Implementation Resources


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

Hospital to Medical Home is a Healthy Tomorrows Partnership for Children Program (HTPCP) in Toledo, Ohio that connects hospitalized pediatric patients in a tertiary care center to primary care pediatric medical homes. The project utilized evaluation results to demonstrate its impact on children and families and expanded  to a sustainable statewide program in partnership with the Ohio’s Maternal and Child Health Block Grant program at the Bureau for Children with Medical Handicaps.

The program utilizes a hospital based “medical home liaison (MHL)” who  builds relationships with families utilizing a strength/respect based communication tool, “Listening with Connection” using precepts of
Hand in Hand Parenting. The MHL meets families in the hospital and connects them to primary care providers. The liaison is intimately involved with measurement and evaluation of the program by conducting follow-up with every family both immediately after discharge from the hospital and one year later. Evaluation data shows that 97% of patients kept their first primary care appointment after hospital discharge. At one year, 95% were able to identify their primary care provider and 87% had kept “all or almost all” of their appointments with their primary care provider, subspecialists, and community resources.

In a recent interview with the National Center for Medical Home Implementation (NCMHI), project director Pam Oatis, MD, FAAP, explained that being able to quantify the impact of the project allowed hospital leadership to support the program and ensured its sustainability beyond the grant. Additionally, Ohio’s Title V program adapted the initiative on a systems/state level, providing medical home training to over 700 pediatric providers (including physicians, nurses, Head Start teachers and childcare providers). The state utilized questions from the National Survey of Children with Special Health Care Needs to evaluate, at a state level, the number of children and youth with special health care needs receiving care within a medical home as a result of the Hospital to Medical Home program. The state is currently collecting data and results will be available in the future.

The Hospital to Medical Home Program created multiple resources throughout the implementation of its HTPCP grant, including a comprehensive care notebook for families and an e-Learning module. For more information, visit the
Ohio state page, Healthy Tomorrows Partnership for Children Program Web site, Hand in Hand Parenting, or contact Dr Oatis directly at