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W h a t i s a P e d i a t r i c M e d i c a l H o m e ? B u i l d i n g a M e d i c a l H o m e
P a r t n e r s h i p F a m i l i e s a n d
P r o v i d e r s W o r k i n g T o g e t h e r

T h e m e d i c a l h o m e a p p r o a c h v a l u e s
a n d s u p p o r t s f a m i l i e s i n t h e i r r o l e a s
p r i m a r y c a r e g i v e r a n d e x p e r t o n
t h e i r c h i l d . P r i m a r y h e a l t h c a r e
p r o v i d e r s b r i n g t h e i r e x p e r i e n c e
w i t h m a n y c h i l d r e n a n d c o n d i t i o n s
a n d u s e t h e i r m e d i c a l e x p e r t i s e t o
h e l p f a m i l i e s u n d e r s t a n d a n d
i n t e g r a t e r e c o m m e n d a t i o n s f r o m a
v a r i e t y o f s o u r c e s .

M e d i c a l H o m e i s n o t a
d e s t i n a t i o n , b u t a j o u r n e y w i t h
c o l l a b o r a t i o n a m o n g f a m i l y ,
c o m m u n i t y a n d h e a l t h c a r e
p r o v i d e r s .
T h e M e d i c a l H o m e

A Medical Home is a source of high-
quality health care in partnership with a
child and his/her parents. Families, health
care providers and their office staff work
together to set priorities and plan a childs
care, to find and coordinate needed ser-
vices in the community, and to provide
supports in the home. A medical home is
an information resource and a central lo-
cation of a childs personal health records
built with:


Respect, mutual trust and collabora-
tive decision-making in health care
encounters

Identification of medical and non-
medical services needed to optimize
outcomes

Connections to supports and ser-
vices to meet child and family needs

Coordination of specialty care and
community services in a setting of
acute and preventive primary health
care

Respect for cultural and religious
beliefs and personal preferences
W h a t i s a
P e d i a t r i c
M e d i c a l
H o m e ?
W H Y B e c o m e a M e d i c a l H o m e ?

M e d i c a l h o m e n e s s r e f l e c t s
p r o v i s i o n o f h i g h - q u a l i t y h e a l t h
c a r e . A l l c h i l d r e n a n d f a m i l i e s
b e n e f i t f r o m t h e p r i n c i p l e s o f c a r e
p r a c t i c e d i n a m e d i c a l h o m e .
C o l l a b o r a t i v e r e l a t i o n s h i p s w i t h
f a m i l i e s o p t i m i z e c o m p l i a n c e a n d
p a t i e n t o u t c o m e s . P a r e n t s a n d
p a t i e n t s a r e b e t t e r a b l e t o
u n d e r s t a n d t h e i r m e d i c a l c o n d i t i o n ,
s e t g o a l s , c o m m u n i c a t e w i t h t h e i r
h e a l t h c a r e p r o v i d e r s , g e t
p r e s c r i p t i o n s f i l l e d a n d a c c e s s
r e s o u r c e s .
F a m i l y a n d H e a l t h - C a r e
P r a c t i c e B e n e f i t s


O p p o r t u n i t i e s f o r o u t c o m e s -
b a s e d c l i n i c a l i m p r o v e m e n t

I n c r e a s e d w e l l n e s s r e s u l t i n g
f r o m c o m p r e h e n s i v e c a r e

I m p r o v e d c o o r d i n a t i o n o f c a r e

D e c r e a s e d c a r e g i v e r s t r a i n

I n c r e a s e d p a t i e n t a n d f a m i l y
s a t i s f a c t i o n

I n c r e a s e d p r o f e s s i o n a l
s a t i s f a c t i o n

Q u a l i t y a n d C o s t B e n e f i t s *


D e c r e a s e d p a r e n t a l w o r k
a b s e n c e s

A v o i d e d h e a l t h c a r e v i s i t s

R e d u c e d h o s p i t a l i z a t i o n s

R e d u c e d e m e r g e n c y d e p a r t m e n t
u t i l i z a t i o n

* E s p e c i a l l y f o r t h e S p e c i a l N e e d s P o p u l a t i o n
W H O a r e C h i l d r e n
a n d Y o u t h w i t h
S p e c i a l H e a l t h C a r e
N e e d s ?

The special needs population includes
children and youth from birth to adulthood
with chronic childhood-onset medical
conditions and/or developmental disabilities
which are expected to last 12 months or
longer. These chronic medical conditions
require more frequent encounters with the
health care system and related services than
would be expected for most children of the
same age
.
Examples of such chronic conditions
include: congenital heart disease, asthma,
diabetes, childhood cancer, severe congenital
anomalies, hemoglobinopathies and cystic
fibrosis. Physical disabilities such as spina
bifida, cerebral palsy and muscular dystrophy
are included. Developmental disabilities
include conditions such as intellectual
disability, autism spectrum disorders, vision
or hearing disorders, ADHD, epilepsy and
mental health disorders.

6/08
After the VisitHelp Coordinate Care
Determine the best methods and times to communicate with
families. Consider email, telephone communication and fax.
Incorporate care reminders for families.
Offer educational resources to child and family.
Share community resource information with familiesconsider a family resource room,
bulletin board, notebook, brochures highlighting local classes and resources, such as parenting
classes, support groups and advocacy organizations.
Assist in transitioning to adult health care.
Make CYSHCN care plans available to on-call clinicians.
Communicate with sub-specialists.
Provide diagnosis-specific information and resources.
Remember an Emergency Care Plan.
w w w . c s h c n . o r g / r e s o u r c e s / e m e r g e n c y p r e p a r e d n e s s . c f m
w w w . a a p . o r g / a d v o c a c y / b l a n k f o r m . p d f
Anticipate and
Prepare
Orient families to your
practice:

Identify staff roles

Outline after hours access.
Use pre-visit contacts to determine child and family
concerns, needs and goals e.g. waiting room visit
forms or a phone call a day ahead from care
coordinator.
Fit the visit to the child and familye.g. schedule at
their best time.
Offer assistance or alternatives for waiting room
challenges, e.g. infection exposures or medical
equipment use.
Determine cultural or personal preferences. Ask about
literacy, translation needs and spiritual beliefs.
Document these in the patient record.
Add visit time as needed.
M a x i m i z e t h e
E n c o u n t e r

Provide preventive services including
immunizations, developmental surveillance
and screening.
Integrate evidence-based medicine.
Collaborate with family to determine:

Timing of exam elements

Treatment approach

Method for measuring growth.
Develop care plan indicating time frame &
responsible person(s).
Schedule non-acute visits for care
coordination for CYSHCN.
1. Engage parents as partners at the practice
level.
2. Identify children and youth with special
health care needs (CYSHCN)Build and
use a registry; use a chart coding system;
stratify by levels of complexity.
3. Use planned visit encounters.
4. Develop
care
coordination
and
communication at the practice level.
Work Collaboratively with Families and Your Community
Establish family feedbacke.g. practice surveys, parent advisory groups.
Link families to other families for information and support.
Research and catalogue community resources.
Establish and maintain relationships with key community and state resource contacts.
Advocate for improved community resources and collaboration.
Methods:
Determine levels of complexity for CYSHCN.
Establish a family advisory group.
Institute care coordination and designate a
care coordinator.
Co-manage care with specialists and deter-
mine information exchange method.
Identify and share evidence-based practices.
Implement a care planning process.
Catalogue local resources & contact persons.

Meet community partners - do Lunch &
L
earns.
Steps to Take
Information and resources can be found at
www.medicalhome.org
or email info@medicalhome.org This
brochure funded by the WA State Children with Special Health Care Needs Program and developed by the
Washington State Medical Home Leadership Network.
For more information:
www.medicalhome.org
Go to Physicians tab Quality Improvement

Top Strategies for
Becoming a Medical Home
From the Center for Medical Home Improvement