Ambulatory and Community Health Network of Cook County

Background Information

Type of Practice: State chapter of the American Academy of Pediatrics (local non-profit organization)

Location: Chicago, IL

Population Served: 10 pediatric practices participated in the quality improvement initiative, serving approximately 2,000 families

Pediatric Medical Home Implementation Strategies

• Identify existing initiatives, projects, or demonstrations in your state upon which to build or expand.
• Identify partners and stakeholders who may be able to collaborate with your organization in implementing a pediatric medical home project. These partners may include the following:
  • State Children with Special Health Care Needs program (Title V)
  • State Medicaid
  • Family-to-Family Health Information Center
  • State chapter of the American Academy of Family Physicians
  • State chapter of the American Academy of Pediatrics
  • Early Intervention programs
• Convene a multisdisciplinary planning group of partners and stakeholders.
• Identify a variety of clinics within a health care system that will participate in a quality improvement project; look for variety in geographic location and population served (insurance status, socioeconomic status, demographics).
• Recruit multidisciplinary teams in each practice to participate in the quality improvement project. Team members may include the following:
  • Physicians
  • Nursing staff
  • Medical assistants
  • Administrative staff
  • Clinic directors
  • Parent partners
• Identify a champion among each quality improvement practice team.
• Facilitate a four day in-person learning session.
• Offer incentives for participation including the following:
  • Continuing Medical Education (CME) credit
  • Maintenance of Certification points
  • Assistance with meeting national medical home recognition or certification standards
• Assign a quality improvement facilitator to each clinic/practice team in order to provide support and technical assistance to each practice team throughout the duration of the project.
  • Support practice teams in implementing Plan-Do-Study-Act (PDSA) cycles by organizing meetings between teams and quality improvement facilitators monthly over two years.
  • Facilitate in-person meetings at each clinic with quality improvement facilitators.
• Encourage facilitation of referrals between clinicians, practices, and community resources to enhance care coordination.
• Work with adult and pediatric clinicians to develop written policies for clinicians and patients to facilitate transitioning youth to adult health care.
• Work with an independent evaluator to implement a rigorous evaluation plan. The plan may include the following components:
  • Disseminating the Medical Home Index at baseline and at the end of the project for clinics to conduct a self-assessment of their own medical home implementation.
  • Disseminating the Medical Home Family Index at baseline and at the end of the project to allow families/caregivers to rate their satisfaction levels.
  • Utilize baseline results of both surveys to identify changes and improvements for PDSA cycles.
• Track process measures and other quality improvement data.
• Utilize national resources and technical assistance centers including the following:
  • National Center for Medical Home Implementation
  • Got Transition
  • Center for Medical Home Improvement
  • Local chapters of the American Academy of Pediatrics
• Communicate accomplishments to stakeholders through e-Newsletters, emails, and the project Web site.

Challenges

• Staff turnover at both the leadership and clinic staff level was a challenge in project implementation. The project leadership recommends implementing a quality improvement training program for new staff to ensure understanding of medical home and quality improvement science.
• The project identified the following areas for continued improvement:
  • Communication strategies that clinicians and practices can utilize to explain complex medical conditions to families.
  • On-going training and professional development for staff to support culture change.
  • Inclusion of parent partners as active and engaged members of quality improvement teams.

More Information

• For more information, contact Kathy Sanabria, MBA, PMP, Associate Executive Director of the Illinois Chapter of the American Academy of Pediatrics.
• Visit the Illinois Chapter of the American Academy of Pediatrics webpage​.
• Visit the National Center for Medical Home Implementation "For Practices" Web page to download copies of the Medical Home Index and Medical Home Family Index.