Implementation Resources

      • For Practices: Obtain information about core components of the pediatric medical home including family-centered care, care coordination, and team-based care.
      • For Families and Caregivers:  Learn how to collaborate with your child's pediatric practice and become active participants in your child's care.
      • For States: Obtain information about medical home initiatives in your state, including key contacts, partners, and stakeholders.

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October 2015

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 From Our Web Site

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

Healthcare Without Walls is a Healthy Tomorrows Partnership for Children Program (HTPCP) in Atlanta, Georgia. The program initially began by serving women with substance abuse issues who had experienced homelessness.  Over time, program leadership recognized a need to provide comprehensive primary care health services not only to women but also to their children within the medical home model. To begin the medical home transformation process, leadership recruited a medical home improvement team consisting of a primary care pediatrician, a care coordinator, and an epidemiologist. A community advisory council guided all medical home transformation efforts. A patient registry was established to begin proactively tracking patient populations. Within a year, the team successfully reduced pediatric Emergency Department visits, connected uninsured eligible children to Medicaid, and screened for and identified developmental delays in accordance with the Bright Futures periodicity schedule.

In a recent interview with the National Center for Medical Home Implementation (NCMHI), Medical Director Leslie Rubin, MD, explained that the transformation “did not occur overnight.” The project faced many challenges along the way, and despite positive results seen from the program to date, some challenges still remain.

Dr Rubin discussed that one of the biggest challenges was finding the right staff and the appropriate amount of time to build trust and relationships with patients and family members.  When the project first began, the clinic underwent rapid staff turnover due to the difficulty of caring for a complex and vulnerable population. Staff needed to have appropriate training and sensitivity in cultural competency and family-centered care in order to be able to build a relationship with the patient population. Demonstrating the positive outcomes of such a project to staff enhanced buy-in and improved team-based care.

Despite its many successes, the project still struggles with providing continuity of care in the community. The nature of the population served makes the provision of continuous care more difficult, since patients often move geographically and do not return to the same clinic for care. The project is researching new strategies for care coordination at the systems level to ensure continuity of care. For more information view the NCMHI Georgia state page and the HTPCP Web site.