Texas Children's Health Plan is a Medicaid managed care organization that collaborated with the Baylor College of Medicine to open the Centers for Children and Women, clinics that serve as a patient- and family-centered medical home. The project's family-centered, multi-disciplinary approach to care has resulted in a reduction in Emergency Department visits, significant cost savings, and high family satisfaction ratings.
- Implement quality improvement methodology to facilitate implementation of the medical home model of care.
- Co-locate behavioral health, dental health, and primary care services.
- Train all staff in motivational interviewing to encourage a family-centered approach to care.
Type of Practice: Capitated Clinic in a Health Plan
Location: Houston, TX
Population Served: Since inception in 2013, the clinic has served over 14,000 Medicaid beneficiaries.
Pediatric Medical Home Implementation Strategies
- Utilize quality improvement methodolgy to implement tests of change in clinic.
- Engage families in quality improvement activities to ensure the family perspective is integrated into changes tested throughout the clinic.
- Distribute family satisfaction surveys monthly; analyze survey results and test changes in practice based on feedback obtained from families.
- Expand clinic hours to enhance access to care.
- Co-locate behavioral/mental health and dental services with primary care.
- Convene a multidisciplinary health care team to provide comprehensive care to patients and families. The team may include the following members:
- Nursing staff
- Health educators
- Social workers
- Patients and families
- Continuously promote implementation of team-based care through the following strategies:
- Facilitate daily team huddles
- Organize debriefs throughout the day to discuss specific issues and challenges
- Train all staff in TeamSTEPPS
- Integrate a care coordinator (Registered Nurse) into the clinical practice to conduct the following activities:
- Lead daily huddles
- Maintain population health registries
- Coordinate between primary care and behavioral health services for patients and families
- Conduct outreach to families between appointments
- Collaborate with pharmacy staff to enhance medication adherence
- Facilitate annual cultural competency training for all staff.
- Develop care plans in collaboration with pediatricians, subspecialists, and families.
- Train all staff in motivational interviewing strategies to ensure engagement of families in the creation of care plans and other clinic activities.
- Implement an evaluation strategy to determine the effectiveness of specific interventions/changes. Evaluation components of the project may include the following:
- Tracking Body Mass Index for patients who participate in motivational interviewing with clinicians.
- Utilize the Healthcare Effectiveness Data and Information Set (HEDIS) metrics on Attention-Deficit/Hyperactivity Disorder (ADHD) medication initiation to track effectiveness of behavioral health integration.
- Opening a clinic that functions as a medical home involved significant training and culture change among staff, resulting in high rates of staff turnover.
- To overcome this challenge the project facilitated multiple staff trainings on components of the medical home model such as team-based care, cultural competence, and motivational interviewing.
- For more information, contact Heidi Schwarzwald, MD, MPH, Director of Pediatrics at the Centers for Children and Women.
- For more information on the TeamSTEPPS training program, visit the Agency for Healthcare Research and Quality.
- For more information on motivational interviewing, visit the Motivational Interviewing Network of Trainers.
American Academy of Pediatrics