Medical Home Resources for Practices

Getting Started

The following resources support pediatric clinicians and practice teams in pediatric 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:

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:

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

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:

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:

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:

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:

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.