The Illinois Chapter of the American Academy of Pediatrics (ICAAP) collaborated with multiple partners to expand a small medical home pilot project within a health care system, the Ambulatory and Community Health Network (ACHN) of Cook County. With support from the Maternal and Child Health Bureau, ICAAP implemented an intensive quality improvement project at ACHN of Cook County to successfully improve patient- and family- centered care.

Implementation Insights:

  • Build on existing projects rather than creating entirely new initiatives.
  • Foster partnerships with multiple pediatric health stakeholders.
  • Implement a rigorous evaluation methodology to demonstrate impact of work.

    Updated: June 2016

 Background Information

  • Type of Practice: State chapter of the American Academy of Pediatrics (local non-profit organization)
  • Location: Chicago, IL
  • Population Served: 10 pediatric practices participated in the quality improvement initiative, serving approximately 2,000 families

 Pediatric Medical Home Implementation Strategies

  • Identify existing initiatives, projects, or demonstrations in your state upon which to build or expand.
  • Identify partners and stakeholders who may be able to collaborate with your organization in implementing a pediatric medical home project. These partners may include the following:
        • State Children with Special Health Care Needs program (Title V)
        • State Medicaid
        • Family-to-Family Health Information Center
        • State chapter of the American Academy of Family Physicians
        • State chapter of the American Academy of Pediatrics
        • Early Intervention programs
  • Convene a multisdisciplinary planning group of partners and stakeholders.
  • Identify a variety of clinics within a health care system that will participate in a quality improvement project; look for variety in geographic location and population served (insurance status, socioeconomic status, demographics).
  • Recruit multidisciplinary teams in each practice to participate in the quality improvement project. Team members may include the following:
        • Physicians
        • Nursing staff
        • Medical assistants
        • Administrative staff
        • Clinic directors
        • Parent partners
  • Identify a champion among each quality improvement practice team.
  • Facilitate a four day in-person learning session.
  • Offer incentives for participation including the following:
      • Continuing Medical Education (CME) credit
      • Maintenance of Certification points
      • Assistance with meeting national medical home recognition or certification standards
  • Assign a quality improvement facilitator to each clinic/practice team in order to provide support and technical assistance to each practice team throughout the duration of the project.
      • Support practice teams in implementing Plan-Do-Study-Act (PDSA) cycles by organizing meetings between teams and quality improvement facilitators monthly over two years.
      • Facilitate in-person meetings at each clinic with quality improvement facilitators. 
  • Encourage facilitation of referrals between clinicians, practices, and community resources to enhance care coordination.
  • Work with adult and pediatric clinicians to develop written policies for clinicians and patients to facilitate transitioning youth to adult health care.
  • Work with an independent evaluator to implement a rigorous evaluation plan. The plan may include the following components:
        • Disseminating the Medical Home Index at baseline and at the end of the project for clinics to conduct a self-assessment of their own medical home implementation.
        • Disseminating the Medical Home Family Index at baseline and at the end of the project to allow families/caregivers to rate their satisfaction levels.
        • Utilize baseline results of both surveys to identify changes and improvements for PDSA cycles.
  • Track process measures and other quality improvement data.
  • Utilize national resources and technical assistance centers including the following:
        • National Center for Medical Home Implementation
        • Got Transition
        • Center for Medical Home Improvement
        • Local chapters of the American Academy of Pediatrics
  • Communicate accomplishments to stakeholders through e-Newsletters, emails, and the project Web site. 


  • Staff turnover at both the leadership and clinic staff level was a challenge in project implementation. The project leadership recommends implementing a quality improvement training program for new staff to ensure understanding of medical home and quality improvement science.
  • The project identified the following areas for continued improvement:
      • Communication strategies that clinicians and practices can utilize to explain complex medical conditions to families.
      • On-going training and professional development for staff to support culture change.
      • Inclusion of parent partners as active and engaged members of quality improvement teams.

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