This academic medical center established a medical home for children and youth with special health care needs using a strategic team driven approach. The model was so successful it was implemented in four academic practice locations.
- Create a method to identify high risk patients that require longer appointments, chronic care plans, and care coordination support.
- Enhance team-based care by allocating specific times in staff calendars for interdisciplinary meetings.
- Expand a traditional practice team to include practice-based nurse care managers, psychiatric nurse practitioners, and community health workers.
Type of Practice: Academic Institution
Location: New York City, New York
Population Served: Approximately 4,500 individuals have been served by this program, predominantly Hispanic and African American Medicaid beneficiaries.
Pediatric Medical Home Implementation Strategies
- Create a registry of children and youth with special health care needs.
- Stratify children and youth with special health care needs according to risk based on medical complexity, utilization, and/or psychosocial stressors.
- Implement high risk appointments (longer in time on clinician schedules to ensure all concerns and needs are addressed for complex patients).
- Encourage team-based care through multiple strategies, including the following:
- Integrate a practice-based Registered Nurse care manager into the health care team to assist with case management and care coordination.
- Partner with local community based organizations to recruit community health workers to serve as cultural brokers.
- Schedule weekly interdisciplinary team meetings; include social workers, nurses, office registrars, care managers, community health workers, physicians, and mental health providers in these meetings.
- Work with staff to protect aforementioned meetings in all calendars/schedules to ensure no other appointments are scheduled over team meetings.
- Utilize interdisciplinary team meetings to regularly obtain feedback from all staff members (clinical and non-clinical).
- Implement "teach-back" methodology with families/caregivers to ensure that information and action plans are truly understood by each family member and caregiver.
- Assign primary care providers to each family and child, ensure that all children and families see their assigned primary care provider with each visit.
- Create after-visit summaries with families.
- Educate faculty and housestaff on new workflows.
- Partner with national programs, such as the Medical Homes Chapter Champions Program on Allergy, Asthma, and Anaphylaxis.
- Implementation of team-based care was challenging for this academic institution due to lack of buy-in from some team members. The project was initially established in one of four academic practices but has since been implemented in all four locations. The scale-up of the work encouraged team-based care across the organization.
- The project continues to struggle with identifying funding sources to support its efforts long term. The project is implementing a large scale evaluation to assess the impact of its work and plans on using evaluation results to secure future funding.
- Information technology changes occur quickly and require frequent staff training. The team-based approach of the project provides opportunities to train and update staff on technological changes and advances.
- For more information, contact L. Adriana Matiz, MD, FAAP, Associate Professor at Columbia University Medical Center.
- For tools, resources, and information on how to implement teach back strategies with patients, visit the following resources:
- To view examples of after visit summaries for patients and families, view the "Building your Medical Home: An Introducation to Pediatric Primary Care Transformation" online resource guide.
American Academy of Pediatrics