Implementation Resources (Tools and More)

Implementation Resources (Tools and More)

Implementation Resources from the National Center for Medical Home Implementation

  • Building Your Medical Home Online Resource Guide: Co-management Resources
    This comprehensive
    resource guide provides tools, resources, and templates to encourage communication and collaboration between primary care clinicians and specialists. These resources include the following:

Additional Implementation Resources

 ​Training, Events, and Conferences

​Training, Events, and Conferences

 ​Partners and National Initiatives

​Partners and National Initiatives

 ​Special Feature: An Interview with a Healthy Tomorrows Partnership for Children Program Grantee

​Special Feature: An Interview with a Healthy Tomorrows Partnership for Children Program Grantee

The Community-based Pediatric Enhanced Care Team-3 (CPECT-3) is a Healthy Tomorrows Partnership for Children Program (HTPCP) based in Winston-Salem, North Carolina. CPECT-3 is part of the Pediatric Enhanced Care Program (PECP) of Brenner Children's Hospital, a tertiary care children's hospital, serving children with medical complexity and their families. The program focuses on provision of coordinated care to children with medical complexity through comprehensive co-management with the child and family's primary care patient-centered medical home. Many families and children served through the program live in rural areas far from the tertiary care center, making co-management with local primary care practices a high priority for the project.

The CPECT-3 team consists of a lead physician, a social worker, a patient navigator, and a family support services specialist. The team collaborates with the registered nurses of PECP, and works closely with the patient, family, and primary care medical home team to enhance co-management and improve quality of care through the following activities:

  • Upon enrollment into the program, the team social worker (based out of the tertiary care center) connects with the child's primary care physician. Medical records, including care plans, are shared between the primary care medical home team and the tertiary care team either electronically (through an Electronic Health Record), through email, or through fax. At times, children are referred to the program by primary care physicians through telephone calls with the tertiary care social worker.
  • The CPECT-3 social worker and patient navigator identify a preferred method of communication (phone, email, in-person) with the primary care medical home team. By building a relationship with the local primary care team, the CPECT-3 team can understand and leverage local community resources and supports available for the child and family. As such, the tertiary care team is able to identify the best possible referrals and resources needed by the family and child in their community.
  • Depending on the complexity of the child and the needs of the family, the tertiary care team may physically meet with the primary care physician in their community. This multi-disciplinary team meeting involves discussion of patient and family goals and development of a comprehensive care plan in partnership with the family, patient, primary care, and tertiary care team.

Building strong partnerships between primary care medical home teams and the CPECT-3 tertiary care team has resulted in provision of high quality care for children with medical complexity. The program has been implemented across 10 counties/regions and has expanded beyond its HTPCP funds. Principles of co-management and care coordination are integrated into all activities of the program. For more information, visit the Healthy Tomorrows Partnership for Children Program Web page or the North Carolina National Center for Medical Home Implementation Web site.