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.

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Implementation Insights:

  • 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.
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American Academy of Pediatrics