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 InstitutionLocation: New York City, New YorkPopulation 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. Challenges 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. More Information For more information, contact L. Adriana Matiz, MD, FAAP, Associate Professor at Columbia University Medical Center: firstname.lastname@example.orgFor tools, resources, and information on how to implement teach back strategies with patients, visit the following resources:Institute for Healthcare Improvement: Always Use Teach Back!North Carolina Program on Health Literacy Teach Back ToolkitTo view examples of after visit summaries for patients and families, view the "Building your Medical Home: An Introducation to Pediatric Primary Care Transformation" online resource guide.View additional information about the Medical Home Chapter Champions Program on Asthma, Allergy, and Anaphylaxis.