Implementation Resources

  • Core Principles and Values of Effective Team-Based Health Care
    This Institute of Medicine
    discussion paper presents the rationale and strategies for implementation of a team-based approach in health care. Examples of best practices, including those in pediatric practice settings, are included and can be used as models for pediatric clinicians and practices looking to implement team-based care.
  • Team-Based Care Implementation Strategies
    The Institute for Healthcare Improvement Web site provides examples of strategies to promote and enhance team-based care through team huddles, staff meetings, and production planning meetings. Additional team-based care strategies such as staff cross training and communication are provided.
  • Fostering Partnerships and Teamwork in a Pediatric Medical Home: Video Series
    Developed by the National Center for Medical Home Implementation, this three part “how-to” video series provides instructions on multiple team-based care implementation strategies such as team huddles and family engagement.
  • Key Elements of Highly Effective Teams
    This article defines team-based care in the context of pediatrics and provides implementation strategies and team member roles. The article, published in Pediatrics,  emphasizes the importance of leadership and open communication with team members, particularly those working to enhance family-centered and coordinated care.
  • Team-based Care Implementation: Integrating Frontline Workers into Team-Based Care Models
    This Brookings Institute report provides rationale and strategies for clinical practices to incorporate team-based care. The report focuses on the inclusion of front line workers—which make up over 50% of the health care workforce in the United States—in care delivery models such as the patient-centered medical home.
  • Tools for Development and Sustainability of Health Care Teams
    The Safety Net Medical Home Initiatives houses a comprehensive team-based care resource center focusing on assisting practices with implementing and sustaining team-based care. Included are recorded webinars, best practice examples, and a downloadable implementation guide.
  • Redesigning Your Work Space to Support Team-Based Care
    This article describes four design elements that primary care practices can implement  to make team-based care more effective and efficient. The article, published in Family Practice Management, provides examples of floor plans from primary care practices as well as model workstation set ups to increase team member communication and improve patient outcomes.
  • Team-Based Care Resource Center
    TransforMed, a subsidiary of the American Academy of Family Physicians, provides an online resource center which includes tools and the provision of assistance to clinicians interested in implement patient-centered medical home. In particular, the practice-based team care section provides information on interdisciplinary care teams, staffing, effective communication, and other strategies for team-based care implementation.
  • Tips to Improve Care with a Team-Based Model of Care
    The American Academy of Family Physicians developed a collection of videos which discuss different aspects of patient-centered medical homes, including team-based care. The videos provide definitions, strategies for implementation, and case studies from individual practices which can be applied to pediatrics.
  • A Roadmap for Patient and Family Engagement in Healthcare
    Families and patients are key members of any health care teams. For pediatric practices, inclusion of families on the health care team is especially important. This patient and family engagement roadmap created in part by the Gordon and Betty Moore Foundation, presents eight change strategies to increase the engagement of patients and families on health care teams.
  • Powerful Partnerships: A Handbook for Families and Providers Working Together to Improve Care
    This National Institute for Children's Health Quality guide provides tools and strategies for families and pediatric clinicians to collaborate as part of a child’s health care team. Emphasis is placed on the importance of families and clinicians serving as equal partners on a health care team in order to improve child health outcomes and enhance family-centered care.

 Training, Events, and Conferences

November 2014

  • Understanding the Health Care Needs of People with Disabilities
    Friday, November 21, 2014, 2:00 ET
    Join the National Disability Navigator Resource Collaborative (NDNRC) on this weekly Centers for Medicare and Medicaid assisters’ webinar, which will discuss questions people with disabilities—including families of children with special health care needs—need to think about when they are considering their health care options through the Affordable Care Act Marketplace. For more information, visit the NDNRC Web site.

January 2015

  • AMCHP 2015: United to Build Healthier Communities
    January 24 – 27, 2015, Hyatt Regency, Washington DC
    Join the Association of Maternal and Child Health Programs (AMCHP) for its annual conference, bringing together leaders in maternal and child health including state Title V agencies, grantees, and Maternal and Child Health Bureau National Centers.
    Additional Information about the AMCHP 2015 Annual Conference

February 2015

  • Blueprint for Success: The Pediatric Medical Home is Here to Stay
    February 6, 2015, Orlando, Florida, Rosen Centre Hotel
    Organized by the American Academy of Pediatrics, this conference will raise awareness about the value of providing patients and families with a pediatric medical home, address common misconceptions, share perspectives on national policy shaping the movement,  enhance the dialogue with insurers/payers, and equip physicians and health care professionals with practical guidance and tools to transform their practice into a medical home.
    Additional Information about the Blueprint for Success Conference
  • Fostering Partnership and Teamwork in the Pediatric Medical Home: Webinar Series
    This recorded webinar series hosted by the National Center for Medical Home Implementation provides step-by-step instructions on the implementation of team-based care in pediatric practice through team huddles and various family engagement opportunities.
    Additional Information about the Fostering Partnership and Teamwork Webinar Series

 National Initiatives

  • Core Competencies for Interprofessional Collaborative Practice
    report discusses definitions and principles of interprofessional collaboration in the health care setting and emphasizes the importance of interprofessional education in order to achieve optimal health outcomes for patients. Four core competencies for this collaboration are presented, emphasizing the importance of team-based care and teamwork in all clinical settings, including pediatric medical homes.
  • Team-Based Care as a Strategy to Eliminate Primary Care Physician Shortages
    This article discusses the national problem of primary care physician shortages—including primary care pediatricians— and suggests team-based care as a potential solution. The article, published in Health Affairs, suggests utilization of non-physician professionals such as nurse practitioners and community health workers as members of the medical home team. 
  • Implementing Teams in a Patient-Centered Medical Home Residency Practice: Lessons Learned
    Published in the Journal of the American Board of Family Medicine,  this article describes the introduction and implementation of a team-based approach to care in an ambulatory practice. Lessons learned include a need for strong leadership, equal engagement of all team members, and clear communication of vision and goals. Strategies for team-based care implementation including team huddles, team meetings, and the use of non-physician team members are outlined.
  • Health Care Teams: Improving Care in Primary Care Practices
    This JAMA article describes five main characteristics of cohesive health care teams. Examples of two best practices in the primary care setting are provided, with insights on how teamwork in this type of a clinical setting improves patient outcomes.
  • The Role of Lay Health Workers in Pediatric Chronic Disease
    This review article explores the role of non-physician pediatric professionals such as patient liaisons, community health aids, promotoras, among others, in improving the care provided to children with chronic conditions. Results show potential for improved and cost-effective health outcomes from the inclusion of these professionals on a health care team.


 From Our Web Site

Special Feature: An Interview with Healthy Tomorrows Partnership for Children Program Grantees

The Newark School-Based Health Center Program is a Healthy Tomorrows Partnership for Children Program (HTPCP) that provides coordinated, team-based care for some of Newark’s most vulnerable youth and families. The project supports two school-based health centers administered by Jewish Renaissance Medical Center (JRMC), a Federally Qualified Health Center and serves a growing African American and Latino population. The health centers serve as medical homes for students and work to connect appropriate community resources to the families that need them the most.

The health center team consists of front desk and registration staff, a licensed clinical social worker, two family nurse practitioners, a pediatric nurse practitioner, and a family physician. In addition to daily communication between all team members, the health center team meets on a monthly basis with JRMC leadership, including the Chief Medical Officer Nancy Tham, MD. In a recent interview with the National Center for Medical Home Implementation (NCMHI), Dr Tham recommended that any pediatric practice interested in implementing team based care should “include both clinical and non-clinical staff” on the healthcare team. Family and caregiver input is crucial in a pediatric medical home, and these needs are communicated to the health care team with the assistance of the social worker, who serves as a liaison between the families and

The Newark School-Based Health Center Program assures sustainability of programs and resources by maximizing and leveraging community partnerships with organizations such as the Living Cities Foundation and the Greater Newark Healthcare Coalition. The program also works to engage national child health leaders and stakeholders, such as the American Academy of Pediatrics. In a recent interview with the NCMHI, Jorge Cruz, the director of planning and development at JRMC, emphasized the importance of partnership, collaboration, and teamwork to achieve optimal child health outcomes.the clinicians. 

For more information on the Newark School-Based Health Center program, visit the
National Center for Medical Home Implementation New Jersey State Page and the Healthy Tomorrows Partnership for Children Program Web site.