Medical Home Basics

Checklist and Tools

Learning Collaborative

Medical Home Measures

Identifying Patients with Special Needs

Developmental Surveillance & Screening

Care Coordination

Partnering With Families

Family to Family Support

Accessing Community Resources

Culturally Effective Care

Sharing Sensitive News

Transition

Oral Health

Office Organization and Management

Finances and Data Management

Quality Improvement

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Patient-Centered Medical Home Collaborative

Introduction

The Washington Patient-Centered Medical Home Collaborative, a joint project of the Washington State Department of Health and the Washington Academy of Family Physicians, offers proven tools for pediatric and family medical practices  to improve outcomes for their patients.

The Patient-Centered Medical Home Collaborative is a learning process for medical teams to improve primary care for their patients. Through 2011, 33 teams in Washington are creating patient-centered medical homes.

In a medical home the physician and care team build strong relationships with the patient and the patient’s family. The team coordinates care with specialists or other health providers. Patient-centered care makes the patient a partner in health care decisions

For more information about the Washington State Collaborative to Improve Health, go to www.doh.wa.gov/cfh/MH-Coll/default.htm

Strategies from the 2008-09 Learning Collaborative to improve outcomes for patients with chronic diseases:

Top Four Strategies for Becoming a Medical Home

Jeanne McAllister, Co-Director - Center for Medical Home Improvement

1.  Engage parents as partners at the practice level.

2.  Identify children and youth with special health care needs (CYSHCN) - Build and use a registry; Use a chart coding system; Stratify by levels of complexity.

3. Use planned visit encounters.

4.  Develop care coordination and communication at the practice level.

Methods:

•  Establish family advisory groups for the practice

         See Skagit Pediatrics presentation

•  Institute care coordination and designate a care coordinator

          See: http://www.medicalhome.org/physicians/coordinating_care.cfm

                 http://www.medhomeportal.org/about/care-coordination

•  Co-manage care with specialists and determine information exchange method

See: Enhancing Collaboration Between Primary and Subspecialty Care Providers for CYSHCN Workbook

Antonelli, R., Stille, C., and Freeman, L. , Georgetown University Center for Child and Human Development, Washington, DC, 2005.

             (at the National Medical Home Website)

•  Implement a care planning process

          See: http://cshcn.org/planning-record-keeping

•  Catalogue local resources and contact persons

          See: http://www.medicalhome.org/resources/resource_info.cfm

•  Identify and share evidence-based practices

•  Meet with community partners, e.g. lunch and learns