Medical Home Tools and Forms

Posted on: August 16, 2010

Illinois Medical Home Project

About Medical Home | For Providers | For Youth & Families

A medical home is an approach to providing primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.  In a medical home, the primary care team develops a trusting relationship with the family and works as a partner to assure that all of the child’s needs are met.

Through its medical home initiatives, ICAAP works with individual physicians, primary care practices, and community and state agencies to support the dissemination and implementation of the medical home model, with a focus on improving services for children with special health care needs.

Helpful Tools and Forms

Follow the links below to access resources and tools related to the management of medical home including patient assessments, pre- and post-visit planning, and visit procedures.

Special Health Care Needs Screener

National Center for Medical Home Implementation

Hirsch Complexity Index

David Hirsch MD, Center for Medical Home Improvement

Exeter Complexity Index

Center for Medical Home Improvement

Sample Medical Home Phone Script

Sample Care Coordination Tracking Form

La Rabida Children’s Hospital

Sample Care Activities Tracking Form

North Arlington Pediatrics

Sample Family Today’s Visit Questionnaire

Sample Pre-Visit Family Questionnaire

Exeter Pediatrics

Sample Pre-Visit Planning Sheet

Utah Collaborative Medical Home Project

Sample Patient Visit Sheet

North Arlington Pediatrics

Sample Visit Follow Up Sheet

Utah Collaborative Medical Home Project

Sample Post-Visit Family Questionnaire

Exeter Pediatrics

Sample Parent Invitation to Quality Improvement Team

La Rabida Children’s Hospital

Sample Fax Back Form

Sample ER Cover Sheet

Cincinnati Children’s

Early Intervention Referral Form

ICAAP

Sample Developmental Screening Log

Sample Request for Special Education Evaluation

Health Care Checklist

DSCC

Sample Family Assessment

Robert E. Nickel and Larry W. Desch

Effect of Disability on Family Interview

Care Coordinator Job Description Example 1

La Rabida Children’s Hospital

Care Coordinator Job Description Example 2

Care Coordinator Job Description Example 3

Parent Care Coordinator Job Description

Rhode Island Parent Information Network

Care Plans

Sample care plans, letters, and other tools are included in this section.

Sample Care Plan Invitation Letter 1

North Arlington Pediatrics

Sample Care Plan Invitation Letter 2

La Rabida Children’s Hospital

Sample Care Plan Letter

North Arlington Pediatrics

Sample Updated Care Plan Letter

North Arlington Pediatrics

Sample Care Coordination Billing Letter

North Arlington Pediatrics

Sample Care Plan 1

North Arlington Pediatrics

Sample Care Plan 2

North Arlington Pediatrics

Sample Care Plan 3

La Rabida Children’s Hospital

Sample Detailed Summary

Sample Medical Summary

Sample Emergency Medical Form

American College of Emergency Physicians

Sample Emergency Medical Form 2

Utah Medical Home Portal, Family Voices

Patient Materials

Follow the links below for fact sheets, brochures and letters for patients and their families that provide background information on medical home.

Medical Home Parent Fact Sheet

National Center for Medical Home Implementation

Medical Home Information For Families

Sample Medical Home Brochure 1

North Arlington Pediatrics

Sample Medical Home Welcome Letter 1

North Arlington Pediatrics

Sample Medical Home Welcome Letter 2

La Rabida Children’s Hospital

Medical Home Visit Card

ICAAP

Medical Home Visit Card Spanish

ICAAP

For more information about ICAAP’s medical home initiatives, please contact:

Kathy Sanabria, MBA, PMP
Associate Executive Director, Programs
Illinois Chapter, American Academy of Pediatrics
1400 W Hubbard, Suite 100
Chicago, IL 60642
Phone: 312/733-1026 ext 208
Fax: 312/733-1791
ksanabria@illinoisaap.com