Introduction
Imagine a health care approach where a child or youth, his or her family, their primary care physician, plus other health professionals work together and develop a trusting partnership based on mutual responsibility and respect for each other's expertise. All of the players and partners share complete information with each other.
This approach is called a Medical Home, also referred to as a Patient Centered Medical Home or a Personal Medical Home. All children and adults benefit from coordinated, family-centered care, however, Medical Homes are especially important for children with special health care needs and their families.
Children with special health care needs who live in rural areas face many challenges. Local expertise may be lacking and care may be fragmented. There are issues such as transportation to a physician, finding support, obtaining medical information, and working with schools who may not have had experience with unique and rare conditions. Children with complex conditions and their families typically lack a medical home, leaving them with a lack of treatment plans.
A Medical Home is not a building. It is a relationship. It is where families, health care professionals, and community service providers identify and access all medical and non-medical services needed to help a child and family.
Frequently Asked Questions
Tools
Building a Medical Home Partnership: A Wisconsin Toolkit
Web site
Offers stories and insights by Wisconsin physicians and families on creating a Medical Home Partnership. They provide key steps of quality improvement and the small steps that can make big differences for Children and Youth with Special Health Care Needs.
Children's Health Topics: Medical Home
Web site
Defines a medical home, features information sources for various populations, and provides additional resources.
Directory of Primary Care Offices (PCO)
Web site
Lists contact information for each state's Primary Care Office (PCO). PCOs represent the needs of the underserved populations and the providers who serve them. These offices can provide information on Conrad 30 J-1 Visa Waiver programs, loan repayment programs, and recruitment and retention.
Directory of State and Regional Primary Care Associations
Web site
Address, phone, email and web addresses for state and regional Primary Care Associations (PCAs). PCAs work to promote, expand, and optimize access to primary care.
Family-Centered Care Self-Assessment Tool: Provider Tool
Web site
Designed for health care providers in quality improvement activities and to support development of the first key component of a medical home as defined by the American Academy of Pediatrics.
Family-Centered Care Self-Assessment Tool: Users Guide
Web site
Provides a set of steps to use with the Family and Provider Tools for a full assessment of a practice setting or of a family. Can be used as an educational tool to build awareness and knowledge of family-centered care.
Maternal and Child Health Bureau: Helpful Web Sites for Families with Children with Special Heath Care Needs
Web site
Provides resources for children with special needs including medical homes, insurance, screening, and more.
Medical Home Family Stories
Web site
Offers three 15-minute videos and companion materials that can be downloaded. Includes Bernadette's story, Bryan's story, and Kaiyah's story.
Medical Home Index
Web site
Is a validated self-assessment and classification tool designed to translate the broad indicators defining the medical
home (accessible, family-centered, comprehensive, coordinated, etc.) into observable, tangible behaviors and processes of care within any office setting.
Medical Home Initiatives & Resources by State
Web site
Provides medical home information by state, including resources and state contacts.
Medical Homes
Web site
Discusses medical homes, provides resources, and statues of various states.
Melinda Abrams: Why Medical Homes Matter
Web site
Online video of Melinda Abrams, senior program officer for the Program on Patient-Centered Primary Care, reviews the benefits of medical homes as well as how The Commonwealth Fund is helping to address outstanding questions about reimbursement, office redesign, and standardization.
National Center for Medical Home Initiatives for Children with Special Needs
Web site
Works to ensure that children and youth with special needs have a medical home where health care services are accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally-competent.
Patient-Centered Medical Home
Web site
Offers details on what is involved when starting a Patient Centered Medical Home (PCMH). Includes a checklist and information on practice organization, health information technology (HIT), quality measures, and patient experience.
Patient-Centered Medical Home: Building Evidence and Momentum
Web site
Describes various types of Patient-Centered Medical Home (PCMH) pilot and demonstration projects by state as of 2008. Includes contact information of project leaders and stakeholders.
Physician Practice Connections - Patient-Centered Medical Home
Web site
Provides information on the patient centered medical home. Includes fact sheets, overview, summary, joint principles, pricing fee schedule, and more.
Rural Mental and Behavioral Health: A Web Portal for Rural Communities
Web site
Works to help communities to enhance social and emotional outcomes for children and families in rural and frontier areas.
TransforMED
Web site
A national demonstration project, TransforMED Medical Home Model, launched in June 2006 that is focused on helping participating practices implement a new model of care that includes medical home components.
Funding
Charles Lafitte Foundation Grants
The Foundation supports four distinct charitable programs: Education, Children's Advocacy, Medical Issues & Research and The Arts.
Commonwealth Fund Health Grants
Supports independent research on health and social issues and makes grants to improve health care practice and policy.
Walgreen Community Grant Program
Funding for access to health and wellness, pharmacy education programs and mentoring initiatives, civic and community outreach and emergency and disaster relief.
Inactive Funding
Inactive Funding Opportunities -
Lists additional funding programs for this topic that are not currently accepting applications. Programs that are inactive may be offered again in the future.
Regulations, Forms & Other Useful Documents
"Medical Home" Gets Updated: Improving Outcomes While Reducing Costs
Author(s): Anna C. Spencer
Sponsoring organization: National Conference of State Legislatures
Reports on new models for medical home primary-care case management programs.
Journal citation: State Health Notes Volume 29 Issue 511
Date: 03 / 2008
2009 Report to the Secretary: Rural Health and Human Service Issues
Sponsoring organization: National Advisory Committee on Rural Health and Human Services
Reports to the Secretary of the U.S. Department of Health and Human Services on issues related to rural America. Examines three key topics: workforce and community development, creating viable patient-centered medical homes, and serving at-risk children.
Date: 04 / 2009
Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care
Sponsoring organization: U.S. Department of Health and Human Services
Discusses four policy positions, one of them being the medical home model.
Date: 01 / 2006
Building a Medical Neighborhood for the Medical Home
Author(s): Elliott, S. Fisher
Addresses barriers to creating successful medical homes and offers approaches to help overcome these barriers.
Date: 09 / 2008
Building Medical Homes in State Medicaid and CHIP Programs
Author(s): Neva Kaye, Mary Takach
Sponsoring organization: Commonwealth Fund
Discusses how Medicaid and CHIP have strong foundational bases to develop policies that support medical homes and achieve the goals of quality improvement and cost containment.
Date: 06 / 2009
Building the Medical Home: Evaluating the Blueprints
Sponsoring organization: National Health Policy Forum
Identifies forum topics including medical home perceptions. Considers how a medical home might be defined, financed, and evaluated and to whom it should most appropriately be made available.
Date: 06 / 2008
Can Patient-Centered Medical Homes Transform Health Care Delivery?
Author(s): Melinda K. Abrams, Karen Davis, Christine Haran
Sponsoring organization: Commonwealth Fund
Offers information about how medical homes could ensure accessible, patient-centered, and coordinated care for all Americans.
Date: 03 / 2009
Closing the Divide: How Medical Homes Promote Equity in Health Care: Results from the Commonwealth Fund 2006 Health Care Quality Survey
Author(s): Anne C. Beal, Michelle M. Doty, Susan E. Hernandez, Katherine K. Shea, Karen Davis
Sponsoring organization: Commonwealth Fund
Provides results of a survey which discovered that when adults have a medical home, their access to needed care, receipt of routine preventive screenings, and management of chronic conditions improve substantially.
Date: 06 / 2007
Coming Home: The Patient-Centered Medical-Dental Home in Primary Care Training
Sponsoring organization: Health Resources and Services Administration
Outlines nine recommendations for the Title VII, section 747 program to support primary care training and to prepare training programs to educate clinicians to practice in the patient-centered medical home and dental home (PCM-DH). Addresses issues and topics specifically related to rural areas.
Date: 12 / 2008
Community Care of North Carolina: Building Community Systems of Care Through State and Local Partnerships
Author(s): Douglas McCarthy, Kimberly Mueller
Sponsoring organization: Commonwealth Fund
An overview of Community Care of North Carolina, a public-private partnership that comprises local providers who form a medical home for low-income adults and children. Includes references to rural.
Date: 06 / 2009
Continuous Innovation in Health Care: Implications of the Geisinger Experience
Author(s): Ronald Paulus, Karen Davis, Glenn Steele
Sponsoring organization: Commonwealth Fund
Provides evidence that the patient-centered medical home model can improve quality of care and reduce health care costs.
Journal citation: Health Affairs Volume 27 Issue 5 Pages: 1235–45
Date: 10 / 2008
Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care
Author(s): Allan H. Goroll, Robert A. Berenson, Stephen C. Schoenbaum
Sponsoring organization: Society of General Internal Medicine
Presents a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care.
Journal citation: Journal of General Internal Medicine Volume 22 Pages: 410-415
Date: 2007
Health Centers: America’s Primary Care Safety Net Reflections on Success, 2002-2007
Sponsoring organization: U.S. Department of Health and Human Services
Describes how HRSA-funded health centers improve the lives of the more than 16 million people they treat each year. Uses personal stories, examples and background statistics. Highlights agencies who work to overcome language and cultural barriers that often have thwarted efforts to serve poor and minority patients living on the margins of mainstream society.
Date: 06 / 2008
Implementing a Medical Home
Author(s): Christopher Guadagnino
Describes the way that primary care is organized, delivered and reimbursed by three primary care specialty societies in Pennsylvania and New Jersey.
Journal citation: Physician's News Digest
Date: 03 / 2007
Joint Principles of the Patient Centered Medical Home
Sponsoring organization: Patient Centered Primary Care Collaborative
Describes the principles set in place by the AAP, AAFP, ACP, and AOA that characterize the Patient Centered Medical Home.
Date: 2007
Making Medical Homes Work: Moving from Concept to Practice
Author(s): Paul Ginsburg, Hoangmai H. Pham, Ann O'Malley, Myles M. Maxfield, Deborah Peikes
Sponsoring organization: Mathematica Policy Research, Inc.
Looks at key operational issues facing medical home initiatives, including how to qualify physician practices as medical homes, how to match patients to their medical homes, how to engage patients and other providers to work with medical homes in care coordination, and how to pay practices that serve as medical homes.
Date: 12 / 2008
Measuring the Medical Home Infrastructure in Large Medical Groups
Author(s): Diane Rittenhouse, Lawrence Casalino, Robin R. Gillies
Sponsoring organization: Commonwealth Fund
Presents a study of 291 large medical group practices and finds that adoption of medical home infrastructure is low, with very large groups having the highest levels of adoption.
Journal citation: Health Affairs Volume 27 Issue 5 Pages: 1246–58
Date: 10 / 2008
Medical Home
Sponsoring organization: Association of American Medical Colleges
Discusses the medical home concept and its approach to improving health care delivery in the United States.
Date: 03 / 2008
Medical Home on the Go
Author(s): Fia Curley
Sponsoring organization: U.S. Department of Health and Human Services
Overview of a medical home and two mobile units that work with children in Mississippi.
Date: 04 / 2008
Medical Home Practice-Based Care Coordination: A Workbook
Author(s): Jeanne W. McAllister, Elizabeth Presler, W. Carl Cooley
Sponsoring organization: American Academy of Pediatrics
Includes tools and supports needed for a primary care practice to develop their capacity to offer a pediatric care coordination service; particularly for children with special health care needs.
Date: 06 / 2007
Medical Home: AAMC Position Statement
Sponsoring organization: Association of American Medical Colleges
Lists five principles identifying why AAMC believes medical home models hold great promise for improving the health of populations and individuals.
Date: 03 / 2008
Medical Home: An Idea Whose Time Has Come ... Again
Author(s): Leigh Ann Backer
Sponsoring organization: American Academy of Family Physicians
Discusses why physicians, employers, legislators and payers think medical homes may be the key to health system reform.
Journal citation: Family Practice Management
Date: 09 / 2007
Medical Homes Offer Comprehensive Care Approach
Author(s): Candi Helseth
Sponsoring organization: Rural Assistance Center
Describes the successes experienced by two health care centers that offer medical home services to their patients. Advocates in the Community Care of North Carolina (CCNC) and the Lakewood Health System in Staples, Minnesota describe their programs.
Journal citation: Rural Monitor Issue Spring
Date: 05 / 2009
Medicare Medical Home Demonstration Project
Sponsoring organization: Centers for Medicare and Medicaid Services
Addresses the Tax Relief and Health Care Act of 2006, H.R. 6111.
Date: 2006
No Place Like Home
Author(s): Steve Schoenbaum
Sponsoring organization: Commonwealth Fund
Discusses what a medical home is, the history of this approach, and patient-centered care.
Date: 12 / 2006
No Place Like Home: Testing a New Model of Care Delivery
Author(s): John K. Iglehart
Explores the option to use the Medicare program to provide patient-centered medical home services to medically underserved, urban, and rural areas.
Date: 09 / 2008
Partnering with Your Child's School: A Guide for Parents
Sponsoring organization: Council for Exceptional Children
Provides information and resources for families of children with health and/or mental health care needs. Includes information on medical homes for children and the school's role.
Date: 2008
Patient Centered Medical Home History, Seven Core Features, Evidence and Transformational Change
Sponsoring organization: American Academy of Family Physicians
Identifies key elements of a medical
home for delivering a patient-centered
experience.
Date: 11 / 2007
Patient-Centered Care: What Does It Take?
Author(s): Dale Shaller
Sponsoring organization: Commonwealth Fund
Identifies seven key factors for achieving patient-centered care at the organization level.
Date: 10 / 2007
Pediatric Medical Homes: The What and Why of it All
Sponsoring organization: Grantmakers in Health
Briefly describes the history of the Medical Home concept and its development, funding strategies, collaborations, future implications, and sample programs.
Date: 11 / 2008
Quality Matters: Patient-Centered Medical Homes
Sponsoring organization: Commonwealth Fund
Discusses patient-centered medical homes including establishing, sustaining, and reimbursement issues.
Date: 01 / 2008
Supporting the Patient Centered Medical Home in Medicaid and SCHIP: Savings and Reimbursement
Author(s): Rohan Beesla
Sponsoring organization: National Academy for State Health Policy
Addresses the inequity issue in the United States health care delivery system while stressing the importance of the patient centered medical home model for primary care.
Date: 2008
Testimony--Achieving Person-Centered Primary Care: The Patient-Centered Medical Home
Author(s): Melinda Abrams
Sponsoring organization: Commonwealth Fund
Presents testimony on person-centered care for older adults in ambulatory care settings.
Date: 07 / 2008
Organizations
American Academy of Family Physicians (AAFP)
National organization
Works to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity.
American Academy of Pediatrics (AAP)
National organization
Committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.
Center for Medical Home Improvement
National organization
Works to build, strengthen and promote medical homes for children with special health care needs.
Family Voices
National organization
Grassroots network of families and friends, advocates for health care services that are family-centered, community-based, comprehensive, coordinated and culturally competent for all children and youth with special health care needs.
Terms & Acronyms
Medical Homes Also referred to as Patient-Centered Model Homes. This is a model of care, originally used in reference to the care of children with special needs, and now expanded to include the care of all patients. The principles are: each patient receives care from a personal physician; the personal physician leads a team of providers who are responsible for a patient's ongoing care;
the personal physician is responsible for the "whole person"; a patient's care is coordinated across the health system and community; quality and safety are hallmarks of the practice; enhanced access to care is offered through open scheduling, expanded hours, and new care options such as group visits; and
the payment structure recognizes the enhanced value provided to patients.
Primary Care Service Area (PCSA) A geographic unit used for the measurement of primary care resources, utilization, and associated outcomes. Identifies clusters of people receiving primary care within geographic boundaries, and represents market areas for primary care services.
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