Medical Homes in Cook County

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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, subspecialists, and community and state agencies to support the dissemination and implementation of the Patient Centered Medical Home model, with a focus on improving services for children with special health care needs and their families.

ICAAP has been providing quality improvement (QI) facilitation support to the Ambulatory and Community Health Network (ACHN) of the Cook County Health and Hospitals System (CCHHS) since 2011 with a goal of helping the system to implement the Building Medical Homes for the  ACHN.  This is an innovative models grant funded by the federal Maternal and Child Health Bureau.  Please read below to learn more about this exciting grant program.

Grant Information
Grantee: Illinois Chapter, American Academy of Pediatrics (ICAAP)
Address: 1400 W. Hubbard, Suite 100, Chicago, IL 60642
Principal Investigator for ICAAP: Kathy Sanabria, MBA, PMP, PCMH CCE, Associate Executive Director; Project Manager, Dru O’Rourke
Lead Pediatricians: Judy Neafsey, MD, Medical Director of Specialty Care and Director of Ambulatory Pediatrics for the Ambulatory and Community Health Network, Cook County Health and Hospitals System September 2011-March 2013 (retired); Denise Cunill, MD, ACHN Patient Centered Medical Home Pediatric Lead, April 2013 to present
Program Period: September 1, 2011 to December 31, 2014
Program Contact Info: Phone: 312-733-1026, ext 208; Fax: 312-733-1791;
Funder: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
Funding Level: $86,500 per year for three years with an additional no cost-extension period

Building Medical Homes for the Ambulatory and Community Health Network (ACHN) of Cook County: About the Program

This is a three-and-a-half-year innovative models grant project funded by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau with additional modest support from the Chicago Community Trust and the Prince Charitable Trusts.  The goals of the program are to spread the Illinois Medical Home Model™ within the ACHN and provide on-site facilitation support to five high-volume pediatric clinics to establish a medical home quality improvement process and improve care coordination and management.  The ACHN sites with which we work most intensively are Fantus Health Center, Cicero Community Health Center, Vista Community Health Center, Cottage Grove Community Health Center, and Logan Square Community Health Center.  Eight other ACHN sites that care for children were included in the final year of the project and participated in the final Medical Home Learning Session (LS) 4 held November, 4, 2014 to spread pediatric QI efforts across the ACHN.  Additional ACHN sites that participated in the LS include:  Austin Community Health Center, Englewood Community Health Center, Jorge Prieto Community Health Center, Morton East School-Based Health Center, Near South Community Health Center, Oak Forest Community Health Center, Robbins Community Health Center, and Sengstacke Community Health Center.

The Building Medical Homes for the Ambulatory and Community Health Network initiative is directed and administered by ICAAP and  helps clinic staff and practices redesign systems and services to be more  proactive and better able to  meet the needs of patients and families through  implementing the Patient Centered Medical Home model.  These strategies are also effective with adult patient populations.  Please see the project abstract for specific information about goals and objectives.

Ambulatory and Community Health Network Sites

ACHN Core High-Volume Pediatric Sites Lead Physicians City
Cicero Community Health Center Anne Jacobson, MD Cicero
Cottage Grove Community Health Center Tais Crawford, MD Ford Heights
Fantus Health Center Jay Mayefsky, MD, MPH Chicago
Logan Square Community Health Center Denise Cunill, MD Chicago
Vista Community Health Center Swati Bhobe, MD Palatine


Photos from the Building Medical Homes for the ACHN Learning Session 4 held November 4, 2014

These photos were  taken at the final ACHN Medical Home Learning Session held November 4, 2014, 8 am to 4:15 pm at the Illinois Medical District Commission Building.  55 participants from the ACHN attended.

Jay Mayefksy, MD, MPH, lead pediatrician for Fantus Health Center, was provided with a certificate of appreciation for his support on the grant project and overseeing the expedited Institutional Review Board process.  Denise Cunill, MD, pediatric PCMH ACHN lead, was recognized for guiding grant activities upon the retirement of Judy Neafsey, MD, lead pediatrician 2011 – March 2013.  Parent partner, Linda Jackson, with Fantus, was also thanked for her ongoing attendance at monthly QI team meetings and for serving as the lead parent partner for the grant and attending all Learning Sessions.

Learning Session 4 Materials – November 4, 2014

Below are the LS4 program materials.  This web page has been created to provide the ACHN pediatric sites with easy access to PCMH materials specific to this grant project.  We also are open to sharing our work with others.

Learning Session 4 Agenda

Project Synopsis - Kathy Sanabria

Introduction Slides – Kathy Sanabria

Medical Home Index - Center for Medical Home Improvement (clinic staff self-assessment survey)

Medical Home Family Index - Center for Medical Home Improvement (modifed family experience survey for ACHN)

Applying QI Principles to PCMH Transformation Slides – Irv Pikelny

Medical Home Network Connect Slides – Jon Ashworth

Overview of CCHHS Policies Slides – Mercy Kuriakose

Cicero Health Center Storyboard - Cicero QI Team

Cottage Grove Health Center Storyboard - Cottage Grove QI Team

Fantus Health Center Storyboard - Fantus QI Team

Logan Square Health Center Storyboard - Logan Square QI Team

Vista Health Center Storyboard - Vista QI Team

Closing Slides - Summary, Recommendations and Next Steps – Kathy Sanabria

Learning Session 3 Materials -April 10, 2013

Learning Session 3 Agenda

Introduction Slides - Kathy Sanabria

MHNConnect Implementation in the ACHN Slides - Megan Moore

CCHHS MHNConnect Policy

CCHHS Transition of Care Policy

Learning Session 2 Materials – October 10, 2012

Learning Session 2 Agenda

How to Improve Practice Accessibility: Building Community-Based Medical Homes for Children Program - Dr. Thomas McInerny

Working Together to Improve Care Coordination for Children Birth to Three with Developmental Concerns - Juanona Brewster

Developmental Screening QI Project Materials

Developmental Screening and Referral to Early Intervention-Quality Improvement Activity - Kathy Sanabria

Developmental Screening QI Activity Learning Objectives

Developmental Screening QI Activity Executive Summary

EDOPC Overview

Standardized Illinois Early Intervention Referral Form

Illinois Early Intervention Program Referral Fax Back Form

Developmental Screening Referral Log Example

AAP Developmental Screening Guidelines

Implementing Developmental Screening and Referrals: Lessons Learned from the National Project

Next Steps for the ACHN Sites

Learning Session 1 Materials – April 25, 2012

Learning Session 1 Agenda

Introduction Slides

Advances in Medical Home Transformation - Sue Butts Dion

Maine Patient-Centered Medical  Home Pilot Halfway Report

Utilizing a Registry for Health Care Management: A Team Perspective  - Linda Follenweider

La Rabida’s Premier Kids Medical Home QI Program - Edith Chernoff and Pam Northrop

Fantus’ Ambulatory Pediatrics Medical Home - Jodie Bargeron, Marie DiGiacomo, Linda Jackson

Thinking About Care Coordination in New Ways - Laurie Vlcek

ACHN Developmental Screening QI Activity - Dr. Judy Neafsey and Kathy Sanabria

Developmental Screening and Referral to Early Intervention Webinar Materials- January 7, 2013

On January 7, ICAAP hosted a webinar to provide an overview of the ACHN developmental screening QI activity for ACHN providers and clinic staff participating in the developmental screening QI activity from Cicero, Cottage Grove, Fantus, Logan Square, Vista, and other interested ACHN sites.  The webinar recording is located here.

Webinar Slides

Developmental Screening Data Collection Instructions

Chart Review

Developmental Screening Referral Log Example

Medical Home Training and Resources

Resources for Providers

Resources for Youth and Families

Assessing and Increasing Readiness for Patient Centered Medical Home Implementation – Robert Wood Johnson Foundation

Medical Home Newsletters

Illinois Medical Home Newsletter, 6th Edition, November 2012

Illinois Medical Home Newsletter, 5th Edition, June 2011

Illinois Medical Home Newsletter, 4th Edition, June 2010

Illinois Medical Home  Newsletter, 3rd Edition, March 2009