation, an online resource guide, features helpful resources that support coordination of care across settings and providers, such as a New Patient Referral/Consultation Information Form and Co-Management Letter and Agreement customizable form.
As part of the American College of Physicians High Value Care Coordination Project, a toolkit was created to facilitate more effective, high value, patient-centered care coordination between primary care and subspecialty/specialty practices.

Transition to Adult Care

Clinical Report

The Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home clinical report is jointly authored by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP) and provides practical, detailed guidance on how to plan and execute better health care transitions for all patients. The Council on Children with Disabilities (COCWD) led the development of this document. A step-by-step algorithm, on how to plan and execute better health care transitions for all patients, is included.

Center for Health Care Transition Improvement (Got Transition)
Got Transition/Center for Health Care Transition is a national partner of the AAP and National Center for Medical Home Implementation. Got Transition works with a broad range of partners to improve transition from pediatric to adult health care. Specifically, it works to:

Expand use of the Six Core Elements of Health Care Transition
Expand knowledge and competence through training of health professionals
Develop youth and family leaders
Promote policy improvements
Serve as a clearinghouse for information, tools, and resources

Transitions of Care Toolkits
Transitions of care toolkits containing tools developed to assist physicians in transitioning young adults with specific chronic diseases/conditions into adult care settings are now available. It was developed by the American College of Physicians (ACP) Council of Subspecialty Societies, with participation from the American Academy of Pediatrics (AAP), medical specialty groups and patient advocacy organizations. The toolkit is derived from the Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home clinical report and the Six Core Elements of Health Care Transition model of Got Transition. Click here for more information and to access the Transitions of Care Toolkits.

Transitions for Special Populations
Ensuring safe, efficient, patient- and family-centered transition from pediatric to adult health care is a critical part of the medical home model for all children and is particularly important for children and youth with special health care needs. For more information about transitions for special populations, visit the AAP Council on Children with Disabilities.

Financing Strategies
The Catalyst Center researches policies and programs that work to reduce uninsurance/underinsurance and improve the financing of care for youth with special health care needs (YSHCN). On its Web site, the Center outlines strategies used by states to fund transition of YSHCN from pediatric to adult health care. Click here to read more about these strategies.

Additional Resources

Click here for the AAP News article, Coding, payment options for pediatric to adult care transition services.
Click here for a one page summary of key transitions-related resources.
AAP Section on Adolescent Health
AAP Section on Internal Medicine and Pediatrics (Med-Peds)

External Resources

National Academy for State Health Policy

The National Academy for State Health Policy (NASHP) is an independent, non-profit academy of state health policy makers dedicated to helping states achieve excellence in health policy and practice.

Patient-Centered Primary Care Collaborative

The Patient Centered Primary Care Collaborative (PCPCC) is a large, multi-stakeholder organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home (PCMH). The PCPCC disseminates PCMH results and outcomes; advocates for public policy; and convenes health care experts, thought leaders and patients and families.

Medical Home Recognition and Certification Programs

General Medical Home Certification Resources
Guidelines for Patient-Centered Medical Home (PCMH) Recognition and Accreditation Programs

This list of guidelines was created to assist organizations that provide recognition and/or accreditation in the development of their programs.

Certification Programs

There are currently four main organizations that recognize, certify or otherwise accredit health care providers and organizations as medical home based upon a specified set of standards.

National Committee for Quality Assurance Recognition Programs

The National Committee for Quality Assurance offers multiple practice programs including Patient-Centered Medical Home recognition and Patient-Centered Specialty Practice recognition.

The Joint Commission Primary Care Medical Home Accreditation Program

The Joint Commission launched its PCMH certification for Joint Commission accredited ambulatory care organizations in 2011. The certification focuses on care coordination, access to care and how effectively a primary care clinician and interdisciplinary team work in partnership with the patient and family, where applicable.

URAC Patient Centered Health Care Homes Program

The URAC (formally the Utilization Review Accreditation Commission) PCMH program includes voluntary education and self-assessment to comprehensive on-site validation of the range of processes and management functions leading to URAC PCMH achievement.

Accreditation Association for Ambulatory Health Care Medical Home Accreditation Program

The Accreditation Association for Ambulatory Health Care (AAAHC) offers two options for organizations to achieve recognition as a Medical Home: Medical Home On-site Certification and Medical Home accreditation.

What's New!

Attention pediatric residency programs and educators! A series of five case-based, educational modules on key medical home principles for pediatric residency programs are now available from the American Academy of Pediatrics.

Infographics
Download your copy of new infographics on pediatric medical home and practice transformation today!

Medical Home

Medical Home

AAP Medical Home Resources

What's N​​ew!​

What's New!