The Pennsylvania Medical Home Program (PA MHP) is a project of the Pennsylvania Department of Health and the Pennsylvania Chapter of the American Aca​demy of Pediatrics (PA AAP).  The project's advisory committee provides guidance to the PA MHP and includes the following diverse multidisciplinary professionals:

  • Families and family organizations (such as the Pennsylvania Family-to-Family Health Information Center and Parent to Parent of Pennsylvania)
  • Pediatricians and other healthcare professionals
  • Social service representatives
  • State and local government representatives

Based on the Educating Physicians in their CommunitiesTM (EPIC) model, a trademark of the PA AAP, the PA MHP educates and supports primary care practice teams on the adoption and implementation of the medical home model.

Maternal and Child Health Block Grant (Title V) funds support implementation of the PA MHP and as such, facilitate improvement of Pennsylvania's chosen Title V National Performance Measure (NPM), the percent of children with or without special healthcare needs who receive care within a medical home (NPM 11). The PA MHP also supports efforts to improve transition from pediatric to adult health care.

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Published: November 2016

 Program Components

The Pennsylvania Medical Home Program (PA MHP) is focused on continuous quality improvement (CQI) and adoption of medical home principles at the practice level. The program is designed to:

  • Enhance community-based care coordination
  • Improve healthcare delivery to all children, with additional emphasis on serving children and youth with special healthcare needs (CYSHCN)
  • Engage family members in decision-making
  • Assist youth transitioning into adult-oriented systems

Practice teams participating in the PA MHP receive education through regional learning collaboratives, webinars, and bi-annual conferences. Practice coordinators and parent advisors facilitate and sustain CQI within teams via on-site technical assistance. 

The PA MHP assists practice teams in the following transformation efforts: 

  • Complete an evidence-based training focused on implementation of medical home principles
  • Engage parent partners in specific CQI tasks and practice transformation meetings
  • Develop and implement a system to identify and stratify CYSHCN based on medical complexity
  • Complete the Medical Home Index annually
  • Participate in webinars, learning collaboratives, and conferences
  • Enhance transition efforts for CYSHCN

Participating practice teams may apply for two years of care coordination funding through the PA MHP. In addition to the tasks listed above, teams seeking care coordination funding must accomplish the following:

  • Participate in monthly teleconferences, webinars, learning collaboratives, and bi-annual conferences
  • Recruit parent partners to serve as members of the team
  • Facilitate shared decision-making with families/caregivers of CYSHCN
  • Demonstrate active efforts in making practice-level policy changes
  • Demonstrate practice transformation via data collection and reporting

 Payment Model

Since 2002, Maternal and Child Health Service Block Grant funds have been utilized to support the Pennsylvania Medical Home Program (PA MHP). Additional funding for learning opportunities, conferences and special initiatives, is leveraged from other organizations.

The PA MHP works closely with the Pennsylvania Department of Human Services, which administers Medicaid in Pennsylvania, as well as other payers, to facilitate enhanced payment through a pay for performance model to practices supporting the following medical home functions:

  • Youth transition to adult-oriented systems
  • Measurement of health outcomes
  • Care plan development/maintenance
  • Patient engagement
  • After-care support
  • Use of the Healthcare Effectiveness Data and Information Set (HEDIS) for the National Committee for Quality Assurance.

The PA MHP is collaborating with the Pennsylvania Department of Human Services on the development of a new Per-Member-Per-Month payment model, however this model has not been implemented at this time.


Between 2002 and 2016, the Pennsylvania Medical Home Program (PA MHP) trained over 150 diverse pediatric and adult practice teams in medical home principles. Practice teams represent diverse settings (hospital-based practices, private practices, and community-based health centers) and geographic locations (34% urban, 32% suburban, 34% rural). Since 2002, the PA MHP has served approximately 491,000 children, including 83,470 children and youth with special health care needs (CYSHCN).

Practice teams implemented medical home principles through the following activities:

  • Created and maintained patient registries
  • Created and updated care plans
  • Held team meetings
  • Facilitated meetings with community partners
  • Recruited and engaged parent partners
  • Participated in quality improvement activities, including data collection
  • Attended PA MHP conferences and webinars
  • Designated specific scope of duties for a care coordinator in practice; participated in care coordination activities

 Since 2008 the PA MHP Family Survey has been used to collect data from 3,390 families of CYSHCN about their experiences and interactions with participating practice teams. Results indicate the following:

  • Over 77% of parents believed that care coordination services were "always or usually helpful."
  • Over 75% of parents believed the healthcare their child received was excellent or above average.

A 2014 study examining a subset of 20 pediatric practice teams participating in the PA MHP and caring for a total of 967 children and young adults with asthma. The study demonstrates that as a result of 9,240 care coordination encounters over 100 days for 967 children and youth with asthma:

  • 54 hospitalizations were prevented
  • 281 emergency department visits were prevented
  • 122 school absences were prevented
  • 38 fewer parental work days were missed

Finally, data from the 2009/2010 National Survey of Children with Special Needs demonstrate that between 2007 and 2010, families living in Pennsylvania reported increases in receiving family-centered care, culturally effective care, and a decrease of problems obtaining necessary referrals as needed.

 Fast Facts

  • 1,572,275: the number of Pennsylvania children enrolled in Medicaid and the Children's Health Insurance Program (CHIP) in FY2014
  • 89.5%: the participation rate for Pennsylvania children eligible for Medicaid and CHIP in 2014
  • 91.0%: the national participation rate for children eligible for Medicaid and CHIP in 2014