Medical Home Information for Physicians
Medical Home Primer: 3rd Edition
Medical Home Information for Families
Creating a Medical Home
Parent Partnership
Practice Assessment
Consumer Awareness
Practice Improvements
Acute Illness Managment
Preventive Care Managment
Chronic Condition Management
Diagnosis Modules
Transition Information
Community Resources
Medical Home Reimbursement
Quality Improvement
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. A medical home is a community-based primary care setting that integrates quality and evidence-based standards in providing and coordinating family-centered health promoting in wellness, acute and chronic condition management.
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.
The Medical Home Model has been actively promoted by the American Academy of Pediatrics (AAP) in partnership with the Maternal and Child Health Bureau (MCHB) since 1998. This partnership has now expanded to include the American Academy of Family Physicians, the American College of Physicians and the American Osteopathic Association. Their consensus statement articulates how families and patients identify a primary care practice to provide accessible, continuous, and coordinated care.
Beginning in 2010 primary care physicians will be required to demonstrate quality improvement for direct patient care in order to meet board recertification requirements.
The purpose of this web site is to offer busy primary care professional staff a menu of suggestions that can be incorporated into the practice and improve quality health care in the medical home that you provide to patients and families. There is no particular order that you must follow in order to establish a medical home - you can choose any of the various activities or suggestions offered here to begin developing your medical home. Many suggested changes are simple to adopt and most are not costly. The 3rd edition of The Medical Home Primer for Pediatricians and Family Physicians is another resource for information and suggestions on establishing a medical home. It is available online and offers continuing medical education credit for physicians who complete and submit the exam.
If you are not familiar with the medical home model, you can click on the left side of this page and review the Primer for Physicians and the Information for Families.
The following is a brief description of the many activities you will find here that you can begin to integrate into your practice to make medical home a stronger foundation of quality health care.
Parent Partnerships: This section emphasizes the importance of partnering with families and provides examples of how some practices have engaged families to improve quality of care.
Practice Assessment: Using validated assessment tools can help you determine "where you are" and assist you in defining "where you want to be". There are several questionnaire-type practice assessment tools that are described in this section. A practice assessment using such instruments provides a good baseline benchmark of where the practice is now and potential areas where further improvement can be made.
Consumer Awareness: Educating families about medical home is important. It sends the message that you care about quality health care and the partnership that they can bring to the practice. This section highlights strategies through brochures, posters and other opportunities to inform families about medical home.
Practice Improvements: Many examples are illustrated in this section that demonstrate practice improvements. These range from practical strategies to changes based on professional policies and best practice guidelines. Bulletin boards, internet access, screening procedures, pre-visit questionnaires, appointment scripts, care plans, cultural issues, and suggestions for using Plan-Do-Study-Act (PDSA) cycles to bring about effective change are just a few of the examples.
Preventive Care Management: Quality improvement strategies described in this section include the use of visit preparation cards/scripts, bulletin boards and providing internet access and/or reference library to specifically address measures to prevent the spread of infection and disease. Policy statements on immunizations, safety, flu vaccines, obesity, and Bright Future Guidelines are also highlighted as guides to improving care.
Acute Illness Management:Quality improvement strategies described in this section include the use of visit preparation cards/scripts, bulletin boards and providing internet access and/or reference library to specifically address caring for children with common acute illnesses. Policy statements on bronchiolitis, febrile seizures, otitis media and urinary tract infections are also highlighted as guides to improving care.
Chronic Condition Management: The most challenging component of the Primary Care Medical Home Model is managing children with chronic health conditions. This section introduces you to various strategies that practices have used to identify CYSHCN and defines how such a registry is beneficial to the practice. This section also offers a list of practical strategies for improving care and includes information on common chronic health conditions plus critical information about newborn metabolic and hearing screening.
Diagnosis Modules: Managing chronic health conditions and providing care coordination are new aspects to primary care. This section provides comprehensive information and anticipatory guidance about some of the most common chronic health conditions encountered in primary care including Asthma, Cerebral Palsy, Autism, Down Syndrome and Epilepsy, among others.
Transition Information: Assisting children and families to prepare and plan for adulthood and adult health care services is detailed in this section. Many useful tools are provided along with planning strategies and resources for additional information.
Community Resources: Knowing community resources is extremely important in providing good care to families. This section introduces you to the Life Span Database developed by the Arc of Illinois and other opportunities that will improve your practice’s awareness of community resources.
Medical Home Reimbursement: There are many potential financial challenges facing the implementation of the medical home in physician practices. Both coding for care and services provided to patients and negotiating with payers for the most appropriate contracts will be addressed in this section.
Quality Improvement: Once your practice is serious about developing quality improvement changes, you are ready to implement a more formal quality improvement process where families collaborate with staff to improve care delivery. Here is where you will also learn how to meet board recertification requirements involving quality improvement.
