This academic medical center established a medical home for children and youth with special health care needs using a strategic team driven approach. The model was so successful it was implemented in four academic practice locations.

Implementation Insights:

  • Create a method to identify high risk patients that require longer appointments, chronic care plans, and care coordination support.
  • Enhance team-based care by allocating specific times in staff calendars for interdisciplinary meetings.
  • Expand a traditional practice team to include practice-based nurse care managers, psychiatric nurse practitioners, and community health workers.

    Updated: January 2016

 Background Information

  • Type of Practice: Academic Institution
  • Location: New York City, New York
  • Population Served: Approximately 4,500 individuals have been served by this program, predominantly Hispanic and African American Medicaid beneficiaries.

 Pediatric Medical Home Implementation Strategies

      • Create a registry of children and youth with special health care needs.
        • Stratify children and youth with special health care needs according to risk based on medical complexity, utilization, and/or psychosocial stressors.
        • Implement high risk appointments (longer in time on clinician schedules to ensure all concerns and needs are addressed for complex patients).
      • Encourage team-based care through multiple strategies, including the following:
        • Integrate a practice-based Registered Nurse care manager into the health care team to assist with case management and care coordination.
        • Partner with local community based organizations to recruit community health workers to serve as cultural brokers.
        • Schedule weekly interdisciplinary team meetings; include social workers, nurses, office registrars, care managers, community health workers, physicians, and mental health providers in these meetings.
        • Work with staff to protect aforementioned meetings in all calendars/schedules to ensure no other appointments are scheduled over team meetings.
        • Utilize interdisciplinary team meetings to regularly obtain feedback from all staff members (clinical and non-clinical).
      • Implement "teach-back" methodology with families/caregivers to ensure that information and action plans are truly understood by each family member and caregiver.
      • Assign primary care providers to each family and child, ensure that all children and families see their assigned primary care provider with each visit.
      • Create after-visit summaries with families.
      • Educate faculty and housestaff on new workflows. 
      • Partner with national programs, such as the Medical Homes Chapter Champions Program on Allergy, Asthma, and Anaphylaxis.


  • Implementation of team-based care was challenging for this academic institution due to lack of buy-in from some team members. The project was initially established in one of four academic practices but has since been implemented in all four locations. The scale-up of the work encouraged team-based care across the organization.
  • The project continues to struggle with identifying funding sources to support its efforts long term. The project is implementing a large scale evaluation to assess the impact of its work and plans on using evaluation results to secure future funding.
  • Information technology changes occur quickly and require frequent staff training. The team-based approach of the project provides opportunities to train and update staff on technological changes and advances.

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