Discover a collection of tools and resources for pediatric practices interested in learning more about the pediatric medical home.
Getting Started
The following resources support pediatric clinicians and practice teams in pediatric medical home implementation:
- Building Your Medical Home: An Introduction to Pediatric Primary Care Transformation
Created by the former National Center for Medical Home Implementation, this online resource guide provides direction, resources, and tools to pediatric medical home clinicians and practices seeking to advance their knowledge and understanding of the medical home concept as it relates to practice transformation. - Medical Homes @ Work e-Newsletter
This monthly publication from the National Resource Center for Patient/Family-Centered Medical Home provides the most up to date tools, resources, literature, and educational opportunities for state Maternal and Child Health Title V / Children and Youth with Special Needs Programs, family/caregivers, pedaitric clinicians, and others with medical home implementation. - American Academy of Pediatrics Policy Statement: The Medical Home
This policy statement from the American Academy of Pediatrics provides adefinition and framework for the pediatric medical home and its core components. - Fostering Partnership and Teamwork in the Pediatric Medical Home: A "How-To" Video Series
This 3-part video series provides step-by-step instructions on increasing family-centered care and team work.
Family-Centered Care
Provision of family-centered care is a key function of a pediatric medical home. At its core, the pediatric medical home acknowledges and respects that families are the primary caregivers, experts, and supports for their child.
Family-centered care honors the strengths, cultures, traditions, and expertise that family members bring to the medical home team and fosters a respectful partnership between families and clinicians.
The following are resources for child health professionals interested in implementing and enhancing family-centered care:
- Enhancing Family Engagement through Quality Improvement Fact Sheet
- Building Your Medical Home: Implementing Family-Centered Care
- Positioning the Family and Patient at the Center: A Guide to Family and Patient Partnerships in the Medical Home
- Family-Centered Care Assessment Tool for Families
- Family-Centered Care Assessment Tool for Providers
- Medical Home Family Index and Survey:
- Creating a Patient and Family Advisory Council: A Toolkit for Pediatric Practices
- Family Engagement Guide: The Role of Family Health Partners in Quality Improvement Within a Pediatric Medical Home
- Parent Partners: Creative Forces on Medical Home Improvement Teams
- Extra-Ordinary Care: Improving Your Medical Home, A Learning Guide for Families and Caregivers
- Patient-Clinician Communication: Basic Principles and Expectations
- Powerful Partnerships: A Handbook for Families and Providers Working Together to Improve Care
- The Pediatrician's Role in Family Support and Family Support Programs
- Title V Toolbox for Family Participation
- Compendium: Tools for Engaging Patients in Your Practice
- Parent Advisory Groups in Pediatric Practices: Parents' and Professionals' Perceptions
- Fostering Partnership and Teamwork in the Pediatric Medical Home: A "How-To" Video Series
- Family Engagement Self-Assessment Tool
Care Coordination
Care coordination involves the "deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services."
The following is a list of resources for child health professionals and others interested in implementing and enhancing care coordination:
- Building Your Medical Home: Coordinated Care
- Patient- and Family- Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems
- Beyond the Medical Home: Coordinating Care for Children
- Pediatric Care Coordination: Beyond Policy, Practice, and Implementation, a Webinar Series
- Pediatric Care Coordination Curriculum
- Care Coordination Measurement Tool
- Sample Care Coordinator Job Descriptions:
- Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework
- Implementing a Care Coordination Program for Children with Special Healthcare Needs: Partnering with Families and Providers
- Primary Care Referral and Feedback Form
- Assessment of Health Care Transition Activities in Care Coordination
For more information about care coordination, including the National Center for Care Coordination Technical Assistance, visit the care coordination page.
Care Planning
A care plan, or a medical summary, assists with the implementation of successful care coordination within a pediatric medical home. A comprehensive care plan includes all historical, medical, and social aspect of a child and family's needs. It also includes the following:
- Key interventions
- Roles and responsibilities of each care team member
- Contact information
In a pediatric medical home, a care plan should be created in partnership with the family and youth. The following is a list of resources that can be used when creating and implementing a shared plan of care within a pediatric medical home:
- Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs
- Building Your Medical Home: Sample Pediatric Care Plan
- Care Planning Process and Resources
Culturally Competent Care
A family’s cultural background—including beliefs, rituals, and customs—are recognized, valued, and respected within a pediatric medical home. All efforts are made to ensure that the child or youth and family understand the details of the medical encounter and the care plan.
The following resources are available to help with implementation and enhancement of culturally competent care:
- Language Access in Pediatric Primary Care
- Strategies to Enhance Access to Pediatric Medical Homes for Hispanic Communities
- Culturally Effective Care Toolkit
- Health Equity Resources for Pediatric Clinicians
- Providing Care for Immigrant, Migrant, and Border Children
- Signage for Multilingual Healthcare Settings
- Culture, Language and Health Literacy: Resources for Clinicians to Improve Cultural Competency
- Think Cultural Health: Cultural and Linguistic Competency Resources
- More than Words Toolkit Series: Improving the Quality of Translated Patient Materials
- Multicultural Health Care: A Quality Improvement Guide
- Clearview 360: Cultural Competency Organizational Self-Assessment Tool
- A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency
- National Center for Cultural Competency, Georgetown University
Team-based Care
Team-based care improves communication and health care for patients and families. The following resources are available to help with the implementation of team-based care:
- Fostering Partnership and Teamwork in the Pediatric Medical Home: A "How-To" Video Series
- Building Your Medical Home: Form a Medical Home Improvement Team
- Creating Efficiency: Team Huddles
- Team-based Care in Pediatric Medical Homes
- Core Principles and Values of Effective Team-Based Health Care
- Key Elements of Highly Effective Teams
- Primary Care Team Guide
- Cambridge Health Alliance Model of Team-based Care Implementation Guide and Toolkit
Transition to Adult Care
Health care transition is the process of moving from a child to an adult model of care with or without transfer to a new clinician. For pediatric practices, this includes the following:
- creating a transition policy for the practice
- identifying transition-aged youth
- leading routine transition readiness/self-care skill assessments
- including transition needs into a plan of care
- preparing a medical summary
- helping to identify adult providers
- preparing a transfer package
- ensuring the transfer is completed
- measuring progrerss of the transition implementation process
- eliciting feedback from youth and families
Pediatricians can use the following resources to support youth transitioning from pediatric to adult care:
- Clinical Report: Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home
- Six Core Elements of Health Care Transition 3.0: Transitioning Youth to an Adult Health Care Provider
- Implementation Guides for the Six Core
- Six Core Elements FAQs
- Pediatric to Adult Care Transitions Initiative: Customized Tools for Diseases and Conditions
- Incorporating Pediatric-to-Adult Transition into National Committee for Quality Assurance Patient-Centered Medical Home Recognition
- 2021 Coding and Reimbursement Tip Sheet for Transition from Pediatric to Adult Health Care
- Free Continuing Medical Education Podcast: Transitioning Pediatric Patients to Adult Health Care
- Free Continuing Medical Education Video Series: Health Care Transition for Adolescents and Young Adults
- Telehealth Toolkit for a Joint Visit with Pediatric and Adult Health Care Clinicians and Transferring Young Adults
For more information about transitions of care, including Got Transition, the Center for Health Care Transition Improvement, visit www.gottransition.org.
Measuring and Paying for Your Medical Home
Practices that provide care consistent with a medical home approach are well positioned to advocate and negotiate for improved and appropriate payment. The following resources focus on payment for medical home activities within a practice:
- Building Your Medical Home: Sustain Your Medical Home
- Measuring Medical Homes: Tools to Evaluate the Pediatric Patient- and Family-Centered Medical Home
- Medical Home Index:
- Coding for Care Management and Other Non-Direct Services
- Coding Fact Sheets
- The Medical Home for Children: Financing Principles
- Principles of Child Health Financing
Online Implementation Guides for Pediatric Practices and Professionals
Many organizations have created online resource guides, toolkits, and training opportunities for clinicians and practices implementing medical home. The following is a collection of these resources:
Last Updated
07/15/2024
Source
American Academy of Pediatrics