The term "medical home" is becoming more and more commonly used, but frequently has different connotations to people as they see it used in various venues. For some, it refers to a special program for children with special health care needs. For others, it refers only to having a primary care doctor. Some state organizations promote specific components of the medical home model by focusing only on care coordination, written care plans, or care notebooks. In fact, the medical home model applies to all children.

The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a central location for archiving the medical records of a child. In its 2002 policy statement, the AAP expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally sensitive care. A medical home is a community-based primary care setting that integrates quality and evidence-based standards in providing and coordinating family-centered health promotion in wellness, acute and chronic condition management.

A medical home is a way of providing care in a health care practice in your community that works with families to meet all of their child’s needs. This is very important when a child has a chronic health condition or disability. Children with special health care needs, as defined by the US Maternal and Child Health Bureau, are children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. Statistics show that this definition includes between 16-18% of all children.

In February 2007, the AAP, the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA) and the American College of Physicians (ACP) used this 40-year old concept to develop a set of joint principles that describe a new level of primary care which they call the Patient-Centered Medical Home. These principles address the medical home partnership through which access is facilitated to specialty care, educational services, out-of-home care, family support, and other public and private community services important to the overall health of the patient.

Understanding the unique needs of children and families, the AAP developed a preamble to the Joint Principles Statement highlighting certain critical pediatric medical home principles:

Family-centered partnership:

A medical home provides family-centered care through a trusting, collaborative, working partnership with families, respecting their diversity and recognizing that they are the constant in a child’s life.

Community-based system:

The medical home is an integral part of the community-based system, a family centered- coordinated network of community-based services designed to promote the healthy development and well being of children and their families. As such, the medical home works with a coordinated team, provides ongoing primary care, and facilitates access to and coordinates with, a broad range of specialty, ancillary and related community services.

Transitions:

The goal of transitions is to optimize life-long health and well-being and potential through the provision of high-quality, developmentally appropriate, health care services that continue uninterrupted as the individual moves along and within systems of services and from adolescence to adulthood.

Value:

Recognizing the importance of quality health care, appropriate payment for medical home activities is imperative. A high-performance health care system requires appropriate financing to support and sustain medical homes that promote system-wide quality care with optimal health outcomes, family satisfaction, and cost efficiency.

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Many people in the United States do not have access to high quality, point-of-entry primary care. And, there is substantial evidence indicating that sufficient access to high quality primary care results in lower overall health care costs and lower use of higher cost services, such as specialists, emergency room, and inpatient care. As a result of these factors, private and public payers are interested increasingly in developing new models of service delivery that better support the provision of effective, patient-centered primary care, including the Patient Centered Medical Home (PCMH) model. The PCMH is an approach to providing high quality, patient-centered primary care to children, youth, and adults.

In order to support medical homes, payers must define what they expect practices to do and how they will know when practices are meeting those expectations. According to the Patient Centered Primary Care Collaborative (PCPCC), a medical home is “a physician-directed medical practice that provides point-of-entry, enhanced primary care in a continuous fashion, across the health care spectrum, and is comprehensive, coordinated and delivered in the con¬text of family and community.”The PCPCC recommends that practices go through a “voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide” PCMH services. It should be noted that most of the initiatives fostered by the PCPCC are using the national Physician Practice Connections® - Patient Centered Medical Home (PPC-PCMH™) tool developed by the National Committee for Quality Assurance (NCQA).

The AAP has published the Building Your Medical Home Tool Kit that will assist pediatricians in defining entry-level medical home activities. In addition, it will identify those “must pass” items on the national Physician Practice Connections® - Patient Centered Medical Home (PPC-PCMH™) assessment tool in order to achieve a Level I Recognition status.

Pediatricians are now required to demonstrate quality improvement for direct patient care in order to meet American Board of Pediatrics recertification regarding The Program for Maintenance of Certification In General Pediatrics (PMCP-G), Part 4, Component B. It follows, therefore, that pediatricians who must meet Maintenance of Certification requirements can accomplish this by participating in a quality improvement project that also achieves NCQA Recognition status.

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A medical home provides care that is:

Accessible:

• Care is provided in the child’s or youth’s community.
• All insurance, including Medicaid, is accepted.
• Changes in insurance are accommodated.
• Practice is accessible by public transportation, where available.
• Families or youth are able to speak directly to the physician when needed.
• The practice is physically accessible and meets Americans With Disabilities Act requirements.

Family-centered:

• The medical home physician is known to the child or youth and family.
• Mutual responsibility and trust exists between the patient and family and the medical home physician.
• The family is recognized as the principal caregiver and center of strength and support for child.
• Clear, unbiased, and complete information and options are shared on an ongoing basis with the family.
• Families and youth are supported to play a central role in care coordination.
• Families, youth, and physicians share responsibility in decision making.
• The family is recognized as the expert in their child’s care, and youth are recognized as the experts in their own care.

Continuous:

• The same primary pediatric health care professionals are available from infancy through adolescence and young adulthood.
• Assistance with transitions, in the form of developmentally appropriate health assessments and counseling, is available to the child or youth and family.
• The medical home physician participates to the fullest extent allowed in care and discharge planning when the child is hospitalized or care is provided at another facility or by another provider.

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Comprehensive:

• Care is delivered or directed by a well-trained physician who is able to manage and facilitate essentially all aspects of care.
• Ambulatory and inpatient care for ongoing and acute illnesses is ensured, 24 hours a day, 7 days a week, 52 weeks a year.
• Preventive care is provided that includes immunizations, growth and development assessments, appropriate screenings, health care supervision, and patient and parent counseling about health, safety, nutrition, parenting, and psychosocial issues.
• Preventive, primary, and tertiary care needs are addressed.
  •The physician advocates for the child, youth, and family in obtaining comprehensive care and shares responsibility for the care that is provided.
• The child’s or youth’s and family’s medical, educational, developmental, psychosocial, and other service needs are identified and addressed.
• Information is made available about private insurance and public resources, including Supplemental Security Income, Medicaid, the State Children’s Health Insurance Program, waivers, early intervention programs, and Title V State Programs for Children With Special Health Care Needs.
• Extra time for an office visit is scheduled for children with special health care needs, when indicated.

Coordinated:

• A plan of care is developed by the physician, child or youth, and family and is shared with other providers, agencies, and organizations involved with the care of the patient.
• Care among multiple providers is coordinated through the medical home.
• A central record or database containing all pertinent medical information, including hospitalizations and specialty care, is maintained at the practice. The record is accessible, but confidentiality is preserved.
• The medical home physician shares information among the child or youth, family, and consultant and provides specific reason for referral to appropriate pediatric medical sub-specialists, surgical specialists, and mental health/developmental professionals.
• Families are linked to family support groups, parent-to-parent groups, and other family resources.
• When a child or youth is referred for a consultation or additional care, the medical home physician assists the child, youth, and family in communicating clinical issues.
• The medical home physician evaluates and interprets the consultant’s recommendations for the child or youth and family and, in consultation with them and sub-specialists, implements recommendations that are indicated and appropriate.
• The plan of care is coordinated with educational and other community organizations to ensure that special health needs of the individual child are addressed.

Compassionate:

• Concern for the well being of the child or youth and family is expressed and demonstrated in verbal and nonverbal interactions.
• Efforts are made to understand and empathize with the feelings and perspectives of the family as well as the child or youth.

Culturally competent:

• The child's or youth's and family's cultural background, including beliefs, rituals, and customs, are recognized, valued, respected, and incorporated into the care plan.
• All efforts are made to ensure that the child or youth and family understand the results of the medical encounter and the care plan, including the provision of (para) professional translators or interpreters, as needed.
• Written materials are provided in the family's primary language.

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A medical home revolves around a family-professional partnership that is the foundation for wellness, acute and chronic condition management. Medical home is not a program adopted by a practice for children with special health care needs. Although some of the aspects of a medical home are specifically for children with special health care needs, a medical home actually represents quality health care that focuses on family-physician partnerships for all children. "All children deserve a medical home" is one of the Healthy People 2010 national health objectives.

Regardless whether a family brings their child to see a physician for acute health care, preventive care or for management of a chronic health condition, they want to have a trusting collaborative relationship with their child’s doctor. This family-professional partnership should prevail in whatever type of care they are seeking. This partnership is the foundation of the medical home model. Without this trusting collaborative partnership, the family does NOT have a medical home. Beyond this partnership, the medical home model provides a blue print for practices to incorporate best practice models and evidence-based medicine as much as possible. This means knowing community resources, communicating effectively with sub-specialists, implementing professional policy guidelines like developmental screening, immunization schedules and Bright Futures Guidelines in well child care.

Though the group of children with special health care needs is broad in scope and needs, a coordinated, comprehensive, and integrated system of health care is needed for all children. The basic elements of accessibility, continuity, comprehensiveness, coordination, family-centeredness, compassion and cultural effectiveness are critical to the medical home concept.

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