Medical Home Resources for Providers

Posted on: July 23, 2013

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.

 

 

Medical Home Policy Statements and Background Information

Title Author/Organization Year
The Value of the Medical Home for Children Without Special Health Care Needs Webb E. Long, Howard Bauchner, Robert D. Sege, Howard J. Cabral, and Arvin Garg 2012
Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results Patient-Centered Primary Care Collaborative 2012
The Family-Centered Medical Home in Pediatrics Richard Antonelli, MD, MS, FAAP and Renee M. Turchi, MD, MPH, FAAP 2009
Ten Steps to Medical Home Anton J. Kuzel, MD, MHPE 2009
Joint Principles of the Patient-Centered Medical Home AAFP, AAP, ACP, AOA 2007
Building a Medical Home Brick by Brick Timothy A. Geleske, MD, FAAP 2006
Care Coordination in the Medical Home: Integrating Health and Related Systems of Care for Children with Special Health Care Needs AAP Policy Statement 2005
Pediatricians and Families: Working Together to Build Medical Homes Kathy Sanabria, MBA, PMP 2004
The Medical Home AAP Policy Statement 2002
Patient-Centered Medical Home Checklist AAFP

Evidence for Medical Home

Title Author/Organization Year
The Medical Home: Health Care Access and Impact for Children and Youth in the United States Bonnie B. Strickland, PhD; Jessica R. Jones, MPH; Reem M. Ghandour, DrPH, MPA; Michael D. Kogan, PhD; and Paul W. Newacheck, DrPH 2011
Improvement in the Family-Centered Medical Home Enhances Outcomes for Children and Youth with Special Health Care Needs Jeanne W. McAllister, BSN, MS, MHA; Kathleen Sherrieb, MS, DrPH; and W. Carl Cooley, MD 2009
Medical Home for Children and Youth with Special Health Care Needs: A Review of the Evidence Mass General Hospital for Child and Adolescent Health Policy 2009
The Effect of Facilitation in Fostering Practice: Benefits of Care Coordination for Children with Complex Disease The Robert Graham Center 2009
Improved Outcomes Associated with Medical Home Implementation in Pediatric Primary Care Pediatrics 2009
Proof in Practice: A Compilation of Patient-Centered Medical Home Pilot and Demonstration Projects Patient-Centered Primary Care Collaborative 2009
Benefits of Care Coordination for Children with Complex Disease: A Pilot Medical Home Project in a Resident Teaching Clinic Thomas S. Klitzner, MD, PhD; Leslie A. Rabbitt, MPH; and Ruey-Kant R. Chang, MD, MPH 2009
Building a Medical Home Brick by Brick Timothy A. Geleske, MD, FAAP 2006
What is the Evidence to Support Care Coordination? Champions for Inclusive Communities
The Patient-Centered Medical Home Citations Collection Agency for Healthcare Research and Quality
Coordinating the Medical Home with Hospitalist Care Hospital Pediatrics
Achieving Better Quality of Care for Low-Income Populations: The Roles of Health Insurance and the Medical Home in Reducing Health Inequities The Commonwealth Fund
Advancing Primary Care: Opportunities to Support Care Delivery Redeisgn in Practices Serving Medicaid and Racially and Ethnically Diverse Populations Robert Wood Johnson Foundation

Coordinated Care

Title Author/Organization Year
Care Coordination: Reducing Care Fragmentation in Primary Care Safety Net Medical Home Initiative 2011
Early Intervention and the Primary Care Medical Home Juanona Brewster and Dr. Leslie Cordes 2010
On the Threshold to the Adult Medical Home: Care Coordination in Transition Patience H. White, MD, MA and Patti Hackett, MEd 2009
Achieving Effective Care Coordination in the Medical Home Jeanne W. McAllister, BSN, MS, MHA; Elizabeth Presler, PhD, ARNP; Renee Turchi, MD, MPH, FAAP; and Richard C. Antonelli, MD, MS, FAAP 2009
Making Care Coordination a Critical Component of the Pediatric Health System Richard C. Antonelli, MD, MS; Jeanne W. McAllister, MS, MHA; and Jill Popp, MA 2009
Care Coordination for Children and Youth with Special Health Care Needs Richard C. Antonelli, MD, MS; Christopher J. Stille, MD, MPH; and Donna M. Antonelli, BS 2008
The Patient-Centered Medical Home Citations Collection Agency for Healthcare Research and Quality

Quality Improvement and Assessment

Title Author/Organization Year
The Medical Home Index: Pediatrics Center for Medical Home Improvement 2006
The Medical Home Family Index and Survey Center for Medical Home Improvement 2006
How to Improve Institute for Healthcare Improvement
IHI OnDemand Presentations Institute for Healthcare Improvement
PDSA Worksheet for Testing Change Institute for Healthcare Improvement
Measuring Medical Homes: Tools to Evaluate the Pediatric Patient and Family-Centered Medical Home Rebecca A. Malouin, PhD, MPH and Sarah L. Merten, MPH
CAPHS SUrvey with Patient-Centered Medical Home Items Consumer Assessment of Healthcare Providers and Systems
Program Satisfaction Survey La Rabida Children’s Hospital

Comprehensive Care

Title Author/Organization Year
Recommendations for Preventive Pediatric Health Care Bright Futures/AAP 2008
Bright Futures Pocket Guide Bright Futures/AAP 2008

Family-Centered Care

Title Author/Organization Year
Positioning the Patient and Family at the Center: A Guide to Family and Patient Partnership in the Medical Home AAP/National Center for Medical Home Implementation 2013
Tips for Group Leaders and Facilitators on Involving Patients and Families on Committees and Task Forces Institute for Family-Centered Care 2009
Family-Centered, Culturally, and Linguistically Competent Care: Essential Components of the Medical Home Tawara D. Goode, MA; Sonja Harris Haywood, MD, MS; Nora Wells; and Kyu Rhee, MD, MPP, FAAP, FACP 2009
Principles for Patient- and Family-Centered Care National Partnership for Women and Families

Continuous Care

Title Author/Organization Year
Child and Family Connections Listing of Illinois Illinois Department of Human Services – Bureau of Early Intervention 2013
CFC Early Intervention Eligibility Determination Illinois Department of Human Services – Bureau of Early Intervention 2009
Educational Rights and Responsibilities: Understanding Special Education in Illinois Illinois State Board of Education 2009
Transition to Adult Health Care for Adolescents and Young Adults with Chronic Conditions Society for Adolescent Medicine 2003
A Consensus Statement on Health Care Transitions for Young Adults with Special Health Care Needs AAP, AAFP, ACP, ASIM 2002

Culturally Competent Care

Title Author/Organization Year
A Guide for Advancing Family-Centered and Culturally and Linguistically Competent Care National Center for Cultural Competence 2007
Cultural Competence Assessment – Primary Care Bright Futures
Promoting Cultural and Linguistic Competency Self-Assessment Checklist Tawara D. Goode
Culturally Effective Care Toolkit AAP

Enhanced Access to Care

Title Author/Organization Year
Enhanced Access to Care: Providing the Care Patients Need, When They Need It Safety Net Medical Home Initiative 2010
The Americans with Disabilities Act Comes of Age: Implications for Providers Andres J. Gallegos 2010
Access to Medical Care for Individuals with Mobility Disabilities US Department of Justice 2010
Recommendations to Improving Access to Pediatric Subspecialty Care Through the Medical Home Department of Health and Human Services Health Services and Resources Administration 2008

Compassionate Care

Title Author/Organization Year
Delivering Difficult News Frances P. Glascoe, PhD 2004

Coding and Reimbursement

Title Author/Organization Year
Medical Home Payment: It’s Not Just About Coding Anymore Florida Pediatric Medical Home Demonstration Project 2011
Paying for the Medical Home: Payment Models to Support Patient-Centered Medical Home Transformation Safety Net Medical Home Initiative 2010
Building Your Medical Home and Getting Paid Appropriately National Center for Medical Home Implementation
Index of CPT Codes for Medical Home AAP
DSCC Reimbursement Guidelines: Medical Home Services DSCC
Top Ten Underutilized CPT Codes in Pediatrics AAP
Care Coordination Visits Defined PHA
AAP Coding Webinars AAP

Medical Home Tools and Forms

Title Author/Organization

Helpful Tools and Forms

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 Plan Invitation Letter 1 North Arlington Pediatrics
Sample Care Plan Invitation Letter 2 La Rabida Children’s Hospital
Sample Care Plan Letter 2 North Arlington Pediatrics
Sample Updated Care Plan Letter 2 North Arlington Pediatrics
Sample Care Coordination Billing Letter 2 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 1 American College of Emergency Physicians
Sample Emergency Medical Form 2 Utah Medical Home Portal, Family Voices

Patient Materials

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