Tools for Providers

• AAP Policies
• How to Become a Medical Home
• Brochures for Physicians
• Presentations for Physicians

Physicians’ and Parents’ Ranking of Services
This grid is a brief representation of a survey that asked physicians and parents how they would rank what services families need. The responses show that physicians' responses were not reflective of families' needs to help coordinate and manage their child's care. It also demonstrates the importance of partnering with families, asking them what their needs are instead of assuming what they are.

How to Become a Medical Home

• Medical Home Tools
  The Medical Home Index, Assessment Questionnaires and Plan for Measuring Outcomes , and Medical Home Provider Surveys
• MedHome Portal
  The MedHome Portal is a web-based resource aimed at providing primary care physicians with ready access to information, tools, and services to improve their care and coordination of care for their patients with special needs
• Primer on the Illinois Medical Home Model for Physicians
  This monograph offers busy primary care providers a menu of suggestions that can be incorporated into their practice to improve the quality of health care provided to patients and families through a medical home.  These suggestions will provide a naturally evolving approach to building a medical home, but, providers need only consider those options that are most appropriate for their practice setting.  An initial assessment should help guide you through the menu options to determine how to proceed.  Many suggested changes are simple to adopt and most are not costly. 
  
• A Guide for Parent and Practice "Partners" Working to Build Medical Homes for CSHCN.
  A resource for practice and parent partners to help them learn how to engage families as partners with their practice improvement. Developed by the Center for Medical Home Improvement.

AAP Practice Management Online

Practice Management Online (PMO) is available free to all AAP members. By providing pediatricians with the resources they need to have practices that are fiscally sound, efficient, and provide quality health care. PMO has become a virtual home for pediatricians seeking information on practice management activities. PMO addresses 5 key areas: Practice Basics, Payment and Finance, Office Operations, Quality Improvement, and Patient Management.

This project is a collaborative effort between the AAP Department of Practice and the Department of Marketing and Publications, the Section on Administration and Practice Management, and the Committee on Practice and Ambulatory Medicine. It has received unwavering support from the AAP Board of Directors and has been supported in its development by the AAP Friends of Children Fund.

The site is accessible through the “button” on the AAP Member Center or directly at http://practice.aap.org. The Practice Management Online editorial committee invites you utilize the new web site and provide feedback. We hope it is a great resource for you and your practice.

If you would like more information on PMO, contact Trisha Calabrese, AAP staff person, at tcalabrese@aap.org or call 800/433-9016, ext 7124.

Enhancing Collaboration Between Primary and Subspecialty Care Providers for Children and Youth With Special Health Care Needs Workbook
Antonelli, R., Stille, C., and Freeman, L. , Georgetown University Center for Child and Human Development, Washington, DC, 2005.

"An essential component of the Medical Home model is the ability to provide services that are coordinated. But who is responsible for coordinating care?
Without question, the family and patient are the principal coordinators of care. However, it is vital that all providers within the Medical Home model of care understand their interdependent roles and effectively serve the child and family. Indeed, the collaboration between primary and subspecialty providers is a critical aspect of coordinated care
within a Medical Home model."

Goals of This Guide
Discuss the complementary roles of generalist and subspecialist physicians in providing coordinated and effective care for CYSHCN.
Emphasize the centrality of family-professional partnerships.
Describe various models for collaboration among generalist and subspecialist physicians and families.

Ultimately, the value of this guide will be to serve as a framework for discussion about how primary and subspecialty care physicians can work collaboratively to enhance the quality of care that CYSHCN and their families receive. While it is essential to appreciate the structural and functional differences among various health care delivery systems, a core expectation for creating Medical Homes is that each system and community will embrace the critical components underlying collaboration outlined in this guide.

Table of Contents
Why Is Collaboration Between Primary and Subspecialty Care Providers Important?
What Is the Framework for a Collaborative Model of Care for CYSHCN?
Implementation of Collaborative Care Between Primary and Subspecialty Care Providers
Special Challenges and Opportunities
Measures of Health Care Quality
Resources and Tools to Enhance Collaboration in Caring for CYSHCN
Very Useful Web sites

Innovative Approaches for Improving Referral, Consultation, and Shared Management in Primary and Specialty Pediatric Care
Washington, DC -- A new report from the Federal Expert Work Group on Pediatric Subspecialty Capacity and the MCH Policy Research Center profiles promising approaches to strengthen collaboration between primary and specialty pediatric care. The report, Promising Approaches for Improving the Interface between Primary and Specialty Pediatric Care, describes 10 real-world strategies to address referral, consultation, and shared management that can improve the availability of pediatric subspecialty care and enhance health outcomes for children.

The Federal Expert Work Group on Pediatric Subspecialty Capacity was formed by the Maternal and Child Health Bureau in response to growing evidence that access to pediatric subspecialty care in many parts of the U.S. is worsening. The group has 3 main objectives: 1) define the scope of current and projected pediatric subspecialty capacity problems and their consequences; 2) identify promising approaches for improving shared management between pediatric subspecialists and medical homes, reimbursement, continuing education and training, and state/regional delivery system networks; and 3) develop recommendations and a tactical plan to improve access to subspecialty care.

Brochures for Physicians

• SMALL STEPS…BIG DIFFERENCES. THE MEDICAL HOME PARTNERSHIP: Practical Tips for Physicians Caring for Children with Special Health Care Needs - Brochure
  This large-format brochure was developed by New England SERVE with practical tips for physicians, nurses and office staff. It offers specific things clinical and office staff can do to support special needs at four steps in the care process: Before the Visit; In the Exam Room; After the Visit; and In the Community. The back page provides resources for building medical home partnerships in Massachusetts. If you are interested in replicating this brochure with specific information for your state or community, please contact Alexa Halberg at ahalberg@neserve.org or by phone: 617/574-9493.
  
  
• A Provider's Introduction to Strengthening Medical Homes for CSHCN - Brochure Developed by the South Carolina Medical Home Team.

• Down Syndrome Brochure
  Last year, studies published in Pediatrics and American Journal of Obstetrics and Gynecology revealed that often parents are given outdated, depressing information related to Down syndrome. One of the many recommendations coming out of the studies was that when physicians explain Down syndrome to parents, sensitive, accurate and consistent messages must be conveyed.

  To help physicians, The National Down Syndrome Congress (www.ndsccenter.org) has created a new brochure that provides accurate medical information presented in a positive manner.

  To obtain a complimentary copy of this brochure, please contact Sue Joe at sue@ndsccenter.org, or 800/232-6372.

  The NDSC also has other free materials on topics such as dual diagnoses, educational best practices, advocacy and independent living.
  

Overview
1. The Center for Medical Home Improvement model
2. Measurement tools
3. Improvement application for promoting medical homes in primary care

Overview
Primary care practices can:

Develop patient/family centered care
Identify and monitor children with SHCN
Improve coordination of care and communication
Improve documentation to enhance coding and reimbursement.
Improve how the primary care practice team provides chronic care through systems change
Facilitate patient access to services in practice and community

Overview
1. Quality Improvement strategy at Henry Ford Pediatrics
2. Objectives included:Identify 95% of the CSHCN in our practice, Create an electronic IHCP, 95% of the families with CSHCN will be given a copy of their child’s care plan and understand its use, and 30% improvement scores of the Medical Home Index.
3. Challenges and Successes