This group pediatric practice provides family-centered care for children with special health care needs in a low-income, rural community. Patients and families benefit from a full time case manager that assists with coordinating care and following up with specialty providers.
- Co-locate multidisciplinary services including mental and behavioral health with primary care.
- Establish a 24 hour telephone service to enhance access to care.
- Foster relationships with specialty care centers in the community to enhance care coordination.
Type of Practice: Group pediatric practice
Location: Elkin, North Carolina
Population Served: Over 3,000 children and families have been served through this practice; 85% of patients are Medicaid beneficiaries.
Pediatric Medical Home Implementation Strategies
- Expand clinic hours to accomodate evening appointments throughout the week.
- Expand access to care by staffing a full time Registered Nurse to answer family concerns via telephone; provide 24 hour access to a physician (via telephone) in case of an emergency.
- Co-locate multiple services within the clinic to enhance continuity of care, including the following:
- Behavioral and mental health services
- Occupational therapy
- Speech therapy
- Offer classes to families on topics of interest including parenting and nutrition.
- Hire a full time case manager to assist with making specialist appointments, following up on missed appointments, and answering any questions families may have about appointments with specialists.
- Provide patient education materials and evaluation forms in English and Spanish.
- Provide Reach Out and Read books in multiple languages.
- Convene weekly team meetings, invite community partners such as legal aid, public health, and nutrition programs to attend these meetings
- Maintain close relationships with specialists at tertiary care centers for real time access to patient information.
- Despite impressive results including numerous indicators of cost savings for Medicaid beneficiaries, the practice continues to struggle with fiscal sustainability. Leadership recently started a non-profit organization to help raise funds for co-located services within the practices, including further classroom space, an accessible playground and physical therapy.
- For more information, contact Adrienne Classen, MD, Pediatrician at Kids Count Pediatrics
- Visit the Kids Count Pediatrics Facebook page.
- View a video about Kids Count Pediatrics.
American Academy of Pediatrics